Addressing the Issue of Pre-Existing Conditions in ERISA Long-Term Disability Appeals
Most policies’ pre-existing condition limitation provisions apply if you go out on disability within 12 months of the date your coverage becomes effective. If that limitation is triggered, the carrier will apply a “look-back” period – typically 3 months from that first date of effective coverage – to see if you have had any “treatment” for the condition for which you are claiming disability by a “physician.” Policies define “treatment” and “physician” in a very broad manner to include, office visits, telehealth visits, consultations, prescriptions, etc. with a doctor, nurse practitioner, nurse, chiropractor, naturopath, etc.
If you receive a denial letter that mentions your LTD policy’s pre-existing condition limitation, you should seriously consider seeking the advice of an experienced ERISA attorney, to help you navigate the complex analysis involved with pre-existing conditions and effectively challenge the denial. An attorney can thoroughly review your policy to determine if the pre-existing condition exclusion applies and gather evidence to demonstrate that it does not. She can work with medical experts to obtain supporting documentation that establishes the disability as separate and distinct from any pre-existing conditions. By building a strong case, your attorney can demonstrate that your disability is unrelated to any pre-existing condition and that you are entitled to the long-term disability benefits you deserve.
Working with an attorney who understands the intricacies of ERISA long-term disability appeals and the rules regarding pre-existing conditions can significantly enhance your chances of a successful appeal. She can guide you through the legal process, advocate for your rights, and ensure that the insurer’s denial is properly addressed.