People who have a personal or company disability insurance policy expect that it will protect them in the event of an accident or sudden medical event. But that’s not always the case. Long-term disability insurance provider Unum has been sued by consumers who say the company unfairly denies due benefits.

Consumers thinking about buying a disability policy likely have questions. Reading through the fine print is important to clarify what will and won’t be covered in the event of a sudden, disabling event. An insured party could be denied for a pre-existing condition, which may come as a shock.

What is a pre-existing condition?

Most people use disability policies to protect themselves from the unexpected. The sudden onset of a medical problem could derail one’s earning potential, and disability insurance provides peace of mind to that worker about the financial support in place to minimize the risk in the long run.

However, someone who has a pre-existing condition might wonder whether a flare-up of that condition could result in coverage being denied even if they have an active disability policy.

Finance website thebalancecareers.com explains the basics of disability insurance. In general, the term pre-existing condition is used in reference to health insurance benefits. It was a frequent practice before the 2014 Patient Protection and Affordable Care Act for insurers to deny someone coverage because of a pre-existing condition. The term simply refers to a medical condition that began prior to the effective date of a person’s health benefits. This term can also apply to disability benefits.

Can patients be denied for a pre-existing condition by any disability company?

Most insurers have an exclusion in their policy documents that states pre-existing conditions may qualify as a reason to deny benefits. However, some consumers are unaware that being denied due to a pre-existing condition is a common practice insurance companies may use to avoid paying out what might be a legitimate claim for benefits.

What matters in these situations is the policy language about the condition(s). A policy’s wording can make the difference between the insured party receiving benefits and being denied altogether.

How do insurance companies deny benefits for pre-existing conditions?

Two terms are often used in reference to a denied long-term disability (LTD) claim. The first is known as a look-back period, and the second is known as a pre-existing condition waiting period. The look-back provision details what conditions might meet the company grounds to be considered “pre-existing.”

This often means cases in which the insured took medicine, received treatment, or underwent diagnostic testing for a condition that occurred within 12 months of the person receiving coverage under the LTD policy.

The waiting period is the amount of time the person must have been covered by the disability policy before a condition meeting the look-back requirements will be covered, according to policygenius.com.

If an applicant fails to disclose a pre-existing condition during the application phase, and the underwriters don’t discover it in their analysis of the case, benefits could still be denied by the insurance company if and when the applicant attempts to receive benefits for a condition he or she had prior to getting the policy. While health insurance cannot deny coverage for pre-existing conditions, a disability company can, but they do not always do so fairly.

Fighting LTD denial for pre-existing condition

Legal precedents demonstrate how insurers sometimes pin an LTD denial on medical records they say is evidence of a pre-existing condition, but that, in reality, had nothing to do with a chronic health condition that the claimant hid during the application process.

For example, in a 2016 lawsuit, a court ruled that on the LTD denial of a patient who went to the doctor for shoulder pain they thought was due to shoveling snow, but was actually due to a massive tumor. In between going to the doctor for her shoulder pain and discovering the tumor, the patient got a job and signed up for long term disability benefits through her employer.

The insurance company denied the patient’s subsequent LTD claim after she began employment and discovered the tumor, citing the doctor’s appointment for shoulder pain prior to obtaining LTD coverage; however, the decision was reversed by a Wisconsin federal court.

The court pointed out that, at the initial appointment, the doctor and their staff all believed the patient’s shoulder pain was due to a strain from shoveling snow. It wasn’t until later examinations revealed a tumor, noted the court.

The disability claim process is detailed and time-intensive for most applicants, according to Everyday Health. However, experts say that it is possible for disabled applicants to be successful.

“The most important takeaway is that you have to be a self-advocate with patience and persistence,” a social worker and advocate told Everyday Health.

Experts told Everyday Health that LTD applicants, especially those with pre-existing conditions should contact their doctor early in the process and try to not be discouraged.

Filing a LTD lawsuit

Even after receiving a denial on your LTD claim, there is still hope. Many who file for disability claims are initially denied, and are then approved during various stages of administrative appeal.

To combat wrongful LTD insurance denial, those who have exhausted all levels of administrative appeal available to them may be able to turn to litigation. Note that no new evidence can be added to a case after the appeals have been submitted, even if you decide to pursue litigation, so it is essential that you include as much favorable evidence as possible in the appeals process. This will help ensure that your appeal has its best chance of success, as well as ensuring that your attorney has all the information and evidence they need help you win your case.

Filing a lawsuit can be a daunting prospect, so Top Class Actions has laid the groundwork for you by connecting you with an experienced attorney. Consulting an attorney can help you determine if you have a claim, navigate the complexities of litigation, and maximize your potential compensation.

Do YOU have a legal claim? Fill out the form on this page now for a free, immediate, and confidential case evaluation. The bad faith insurance attorneys who work with Top Class Actions will contact you if you qualify to let you know if an individual lawsuit or Unum class action lawsuit is best for you. [In general, Unum bad faith lawsuits are filed individually by each plaintiff and are not class actions.] Hurry — statutes of limitations may apply.

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