Preexisting Conditions in Long Term Disability Cases
As ERISA Short Term and Long Term Disability lawyers we often hear some version of the following complaint or question by disability applicants and claimants: "My ERISA Short Term Disability (STD) or Long Term Disability (LTD) insurance company or Plan Administrator is denying my claim because they say I have a pre-existing condition." If you are a short or long term disability applicant, claimant or beneficiary and this is what is happening to you, it may be worth your while to consult an Short Term/Long Term ERISA disability attorney and this is because the LTD insurance carrier or LTD Plan Administrator may be misrepresenting a condition that is newly symptomatic as pre-existing.
An interpretation of this sort by the Short Term or Long Term Disability insurance company or Plan Administrator is often made where the LTD disability insurance adjuster or analyst sees some minor or fleeting reference in your medical records or history to the condition that you are claiming has just become disabling and interprets that minor reference as evidence that the condition was somehow disabling prior to the time that your LTD coverage vested under the terms of the Plan and/or that not enough time has passed as defined in the LTD Plan or Policy language between claim periods for a disabling condition, their conclusion being that the condition you are now claiming as disabling should be denied as pre-existing.
An example of this could be where you are currently claiming psychiatric or mental impairment as the basis for your STD or LTD claim, and the insurance company adjuster points to a single reference or to a couple of references of depression or anxiety noted in the history of your past medical records. The STD - LTD Plan language in that case might actually specify or be interpreted to mean that such a minor reference should not be used against you because the subject condition was not of significant severity to require active treatment, though the disability insurance adjuster may ignore that provision and call it pre-existing anyway.
Another example is a situation where you are currently claiming disability because of migraines, and the insurance adjuster points out a minor reference to a headache in some past medical record. And more than once we have seen the insurance adjuster stretch the "pre-existing" interpretation of your claim record even further by asserting that because a medication prescribed to you in the past by your physician for some other purpose is a medication that could be used to treat the condition that the adjuster is claiming is pre-existing, even though you and your physician know that the drug was prescribed to you to treat a wholly unrelated condition.
While perhaps this results from an LTD insurance carrier or insurance adjuster taking an overzealous approach to claim handling, there is often more to it then that; it may be that the LTD Plan language or policy language and terms and conditions are not written clearly, or more likely are simply subject as written to differing interpretation and open to argument as applied to the facts of a particular case or claim. Sometimes the insurance adjuster or claims analyst finds or raises a viable defense or at least an arguable point, regardless you can be certain that the insurance adjuster is trained to find weaknesses in your case, and where the claim decision is a close call or open to interpretation in even a minor way, the disability adjuster is much more likely to decide against you and in favor of denying the claim.
You should know however that your ERISA Short Term Disability and Long Term Disability Plan provisions are a contract, in which the contracting parties: the plan beneficiary claimant on the one hand, and the insurance company and/or employer on the other hand, are both subject to the terms of that contract, and that there is a principal in the law that can favor the claimant as the party that did not have control over the drafting of the Plan’s language.
For reasons such as this we strongly suggest that you consult an ERISA Short Term Disability / Long Term Disability lawyer and ask that lawyer to review the record in your case, including the Plan language to ensure that your rights are upheld and that all reasonable arguments are made on your behalf so that you obtain and continue to receive all of the disability benefits that are fair and that you deserve. At The Law Office of Paul J. Dombeck, we can appeal the denial in your case directly to the LTD disability insurance company or plan administrator, and if necessary, pursue a lawsuit in Federal District Court where these claims must typically be appealed if the disability insurance company continues to unfairly deny your claim.
The ERISA and Short Term Disability and Long Term Disability attorneys at The Law Office of Paul J. Dombeck, PLLC offer a free consult to you, and we encourage you to contact us right away at (602)-648-2035.