How to Appeal a Pre-existing Condition Exclusions Denial

Filing a disability insurance claim in Philadelphia, Pennsylvania, is a way to seek financial assistance when you can’t work. Disability insurance helps when illness or injury prevents you from working and earning an income.

However, insurance companies may look for reasons to deny claims. A policy’s pre-existing condition exclusions may determine whether the policy covers your condition.

What is a Pre-existing Condition Exclusions Denial in Pennsylvania?

A disability insurance policy may not offer coverage for all conditions that can prevent someone from working. For example, a policy might not cover self-inflicted injuries or illnesses.

Similarly, a disability insurance policy may not offer coverage when you can’t work due to a pre-existing condition. An insurer might deny your claim if your disability stems from such a condition, preventing you from receiving benefits.

What Qualifies as a Pre-Existing Condition for Disability in Pennsylvania?

Different insurers have different policies regarding what types of conditions may justify pre-existing condition exclusion denials. However, all insurers in Pennsylvania have to obey the law when establishing policies.

A pre-existing condition may be a condition for which you received “medical advice or treatment” within 90 days of becoming covered under a policy. The 90-day period before coverage begins is referred to as the “lookback period.”

For example, maybe you sustained an injury that you sought treatment for 50 days before your coverage began. If this injury worsens to the extent that you can’t work, the insurance company might have grounds to deny your claim.

Be aware that pre-existing conditions don’t qualify as such permanently. Under Pennsylvania law, a pre-existing condition no longer qualifies as pre-existing after you’ve been covered under a group contract for 12 months.

You may have the opportunity to disclose pre-existing conditions when signing up for coverage. Be honest when providing this information. In some instances, insurance companies won’t cover certain conditions if applicants don’t report them from the start.

Can Short-term Disability be Denied for Pre-Existing Conditions?

Seeking short-term disability with pre-existing conditions is no different from seeking long-term disability benefits in this regard. As long as they’re obeying the law, an insurance company can cite a pre-existing condition to deny a short-term disability claim.

Appealing a Pre-Existing Condition Exclusions Denial in Pennsylvania

The fact that the insurance company denied your claim doesn’t necessarily mean you can’t receive benefits. You could appeal their decision.

The specific ways you may show you deserve benefits after a denial for a pre-existing condition can depend on the nature of your case. Potential arguments you might put forth include:

• The condition that caused your disability is not a pre-existing condition. Even if you have a pre-existing condition, an insurer might incorrectly conflate it with a new disability. Providing medical evidence could help you show that your disability results from a new condition.
• Case law establishes that an insurer should have offered coverage. Consider a recent case, Kaiser v. United of Omaha Life Ins. Co. In this case, the plaintiff had sought treatment for shoulder pain shortly before starting a new job. The doctor originally concluded the shoulder pain resulted from shoveling snow. Later, the plaintiff discovered they had a tumor. The insurance company denied their claim because they sought treatment for shoulder pain during the lookback period. However, a court found that seeking treatment for symptoms that end up being related to something more serious shouldn’t affect coverage of that serious condition. Cases like these establish a precedent you could reference when explaining why you deserve benefits.
• The insurance company is interpreting its own pre-existing condition exclusions too broadly. A careful review of the language of a policy could indicate an insurer denied a claim when they should not have.
• The insurance company denied a claim for a disability partially stemming from a pre-existing condition. For example, in a case like Fought v. UNUM Life Ins. Co. of Am., an insurer tried to deny a claim when a claimant developed a staph infection. The claimant developed this infection as a result of elective surgery they underwent during the lookback period. In this case, a court decided the language of the policy did not justify denying a claim in these circumstances.

Contact a Philadelphia, Pennsylvania, Disability Lawyer

An attorney can help in many ways when you’re seeking disability benefits with a pre-existing condition. Examples include:

• Reviewing your policy’s terms to help you understand your coverage
• Assisting with the application process
• Helping with an appeal if you receive a pre-existing condition exclusions denial

At Capitan Law, a Philadelphia disability lawyer is available to help you seek the benefits you may be eligible to receive. Learn more about how we can help with your claim by contacting us online or calling us at (267) 419-7888 for a case review.