The pre-existing exclusion clause is a hurdle that many employees under a group policy have to face when applying for disability benefits soon after coverage has started.
Toronto, ON (PRWEB) June 25, 2014
Some people apply for long-term disability benefits based on claims for physical or psychological injuries or illnesses, or a combination of the two. Insurance companies review available medical information when deciding whether or not to approve a claim.
Most long-term disability policies contain a clause that allows an insurance company to deny benefits on the basis that a “pre-existing” condition exists. Insurers will apply the pre-existing clause where employees under a group policy have only been covered by the policy for a short period of time (less than a year). The pre-existing exclusion period, can vary from policy to policy, but under section 311 of the Insurance Act, (R.S.O. 1990 Chapter I.8) it is not to exceed 2 years.
The pre-existing exclusion clause exists in many group disability insurance policies and is broadly interpreted by insurance companies. Insurance companies review medical records for mentions of prescriptions, referrals and complaints similar to the condition a person is claiming disability benefits for. Insurance companies will not pay benefits for a disability that results from any injury or illness for which the claimant was treated, attended a physician or was prescribed drugs for before coverage applied. It is important to review the policy to determine what the timeframe for the exclusion period is.
So what does this mean for someone applying for long-term disability benefits who is a newer employee at a company, who has recently become eligible for benefits? If the person was applying for disability benefits on the basis of lower back pain as a result of a herniated disc and severe pain, but had attended physiotherapy, attended a doctor and reported back pain or received a prescription for pain medication during the exclusion period, the insurer can use this information to deny benefits, even if it was one visit to the doctor in the previous year.
Or if someone with diabetes has developed severe diabetic neuropathy, vision difficulties resulting in blindness, or serious complications that would render him or her unable to work for various reasons, but the person had been taking insulin regularly or received diabetic management consultations from the family doctor, all the new issues and complications would be related back to the pre-existing condition, being the original illness- diabetes. If a person became unable to work as a result of depression, which resulted from the issues just mentioned, it could still be seen as related to pre-existing issues related to diabetes.
The pre-existing exclusion clause is a hurdle that many employees under a group policy have to face when applying for disability benefits soon after coverage has started. An experienced lawyer can help you to understand the claims process and work with you to determine whether or not the disability is caused by a pre-existing illness or injury.
If you or someone you know has applied for long-term disability benefits and your application was denied as a result of a pre-existing condition, or was denied for any other reason, consult an experienced long-term disability lawyer as soon as possible.
Aaron Waxman and Associates is a Toronto law firm whose practice is focused on long- term disability claims, short term disability claims, psychological illness claims, critical illness claims, life insurance claims, slip & fall claims, occupier’s liability claims, automobile accident claims, traumatic brain injury claims, and other types of personal injury claims.
We only help injured persons; we do not work for insurance companies.
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