What Is a Pre-Existing Condition Exclusion?

A pre-existing condition exclusion occurs when your long-term disability insurance carrier refuses to pay out benefits because they claim your disability is related to a pre-existing condition.

Many insurance policies have a pre-existing condition clause, or exclusionary period, that sets a specific window of time after employment begins during which the employee may not receive disability benefits for a pre-existing condition. According to the Ontario Human Rights Commission (OHRC), any life and disability insurance policies have a two-year exclusion period, although some periods may be shorter. The exact timeframe may be found in the details of an individual policy.

Once the exclusionary period has passed, a worker may become eligible for a disability claim related to a pre-existing condition.

Pre-Existing Condition Exclusions Due to Disclosure

What is a pre-existing condition exclusion? In some cases, a pre-existing condition exclusion may refer to a denial of benefits because a pre-existing condition was not disclosed in an insurance application. If an insurance application process instructed employees to report their pre-existing conditions, and they did not, the insurer could challenge disability claims on these grounds later on.

If, however, an employee did report their pre-existing condition when applying for insurance, they may be eligible for a disability claim related to their pre-existing conditions once the exclusionary period has expired.

Pre-Existing Condition Exclusions May Be Challenged

It is important to have a good understanding of your policy’s exclusions, including the pre-existing condition clause. If an insurance company denied you coverage, it may be possible to reverse their decision with an internal or external appeal. The insurance company may have:

• Unfairly characterized a condition as pre-existing
• Wrongfully denied a claim after the exclusionary period expired
• Made their determination based on an easily resolved technicality
• Denied the claim based on a pre-existing condition when the pre-existing is only a contributing factor and not the exclusive cause of the disability

If you believe your insurance carrier unfairly denied your claim for disability benefits, a disability lawyer may be able to review your policy. There may be actions you may be able to take to challenge your insurance company’s decision and receive compensation.

How to Fight a Long-Term Disability Benefits Claim Denial

When a potential client calls us about a disability denial, we review the insurance policy closely to see if the pre-existing condition exclusion or any other exclusions apply. If we believe that our client may qualify for benefits, we have several options for challenging the denial, which may include:

• Filing an internal appeal with the insurance company
• Taking the case to court and presenting evidence to defend your right to disability compensation

A lawyer may also be able to help you gather new evidence that supports your case. This evidence may include further testing, second opinions, testimony from medical or vocational experts, and more.

If you believe your long-term disability insurance carrier unfairly denied your claim for disability benefits, we may be able to help. Let us review your case and explain if any exclusions apply. If you qualify for benefits, we may be able to take action on your behalf.

Time Limit to a Disability Denial Lawsuit

Under the Limitations Act, 2002, S.O. 2002, c. 24, Sched. B, you may only have two years from the date of your initial denial to file a lawsuit in your case, which is known as the limitation period. In certain cases, the limitation period to file may be shorter than two years.

Filing an internal appeal and receiving a second denial may not extend this deadline. If this time period passes in your case, you may lose your ability to secure compensation from your insurer in court.

For questions about the limitation period in your disability case, contact a disability law firm as soon as possible.

Talk to a Legal Team About Your Long-Term Disability Benefits

If your long-term disability insurance carrier denied your claim, a lawyer may be able to review your case and determine if you have an argument to overturn the decision or pursue compensation.

If you are still wondering about pre-existing condition exclusions or have other questions, contact a member of the Preszler Injury Lawyers team today by calling 1-800-JUSTICE. An initial consultation call with our firm is complimentary, and we work on a contingency-fee with no up-front costs to our clients. We welcome the opportunity to help you understand your policy and fight a wrongful denial.

Our lawyers serve clients throughout Ontario. We may be able to come to you if you are unable to travel to our offices because of your medical condition or treatment schedule.