If you’ve recently applied for long-term disability (LTD) benefits and your insurer is talking about a “pre-existing condition,” you’re not alone. One of the most common reasons LTD claims get denied is due to what’s known as a pre-existing condition clause. But how do insurance companies determine pre-existing conditions in disability insurance? The answer lies in the fine print of your policy. Most group LTD policies include provisions that allow insurers to investigate your medical history, typically within a specific time window before your coverage began, to decide whether your condition existed before your benefits kicked in. This process can be complex, frustrating, and often unfair. In this blog, we break down how these clauses work, what insurers are really looking for, and what you can do if your LTD claim is denied because of a pre-existing condition.
What are long term disability benefits?
Long-term disability benefits are a monthly income benefit that is available through your employer’s group benefits policy. If an injury or illness prevents you from working, you may qualify for LTD benefits.
What is a pre-existing condition?
LTD policies will contain many provisions and exclusions which dictate the payment of benefits. A “pre-existing clause” is a commonly found exclusion within LTD policies.
If you are newly insured under an LTD policy, a pre-existing clause will try to limit your access to benefits.
The following is an example of what a pre-existing clause may look like:
“No benefits are payable for any Disability directly or indirectly related to a Pre-Existing Condition which causes Disability within the first 12 months of insurance under this Benefit. A Pre-Existing Condition is any injury or illness (whether diagnosed or not) for which an Employee was treated or attended by a Physician, or for which Drugs were prescribed, within 90 days prior to the date the Employee’s insurance under this Benefit became effective.”
When does a pre-existing condition investigation start?
The pre-existing clause often applies to new employees insured under the LTD policy. According to the example above, if you have become insured and you have applied for LTD benefits within the first year, your claim will be subject to what’s called a pre-existing condition investigation. Here are some examples that outline when a pre-existing investigation may come into play.
Example 1:
Joe is hired by ABC Corporation on February 1, 2025. As part of his employment package, he is part of ABC Corporations group benefits policy which has LTD coverage. Joe has suffered from frozen shoulder since January 1, 2025, and has been getting treatment for his shoulder all through January. Unfortunately, Joe’s shoulder gets much worse shortly after starting work and he goes off on disability leave March 1, 2025. Joe makes a claim for LTD benefits 3 months after he joins ABC Corporation.
Q: If the above pre-existing clause applies, is Joe’s claim barred by virtue of the pre-existing clause?
A: There’s a good chance it may be. Joe was receiving treatment for his shoulder within the 30 days before his coverage began, right in the “pre-existing window” that the clause indicates.
Example 2:
Joe is hired by ABC Corporation on February 1, 2025. As part of his employment package, he is part of ABC Corporations group benefits policy which has LTD coverage. Joe suffered an injury resulting in frozen shoulder on March 1, 2025 and went off work the same day. Joe receives treatment all through March, April and May for his shoulder. Joe makes a claim for LTD benefits the following month in June. Joe has not received any treatment or suffered from frozen shoulder before March 1, 2025.
Q: Is Joe’s claim barred by virtue of the pre-existing clause?
A: No. Joe’s injury is not pre-existing. Although the insurance company may still conduct a pre-existing review of Joe’s claim, his claim should not be barred by the pre-existing condition clause.
Pre-existing condition denials are complicated. If you suffer from a myriad of medical issues and your insurance company has decided to cherry pick and deny your LTD benefits based on a single (or multiple) pre-existing condition(s), chances are it is an inappropriate denial of your claim. It’s best to speak with a lawyer to challenge the LTD denial.
My Insurer is conducting a pre-existing investigation, what do I need to provide?
Usually, only the time frame set out in the pre-existing condition clause is relevant to the pre-existing investigation.
For example, if an employee makes a claim on June 1, 2024 and the pre-existing period is for 90 days which begins January 1, 2024 and ends April 1, 2024, the insurance company should only be requesting medical records during the relevant period.
If you do not provide authorization for the insurer to obtain the records, your claim will likely be denied due to non-compliance.
If I have a pre-existing condition can the insurance company automatically deny my claim?
No. It is not appropriate (or fair) for an insurer to deny your LTD claim simply because a pre-existing condition is in the mix. It’s very possible your condition has evolved. Many people find themselves living and working with a chronic condition which becomes worse resulting in them being unable to work. Just because a condition existed before does not mean it should be barred by virtue of a pre-existing clause.
Understanding how insurance companies determine pre-existing conditions in disability insurance is crucial if you are applying for long term disability. Most LTD policies include pre-existing condition clauses, which allow them to deny your claim on this basis. However, not all denials are justified. Insurance companies often misinterpret or misuse these clauses to avoid paying benefits. If your LTD insurer has wrongfully denied your claim based on a pre-existing condition, or for any reason, it’s time to get a disability lawyer involved. The disability lawyers at Whitten & Lublin can help you challenge the denial and take back control of your rights. We offer free consultations for short and long-term disability claims. Contact us online or call 416 640 2667.
Author – Aman Chaggar
