|Most long-term disability (“LTD”) policies contain significant exclusions and conditions, which may result in an initial denial of your claim due to a technicality. An initial claim denial, to a certain extent, puts the burden of proof more heavily on you, as the claimant, to substantiate your entitlement to benefits. For that reason, ensuring that your initial claim is “bullet proof” and consistent with the terms of your policy is in your best interests. A qualified Boston long-term disability lawyer can ensure that your initial claim takes into consideration all of the provisions, limitations, definitions and exclusions of your particular policy.|
Let’s explore some of the provisions of your policy that are worthy of scrutiny. In this post, we’ll discuss:
(Next month, we’ll discuss these additional LTD policy terms and provisions: definition of “disability”; definition of “own occupation”; definition of “any occupation”; definition of “partial disability.”)
If your LTD coverage is available to you through your employer, the waiting (or eligibility) period tends to be of relatively short duration – typically the 3-6 months between the time that you become employed and the time that your coverage is effective. This provision of your policy deserves some attention as it may frequently provide you with “service credit” for prior years with your employer or a related employer.
A common cause of confusion is to assume that because you have satisfied the eligibility period, you now have disability coverage commencing on the date you are disabled. This may or may not be true, depending on the terms of your policy’s “elimination period.”
The “elimination period” is a provision that extends the date upon which benefits are payable. The elimination period essentially acts as a second waiting period after you have satisfied eligibility.
It works like this: Once your coverage is effective, a qualifying disability will be “covered” if it is incurred after the effective date. However, no benefits for that disability will be payable until you have satisfied an elimination period. To a certain extent, this is a provision which reserves payout until your disability has become “long term” vs. “short term.” A typical elimination period is 3-6 months. The good news is that many employers coordinate a “short term” disability benefit to fill the gap created by the LTD elimination period.
Pre-Existing Condition Limitation
So, now you have satisfied the eligibility period and you have been disabled for the duration of the elimination period. Are you now eligible to receive LTD benefits? The answer to that question may depend on the policy’s Pre-Existing Condition Limitation provision – otherwise known as the “Pre-Ex.” The Pre-Ex is a common provision in LTD policies that is designed to discourage individuals from procuring LTD coverage knowing that they have a condition that will likely result in a disability in the near future.
The Pre-Ex provision may limit/exclude payment of benefits for certain conditions for a certain period of time. A Pre-Ex provision is frequently referred to as “6/12” or “12/12.” These numbers correlate with:
(1) The number of months for which a condition existed prior to the effective date of coverage; and
2) The period of time for which the excluded/known condition will be temporarily excluded after the effective date of coverage.
For example, if your policy has a “12/12” Pre-Ex, it will exclude from coverage conditions for which you have received medical treatment or consultation during any of the 12 months immediately prior to the effective date of coverage; the exclusion applies only for the first 12 months immediately following the effective date of coverage. A preexisting condition can exist even though a diagnosis has not yet been made.
The Pre-Ex provision is one of the most commonly disputed elements of a LTD policy.
As you can see from this brief overview, LTD policies are complex and loaded with pitfalls for the inexperienced. If you would like a knowledgeable Boston long-term disability lawyer to review your policy in connection with your application for LTD benefits, call us, at 866-396-9722, or send us an email using the form on this page.