Pre-Existing Condition Exclusions in Long-Term Disability Policies Explained

Employees in Chicago making claims for long-term disability benefits are rarely familiar with the insurance policy’s terms before making the claim. They usually are not aware of what is considered a pre-existing condition under the policy, or under what circumstances the insurer can deny the claim due to a pre-existing condition. All policies must be read for how they define a pre-existing condition and how to apply the exclusion, but most policies have some similar features. Most policies define a pre-existing condition as one for which you received some form of treatment or from which you experienced symptoms during a lookback period prior to obtaining coverage under the policy. Then the policies will exclude coverage for disabilities caused by or contributed to by a pre-existing condition if disability occurs within the first 12 months of obtaining coverage under the policy. The exclusions seek to address a phenomenon in insurance called adverse selection, a situation where a person obtains insurance after knowing the person will likely make a claim. A recent case illustrates how such a pre-existing condition exclusion barred a claim.

In Jacobs v. Reliance Standard Life Insurance Co., Civil Action No. 21-323, 2023 WL 2708581 (D.D.C. Mar. 30, 2023), Dr. Jacobs’ disability arose following complications from a November 2017 gastric sleeve surgery. He continued receiving treatment for these complications and started work at Georgetown Physicians Group in August or September 2018. He claimed disability on September 18, 2018. Reliance Standard denied the claim on the basis of the pre-existing condition exclusion. After Dr. Jacobs unsuccessfully appealed, he sued under ERISA § 502(a).

The United States District Court for the District of the District of Columbia ruled against Dr. Jacobs. While there was disagreement as to when Dr. Jacobs began employment and when he obtained coverage under the policy, no matter the date the record showed Dr. Jacobs consistently getting treatment for the complications from the November 2017 surgery such that he would have received treatment for the condition regardless of when the 3-month lookback period applied.

If your claim for long-term disability benefits has been denied due to a pre-existing condition, contact an experienced ERISA long-term disability lawyer immediately.