If you have had a chronic condition that recently worsened, you might be wondering if your long-term disability (LTD) claim could be denied on the basis that your condition was pre-existing. Or, you might have already received a denial because the insurance company is saying your condition is pre-existing.
Many LTD policies do have pre-existing condition exclusions and they are a common reason used by insurance companies to deny claims. Being aware of these provisions can help you determine if your claim is likely to be denied and if you have a good chance of winning an appeal of a denied claim.
What Do Plans Usually Say About Pre-Existing Conditions?
In the context of long-term disability insurance, a pre-existing condition is typically any condition for which you received treatment, care, or advice during a specific period before your coverage began. This period is often called the “lookback period.”
The pre-existing condition exclusion will generally only come into play if you file an LTD claim shortly after you become covered under the policy (often 12 months).
An example of language that you might see in a policy is the following:
Benefits will not be paid for a disability caused by; contributed to by; or resulting from
a Pre-existing Condition unless the Insured has been Actively at Work for one (1) full day following the end of twelve (12) consecutive months from the date he/she became an Insured.
“Pre-Existing Condition” means any Sickness or Injury for which the Insured received medical treatment, consultation, care or services, including diagnostic procedures, or took prescribed drugs or medicines, during the three (3) months immediately prior to the Insured's effective date of insurance.
Here is an example of how this could work in practice: You got covered under your company’s LTD plan on January 1, 2026 and your policy has a 3-month lookback period. Your disability date is May 1, 2026. The insurance company will review your medical history from October 1, 2025 to December 31, 2025 to see what conditions you were treated for. If one of those conditions caused or contributed to your disability, the insurer may deny your claim.
Note that every policy is unique and you should consult the exact terms of your own policy to verify the timeframes.
When Do Insurance Companies Deny Claims for Pre-Existing Conditions?
If your LTD claim is subject to a pre-existing condition review, the insurance company will request your medical records for the lookback period and assess what conditions you received treatment or care for (as defined in the policy) during the relevant period. Some cases are fairly straightforward; if you were diagnosed with a specific condition and were actively treating for it during the lookback period and then that exact same condition causes you to cease working a few months later, the pre-existing condition denial is likely valid.
Many cases are a bit more nuanced. Insurance companies often conflate generalized symptoms and actual diagnosed conditions. Thankfully, many courts assessing these denials have reached decisions that are favorable to claimants in these situations. For example, one court noted that although a claimant doesn’t need to be definitively diagnosed with a condition during the lookback period in order for the condition to be considered pre-existing, there must have at least been “some concern or suspicion at that time that the observed symptoms were caused by the particular condition.” Goerig v. Phoenix Home Life Mut. Ins. Co., No. 97 C 1890, 1998 U.S. Dist. LEXIS 18208, at *7 (N.D. Ill. Nov. 13, 1998). For example, if you sought treatment during the lookback period for symptoms of fatigue, this could be due to any number of conditions. If you were later diagnosed with cancer (after you were covered under the LTD policy) and it turns out in retrospect that your fatigue was due to cancer, the LTD insurer may deny your claim. However, you would likely have a strong basis to appeal that denial, unless there was some reason your provider specifically suspected that you had cancer during the lookback period.
Pre-Existing Conditions that “Contribute To” Disability
When pre-existing condition exclusions are drafted broadly, some additional challenges can come up. Some exclusions state that a claim can be denied if your disability is not directly caused by a pre-existing condition but also contributed to by that condition. This can create additional challenges. For example, if you had pre-existing anxiety and then were diagnosed with disabling PTSD after the lookback period, the insurance company may argue that your anxiety contributed to your disability by making you more vulnerable to the PTSD or because one of your ongoing symptoms that prevents you from working is anxiety.
Challenging Pre-Existing Condition Denials
While these denials may be proper in some circumstances, LTD insurers often apply pre-existing exclusions too broadly. A claim denial is not always the final word and it may be challenged if the insurer is misinterpreting your medical records or applying plan language too broadly.
These appeals often require an attorney who can carefully review policy language, help get needed medical information from your providers, and explain the caselaw governing pre-existing condition denials to the insurance company.
The appeal stage is critical for these cases, as you may only get one meaningful chance to submit evidence. Contact our office today if you would like to speak with an attorney about challenging a pre-existing condition denial