When you file a long-term disability (LTD) claim, you might expect the insurer to focus on why you cannot work now. But if your employer-sponsored plan has a pre-existing condition exclusion, the insurer may also review care you received before your coverage started.
Having a pre-existing condition does not automatically mean you lose benefits. The Employee Retirement Income Security Act (ERISA) sets rules for the claims process. For insured group LTD policies in New Jersey, state insurance rules also limit how insurers define and apply pre-existing condition exclusions.
How the look-back period works
A look-back period covers a set time before your insurance starts. During that period, your insurer checks whether you received care for a health issue that later relates to your disability claim. Your plan documents explain how your coverage works and what limits apply. Your LTD terms may also address earlier medical care.
The exclusion may also apply only if your disability starts within a set period after coverage begins. If it does, the insurer might check whether your earlier care fits the pre-existing condition exclusion. In New Jersey, state rules limit how insured group disability policies apply these terms.
What the insurer reviews
Your medical records show what care you received during the look-back period. The insurer may also check pharmacy records for medicine used to treat the condition that now keeps you from working. It then compares that history with the terms of the exclusion.
If the insurer denies your claim, the denial notice must explain why and point to the plan terms that support its decision. Federal rules give you at least 180 days to appeal an ERISA disability denial. You could compare the notice with your records to see how the insurer linked your earlier care to your current condition.
What you may want to review
The dates in your records and the wording of your plan often affect how the exclusion applies. You may want to keep your denial notice, plan documents and medical records together as you review the reason for the decision. It could also help to note your appeal date and check which records the insurer relied on.
