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Disability Insurance: Long Term: Group

Pre-Existing Condition Provisions

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4/19

Each pre-existing condition provision includes two time periods: a "look back period" and a "pre-existing condition waiting period."

Look Back Provision

A look back provision determines which conditions are considered to be "pre-existing." Typical wording is something like: "A condition for which medical treatment or advice was rendered, prescribed, or recommended, or for which a reasonably prudent person would have sought treatment, within the six months prior to effective date of coverage."

Note the inclusion of the words: "for which a reasonably prudent person would have sought treatment" in the six months prior to the effective date of coverage. That makes it much easier for the company to exclude some conditions for which you never went to the doctor. In one recent case, a company tried to exclude HIV as pre-existing, because the claimant knew he was HIV positive for over eight years, but had chosen not to seek treatment as long as he remained asymptomatic. The insurance company argued that a reasonably prudent person who was HIV positive would go to the doctor at least every six months whether or not he had any symptoms.

Pre-Existing Condition Waiting Period

This is the period of time you must wait before you are covered for a pre-existing condition.

A pre-existing condition waiting period is usually one year. The period can be longer.

The practical effect of a Look Back Provision and a Pre-Existing Condition Waiting Period

To understand the practical effect of these two provisions when taken together, let's assume you have a plan with a Look Back Period of six months and a Waiting Period of twelve months.

Example 1. Suzie is being treated for diabetes. She takes insulin regularly and sees the doctor every three months. Because she had medical treatment in the six months before the coverage started, the plan will not cover a disability related to diabetes until Suzie has been covered under the plan for twelve months. If Suzie leaves work due to a diabetes-related disability after twelve months, the plan will pay benefits.

Note: If using this example, Suzie went on disability during the 12 months Pre-Existing Condition Waiting Period, but didn't file a claim until after the 12 months is up, her claim will still generally be excluded since the disability started during the pre-existing condition period.

Example 2. James had colon cancer which has been eliminated. James is not on medication. His last annual checkup was nine months ago. Since James didn't have a cancer-related charge in the six months before the coverage began, and there was no reason a prudent person would have seen the doctor during that time, cancer is not considered to be a pre-existing condition for purposes of his group disability insurance policy. Should cancer return, even in the first month of coverage, the plan will pay benefits to James.


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