Many long-term disability (LTD) claims are denied because the insurance company argues that the disability is related to a pre-existing condition. Insurers often take the position that the medical issue existed before the employee became covered under the disability policy or long-term disability insurance plan.
However, a denial based on a pre-existing condition is not always correct. In many cases, employees in Ontario are still entitled to LTD benefits despite the insurer’s decision.
Understanding how pre-existing condition clauses work can help determine whether an LTD claim denial may be challenged.
What Is a Pre-Existing Condition in Long-Term Disability Insurance?
A pre-existing condition generally refers to a medical condition for which an employee received treatment, medication, consultation, or diagnosis before their disability insurance coverage began.
Most LTD policies contain clauses stating that benefits may not be payable if:
- The employee received treatment for a condition during a specified period before coverage began; and
- The disability occurs within a defined period after the policy starts, often the first 12 months.
Insurance companies frequently rely on these clauses to deny disability claims.
How Insurers Use Pre-Existing Condition Clauses to Deny LTD Claims
Disability insurers may review an employee’s prior medical history and argue that the current disability is connected to earlier symptoms or treatment.
Common examples include:
- A mental health condition linked to earlier anxiety or stress
- Back pain connected to prior medical complaints
- Chronic conditions such as fibromyalgia or migraines
- Symptoms that appeared before coverage but later became disabling
In some cases, insurers rely on selective medical records to argue that the disability existed before coverage began.
When a Pre-Existing Condition Denial May Be Disputed
A denial based on a pre-existing condition is not always valid. Courts often examine whether the insurer has correctly interpreted the policy and whether the earlier condition is truly related to the current disability.
A denial may be challenged if:
- The earlier condition was minor or unrelated to the current disability
- The employee had recovered and was functioning normally before becoming disabled
- The insurer interprets the policy wording too broadly
- The medical evidence does not support the insurer’s conclusion
Because disability insurance policies are complex contracts, careful review of the policy wording and medical evidence is often required.
Limited Condition Clauses and Other Disability Insurance Exclusions
Many LTD policies also include limited condition clauses that restrict benefits for certain conditions. For example, some policies limit benefits for mental illness or chronic pain conditions.
You can learn more about these policy limitations on our page discussing mental health and long-term disability claims.
What to Do if Your LTD Claim Is Denied for a Pre-Existing Condition
If your long-term disability claim has been denied because of a pre-existing condition, you should consider obtaining legal advice before accepting the insurer’s decision.
Many employees assume that the insurer’s decision is final. In reality, disability insurers sometimes misapply exclusion clauses or rely on incomplete medical evidence.
You may also wish to review our guide on what to do when an LTD claim is denied.
Speak With an Ontario Long-Term Disability Lawyer
Many employees are surprised to learn that a disability insurer’s decision is not always final and may be challenged through legal action.
If your disability claim has been denied because of a pre-existing condition, you may still be entitled to benefits. The disability lawyers at Monkhouse Law help employees across Ontario challenge wrongful LTD claim denials. To discuss your situation, contact Monkhouse Law for a consultation.
Frequently Asked Questions About Pre-Existing Conditions and LTD
Can long-term disability be denied because of a pre-existing condition?
Yes. Many disability insurance policies contain exclusions for medical conditions that existed before coverage began. However, insurers must properly apply the policy wording and medical evidence.
How far back do insurers look for pre-existing conditions?
Most LTD policies examine whether the employee received treatment, consultation, or medication for a condition during a specific period before coverage began, often between three and twelve months.
Can a pre-existing condition LTD denial be challenged?
Yes. Courts may examine whether the earlier condition is actually related to the current disability and whether the insurer interpreted the policy correctly.