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    Told MS is pre-existing condition for LTD

    Hi.

    Has anyone had experience with this and any advice would be appreciated. I took my current job Sept. 6, 2012, signed up for insurances with LTD provided by employer. With the new year, I added a 10% "buy-up" on the LTD insurance which was effective 1/1/13.

    The end of January, due to MS issues, I had to go on short term disability. I was told by Leave Manager handling my case I was eligible for both STD and LTD, although not the 10% buy-up as this had a pre-existing clause to it.

    Fast forward to now. My STD ends in July and I will not be returning to my job due to the cognitive effects of MS. My Leave Manager told me to expect a call from the LTD Claim Manager in June as well as a packet to fill out and send back to the LTD insurance company.

    Today I got the call from the Claim Manager who said based on the start date of my insurance that my MS was considered pre-existing if I had any treatment for it in the preceding 12 months and would not be eligible for LTD. Treatment would include any appointments, medications, consultations, tests, etc. Of course I saw my neuro and of course I am on medication.

    Any thoughts or advice out there? Do I get a lawyer or won't that make any difference? I'm at a loss since the company I work(ed) for told me I qualified and the LTD insurance provider says I won't.

    Thanks, Sue

    #2
    I think full disclosure is required when there's insurance 'buy-up' involved. The buy-up requires that your surrendered your eligibility under the existing LTD coverage. Buy up also keeps the insurance agent's first year commission payments from dropping to much lower renewal policy commission payments.

    Policy surrender when a 'buy-up' is involved typically has very strict, full disclosre requrments.

    Full disclosure that you understood by increasing coverage you were surrendering your eligibility under the existing policy and would be required to meet new eligibility reqirements and exactly what the new eligibility requirements would be.

    Unless HR is a licensed agent who fully disclosed the policy surrender issues involved, I would contest the pre-existing condition exclusion, on that basis.

    It will probably require haring an attorney once you have exhausted your appeals. You can contact your local chapter of the NMSS for a list of LTD qualified attorneys.

    You should also contact your state's Insurance Commissioner to file a report against the insurance company for failing to disclose the policy surrender provisions and the absence of a licensed insurance agent during the policy surrender process.

    There were several huge scandals that involved all the major life insurance companies, in the 1990s.

    Insurance agents sold new policy coverage to replace existing coverage, after first year insurance agents commissions were paid, when commissions are at the highest payment rate.

    There was incentive to keep agent's higher first year commissions by replacing coverage when commission payments fell to renewal rate levels.

    Over the years many insured individuals developed health problems and would no longer meet the pre-existing condition exclusion already met under the existing policy, but would not be met under the new replacement policy.

    Since the 1990's states have developed very strict disclosure requirements that could result in an agent loosing their license to sell insurance for failing to disclose that surrenderig an existing policy could result in loss to the insured individual.

    Let us know how your LTD claim progresses, or if it becomes necessary to hire an attorney.

    Wishing you the very best of luck.

    Comment


      #3
      Thank you for such detailed information. I began today trying to find an attorney with experience in our area with LTD issues but was finally given the phone number for our states attorney referral agency to find someone. I will be following up on this as I not given any information about the "buy up" changing the rules. To complicate things, a different insurance company took over LTD at the same time my buy up became active.

      I will post down the road when I have more information to share.

      Thanks again,
      Sue

      Comment


        #4
        It's a good idea to contact the Insurance Commissioner in your state. The policy surrender issue may be key to reinstating your original LTD policy or possibily prohibiting the insurance company from denying your pre-existing LTD claim on the new policy, particularly if pre-existing limitation was met under the original policy.

        Good luck

        Comment


          #5
          Hi Sue.

          I was wondering how things have progressed, if they have at all. If you haven't already, make sure you request the actual policy from the plan administrator. Our company gives us a certificate, but it is superceded by the policy. So until you get the policy, you can't really be sure of the coverage.

          I know our company's policy for additional LTD is separate from the basic coverage and has its own coverage rules. The buy-up specifically excludes pre-existing conditions.

          The basic has a clause that is for new employees, that if the LTD is initiated prior to 2 years of employment (2 years from coverage effective date), the pre-existing clause is invoked and they are not eligible for LTD. Once employed two years, the pre-existing clause can no longer be used to deny a claim.

          I hope you can resolve this in your favor. I definitely would request the basic policy, as well as the buy up to see what the language is. If you use an attorney, they will need this anyway.

          Good Luck.
          Kathy
          DX 01/06, currently on Tysabri

          Comment


            #6
            Originally posted by pennstater View Post
            The basic has a clause that is for new employees, that if the LTD is initiated prior to 2 years of employment (2 years from coverage effective date), the pre-existing clause is invoked and they are not eligible for LTD. Once employed two years, the pre-existing clause can no longer be used to deny a claim.
            This was EXACTLY my requirement. A 2-year discharge period before pre-existing conditions would be nullified and you could quality for LTD.

            I hope things go well for you.

            Comment


              #7
              I'm still appealing my LTD

              I just got approved for SSDI after my first application (shocked! Expected to be denied by SSDI & have to appeal THEM!) however my employers LTD insurance company rejected my app, not for pre-existing condition because I had a 12 mo elimination period that passed, they said my MS wasn't bad enough. I appealed with the help of my MS specialist's letter to the insurance co. Still waiting on their 'review' and decision. I wish you luck with your situation.
              Possible MS 1993, RRMS, Dx 2007, SPMS 2013. Avonex - Oct '07 - Jul '12, Gilenya - Sept '12 to May '13, Tecfidera - June '13 to present. You see things as they are and you ask why..I dream of things that never were and I ask 'Why Not?!'

              Comment


                #8
                Good for you Curious. I also was approved for SSDI on the first go, actually receiving my first check the month following when my STD ran out.

                I was not able to collect on LTD due to the 2 year clause remarked on my (I believe) Marco.

                I'm glad you were able to get SSDI so quickly.

                Comment


                  #9
                  It is important to be aware of the 2 year 'look back' provision when applying for LTD benefits.

                  If anyone can avoid, postpone application for LTD benefits until after meeting the 2yr pre-existing condition exclusion, 'look back' provision, it's a good idea to do so.

                  Using FMLA, Vacation, paid time off, any kind of Leave of Absence benefits may allow time for recovery and return to work long enough to meet the 2 year pre-existing condition provision.

                  STD claims do not typicall have a pre-existing condition clause. However, applying for STD benefits before meeting the 2yr pre-existing condition limitation in the LTD policy is often considered pre-existing for LTD claims, particularly when 'transitioning' directly from STD benefits to LTD benefit claim.

                  Meeting the 2 year pre-existing condition limitation is not possible for all of us if illness and recovery prevent us from doing so.

                  Congrats on the SSDI 'award'.

                  Comment


                    #10
                    Would the two year time period still apply if the employer changed ins. companies? Meaning, would it restart the clock for yet another two year period?

                    Comment


                      #11
                      Would the two year time period still apply if the employer changed ins. companies? Meaning, would it restart the clock for yet another two year period?

                      Comment


                        #12
                        The employer can change insurance carriers at will for better coverage/policy terms, to avoid a premium increase, a variety of reasons. But the clock usually begins again for the 2yr look back/pre-existing condition payment exclusion from the replacement policy effective date.

                        I would verify to make sure though. It's entirely possible there is a grandfather clause for the 2yr look back/pre-ex exclusion in the new policy, allowing employees who have met the 2yr pre-ex exclusion under the original policy will not have to do so again under the new policy.

                        Comment


                          #13
                          Temagami - I have the same situation. Insurance carrier changed, but am 8 year employee. The contract is vague and would appear that I am excluded because of the 2 yr. look back. But the employee benefits says this does not apply to existing employees, only new. I had to contact my HR dept for them to confirm. The policy is supposed to be endorsed to clarify this. But No new policy yet...I have a lawyer now to help with the application since it is so grey.

                          Definitely write your plan administrator and get a copy of the policy. They are supposed to furnish in 30 days upon request.
                          Kathy
                          DX 01/06, currently on Tysabri

                          Comment


                            #14
                            Thought I would mention the importance of having documentation to support your claim in the event legal action is necessary.

                            If you have access to a computer in the course of your work, get everything in writing. If there is a less formal approach by HR or the insurer, confirm informal discussion in writing to parties involved. Whenever possible, confirm informal discussions in writing with dates, times, names, topic, etc., and cc to involved parties.

                            If you are not in an office setting, make a list of all dates, times, names and topic discussed to document meetings and discussions in person or on the phone.

                            It will be very important to support your claim and gives you enormous favorable credibility.

                            Comment


                              #15
                              Me Too

                              I also got caught up in the pre-exsiting condition crap.. Mine was an up grad when I started feeling bad so they checked all my medical records and i was put back to my original amount of 60 % ... Give the advice to anyone you know that you really don't have LTD until 2 years after you start and 1 year after you make a change!!!! My application to SSis pening but it is encouraging to read of others that got approved first time!!!!

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