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Could this be a good sign?

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    Could this be a good sign?

    I applied for LTD and was denied due to pre-existing condition (wasn't actually diagnosed until after I started my last job with the LTD policy though). I filed an appeal last month, and today I got a letter saying they need more medical information. They already have all of the information that is actually related to my MS though, so anything else they collect won't show anything in their favor. If they didn't just outright deny me again with what they already have available (what they used to deny me in the first place), could this be a good sign? Or am I getting my hopes up for nothing? It's pretty obvious I did have MS before my diagnosis, but when my MS specialist specifically stated I didn't have it yet, I used that as the basis for my appeal.
    Diagnosed 1/4/13
    Avonex 1/25/13-11/14, Gilenya 1/22/15

    #2
    If you filed a LTD claim within the 2yr 'look back' period from the policy effective date, I wouldn't get your hopes up.

    There were a couple of successful court cases challenging denied LTD claims for MS as a pre-existing condition that were un-dx prior to filing a claim. The judge sided with the insured because there was no medical history for the insured, much less a history that would support the suspicion of pre-existing MS or any other condition.

    Most pre-existing exclusion terms were written into insurance policies based assumptions of fraud and/or deception by the applicant. Policy language was based on the assumption that a reasonable person would/should have known they were sick prior to applying for insurance, but avoided medical care for the purpose of aquiring coverage and avoiding dx and the pre-existing condition limitations in the policy.

    Here is a link and exerpt from one non MS case, with a decision favorable to the insured:

    http://www.us.kpmg.com/microsite/tax...article02.html

    The court cited a non-ERISA case, Lawson v. Fortis Insurance Company, 301 F.3d 159 (3rd Cir. 2002), that, although decided after this case was briefed, was cited as precedent by both parties. In Lawson, the individual went to the emergency room with a number of symptoms a few days before her health insurance policy took effect. She was diagnosed with an upper respiratory tract infection. A doctor's visit after the policy's effective date led to a diagnosis of leukemia. As in this case, the insurance company applied the pre-existing condition exclusion and denied claims for leukemia treatments.

    In Lawson, the Third Circuit analyzed the requirement that the earlier treatment be "for" a condition. In reviewing Webster's and Black's Law Dictionaries, the court found that the word "for" has an implicit intent requirement. Thus, the court concluded that "it is hard to see how a doctor can provide treatment 'for' a condition without knowing what that condition is or that it even exists." Applying these principals, the Third Circuit affirmed the district court's decision in favor of Ceccanecchio.

    I found a few LTD cases using google search term:
    pre existing condition clause for Long Term Disability

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      #3
      My advice to those working with MS...and have LTD as an option...Hang in there until the "look back" period is satisfied.

      Comment


        #4
        want to point out that...

        the case I cited in Lawson v. Fortis Insurance Company, involved pre-ex for denied Medical Claims, not LTD, and it was a non-ERISA case, meaning it was probably an individual medical policy versus group LTD coverage from an employer.

        ERISA is a federal mandate that protects employer group 'plans' from miss appropriating assets for any purpose other than to fund the group 'plan', and pay eligible claims for the group of employee participants.

        As a consequence of federal efforts to protect 'plan' assets for all employee participants, recovery for damages by an individual participant are limited=attorneys not particularly interested in the limited paycheck an ERISA case will provide. ERISA litigation is expensive, requires legal expertise and the damage recovery/paycheck is limited by federal statute.

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