One more question about LTD

[lstrl]

I filed for LTD in the beginning of the month, and I just received a letter in the mail that they want to do a pre-existing condition check starting November 2011. They want to know every dr I've seen, every hospital I've ever been to, and every pharmacy I've used between then and December 2012 (they've already got access to the December 2012 data and that won't be considered pre-existing since my policy started November 2012).

Clearly, I've had something going on that's been documented since July 2011. Back then, it was left arm numbness (that had no effect on my working). I did have a c-spine MRI that showed two lesions in October 2011, but that's before their cut off date, so I'm assuming they can't use it against me. I did have a brain MRI from January 2012 that they'll need access to, and I know it states that there are lesions possibly indicative of MS, but I had one done in 2009 that was identical and the neuro back then said they were too small and they were indicative of nothing. Each of the 3 neuros that have seen the 2012 MRI all said that it was nothing as well, so I would think if the insurance company tries to use that against me, it should be easily disputed.

I know my first neuro in 2011 won't have any data that should affect my outcome, but I'm concerned about neuro #2. She didn't take me seriously and did absolutely nothing for me, but even though I thought she didn't listen, she actually did document that I had new symptoms in mid-2012, particularly problematic for my case being left sided weakness. I have no idea what her notes say about it, but she only diagnosed me with transverse myelitis, and that would correlate to my left arm numbness I had with the c-spine MRI to back it up (that started before the pre-existing condition period).

All of the numbness disappeared by the time I saw her for my last visit in August and I had no new symptoms at the time (those didn't come until December). She also did an eye test that was negative and did a walk test each visit that I know was totally normal (and my first visit I wore sandals with a slight heel that I'd never be able to wear today without falling over). She never told me that any part of my exam was ever abnormal.

In all this time, I was never actually treated for anything. The pharmacy check will only reveal birth control pills and a pain pill rx when I sprained my ankle last summer when I stepped in a hole while mowing my lawn (interestingly enough though, it's the left side and that's the side I've had the most problems with, although it's totally unrelated). As for MRI data, all 3 neuros cleared my earlier brain MRI and the next set of tests I had was 12-31-12 that showed actual lesions (only 2 in the brain and both were enhanced by contrast and then the c-spine showed progression but nothing active). Those are current though and won't count against me.

What I'm wondering is, since all tests since 11-2011 were totally negative for MS, does anyone think I actually stand a chance at winning this? After all, the only tests the insurance company has access to that show any indication of MS would be my current MRIs that led to my diagnosis. Plus, I could have passed any neuro exam with flying colors up until 12-2012, when I could barely walk anymore.

[onlyairfare]

I think it is unpredictable. You may want to read the language of your policy very closely for some idea what their stance would be, and how you might craft any appeal, should they rule against you.

In retrospect it would be easy to say that the prior symptoms and lesions were signs of MS, so it is a pre-existing condition, thus the insurer does not have to cover you. However, your doctors did "more or less" say there was nothing significantly wrong with you prior to the diagnosis, or that the left arm problem was transverse myelitis, not MS.

I filed an STD claim for a complication of pregnancy totally unrelated to MS, that occurred before I was formally diagnosed with MS. I had deliberately avoided being diagnosed because of this sort of problem. But because my OB had made a single brief note that I had a symptom consistent with ON, my maternity claim was denied. I had to hire an attorney to get my claim paid, and then of course the insurance company cancelled my policy (I was self-employed at the time).

Most insurers would be performing the "look back" to find a reason not to pay your claim. It is certainly worth applying, and following any appeals process if necessary.

[quietposter]

I believe a pre-existing condition would be a documented condition. Where they never actually pointed to MS as THE condition (you were not officially diagnosed) during that time period, MS should not be considered as pre-existing.

However, you do want to check your plan carefully and ask your plan administrator for help in deciphering the plan. They can be very tricky and usually involve a narrow window of time in which something can be used to deny you.

[lstrl]

Thanks for the advice. I know my situation is on the border and could go either way, so it's nice to hear insight from someone else who may have dealt with this kind of stuff before.

I did print off some LTD info before my employer cut me off from their system (I'm no longer employed there as of 1-15) and the paper does state "in general, if you were diagnosed or received care for a condition before the effective date of your coverage, you will be covered for a disability due to that condition only if: you haven't received treatment for your condition for 365 days before the effective date of your insurance coverage." There are two other bullet points after that one, but they all state or instead of and, so only one has to apply.

When I read that, it sounds like I should be good, but do they consider me even seeing a dr as receiving treatment? Technically, I never received any treatment until this year because nobody believed me before then. I'm pretty sure the only reason the new neuro believed me though was because I finally had lesions in my brain. Nobody would proceed without any lesion activity in the brain, and that definitely wasn't present until 12-31-12.

[onlyairfare]

If the insurance company sticks to its language strictly, you were not diagnosed and you did not receive treatment for MS before the key effective date so you should be covered. The insurer may contend that you and/or your doctor(s) "knew or should have known" you already had MS, therefore they do not have to pay a costly LTD claim for MS disability. Nowadays there are usually questions on the insurance application like "Have you been recommended to have any tests for a disease?" to prevent a claim liability from someone who avoids a diagnosis.

In my case, I sort of did "know" I had MS (technically MS was suspected because I had ON once but I was not diagnosed), so I saw my physicians under the radar screen, paying cash so I would not create any traceable record of possible MS, just in case I actually did have it. I was doing that because if I held my policy for two or more years without a diagnosis or treatment, they could not deny any subsequent MS claims. I actually did go many years relapse-free and undiagnosed, but as a self-employed person supporting 3 young children and a husband in grad school, I couldn't afford to have my policy cancelled.

Insurance companies know that some patients will be like that, and the insurance company can save a lot of money if they ferret out some evidence of pre-ex so they can deny the claim. That will be much more profitable for them (remember I spent many years as a health insurance executive).

It's a sad situation in the US that we have to be so guarded in order to avoid financial catastrophe due to a disease like MS, but that is the way it is. And BTW, 38 years into this, I have never missed a day of work due to MS and I have never filed a disability claim for anything MS-related, though of course I paid premiums almost the whole time, except for the interval between the time I was cancelled and changed to a job with an employer-sponsored policy.