Employer sponsored long-term disability (LTD) policies, governed by the Employee Retirement Income Security Act (ERISA) commonly include pre-existing condition exclusions, where a policy holder is ineligible for disability benefits for a preexisting condition they had symptoms of, treatment for, or a diagnosis during a look back period of typically 3-12 months before coverage began (typically hire date). Insurers review medical records for symptoms, treatments, or consultations during the look back period linked to the current disability claim to make a determination.
For example, say an employee hired January 1, 2026 (policy start date) requests LTD benefits in March 2026 for an issue that they received treatment for in October of 2025. If the policy look back period is 6 months (June 30, 2025 – Dec 31, 2025) and the exclusion period for treatment of a preexisting condition is 12 months, the employee is likely ineligible for LTD benefits.
Most employer sponsored group LTD policies have an exclusion period of 12 months after coverage begins. Many wonder if the exclusion clock resets if they seek ongoing treatment for the same issue that occurred during a look back period. Policy language matters, but typically treatment or ongoing care during the 12 month exclusionary period does not automatically extend or restart the exclusion as long as the employee does not file a disability claim within that window. The “safe harbor” is generally based on time elapsed since coverage started assuming the employee is actively at work/continuously covered for the full 12 months.
How LTD Denials Work in Practice
Insurers apply exclusions broadly. If an employee received treatment, care, or had symptoms for any condition during the look-back that can be construed as “causing, contributing to, or resulting in” the disability within the exclusion period benefits may be denied.
Common triggers for denial may include medical records showing doctor visits for related symptoms (even if undiagnosed), prescriptions, or tests; however, courts may require specific suspicion or treatment for the exact condition, not just vague symptoms insurance companies might deem related.
Denials are frequent early in coverage, but not automatic and many are overturned on appeal if the link is weak or policy language is misapplied.
Step-by-Step Process to Challenge a Denial
When your long term disability benefits are denied, it is crucial to enlist the help of an experienced ERISA/LTD denial attorney who will:
- Review your denial letter
- Note exact policy language, look-back period, timelines, and appeal deadlines (often 180 days for ERISA plans)
- Request the full claim file (all records, reviews, and rationale) in writing
An ERISA attorney will gather compelling evidence to file an appeal including; but not limited to:
- Medical records and timelines, proving the disabling condition was diagnosed/treated after coverage or unrelated to prior issues
- Physician support letters stating “The current disability is not related to any pre-existing condition” or “Symptoms during look-back were for a separate, resolved issue” as examples
- Specialist opinions that differentiate conditions that the insurance company is lumping together (e.g., shoulder pain from exertion vs. later-diagnosed cancer)
- Your attorney will include documentation noting normal functioning before disability onset
With the evidence gathered, an internal appeal will be filed on your behalf adhering to strict deadlines:
- Your attorney will submit a detailed letter with evidence, citing policy terms and why the exclusion doesn’t apply
- Insurers must provide a full explanation of any upheld denial
- A second level internal appeal may be filed if required. If that fails, an external review or lawsuit under ERISA (for group policies) may ensue.
Important Considerations
Exact Policy Wording Matters: Some policies require treatment specifically for the disabling condition (not just any back pain). Others are broader. It is important to review the specific plan document (Summary Plan Description) for the exact definitions. That said, courts sometimes require a clear link or suspicion of the exact condition during the look-back period.
After 12 Months: If the employee in our scenario had continued working and filed the claim after ~Jan 1, 2027 (12 months of coverage), the pre-existing exclusion typically no longer applies, even with prior treatment.
Appeals Are Absolutely Viable: Many LTD denials are overturned with strong medical evidence showing the current disability is distinct, progressed significantly after coverage, or that prior treatment was for an unrelated/minor issue.
Contact Our Long-Term Disability Claim Denial Attorney for Guidance
Our experienced employment law attorneys have concentrated for decades on ERISA claim denials. We will guide you through the process of long-term disability claim denial for of a pre-existing condition. Our attorneys will analyze the policy language, carefully review your medical records, and build a successful appeal arguing the exclusion does not apply in order to secure needed LTD benefits. When you have been denied long-term disability benefits due to a pre-existing condition, contact the law office of Alan C Olson & Associates for immediate assistance at 262-785-9606.
