This article contains general information and is not legal advice. For qualified legal advice, please call 604-876-7000 to get in touch with a BC Disability Insurance Lawyer near you.
*Please note that if you are a union employee and are subject to a collective agreement that references a disability insurance plan, you should immediately discuss your claim with your union representative. Our firm may not be able to assist in these situations. Limitation periods can be very short—sometimes weeks—when a union grievance process is available.
If your disability insurance claim was denied because of a pre-existing condition, you may have more options than you realize.
Pre-existing condition denials are among the most common reasons insurers reject long-term disability (LTD) claims in British Columbia. For many people, receiving a denial letter that references a prior diagnosis or past medical history can feel confusing, almost contradictory.
The truth is simple: insurers don’t evaluate disability insurance claims based on medical proof, they evaluate based on the policy. In other words, your claim won’t always go through, even if you are — from a medical standpoint — unable to work.
Understanding how these clauses work is an important first step for anyone with a pre-existing condition looking for disability insurance coverage..
What Is a Pre-Existing Condition in Disability Insurance?
For disability insurance, a “pre-existing condition” refers to a health condition that existed before your coverage began, or before a specified look-back period defined in your policy.
What many people don’t know is that different insurance policies define pre-existing conditions differently, and the exact wording matters significantly.
Some policies define a pre-existing condition as any condition for which you received treatment, consulted a physician, or had symptoms within a certain number of months before your coverage started. Across different policies, you may find the definition more broad or more specific.
Generally, for pre-existing conditions, insurers examine:
- Whether you had symptoms, even if undiagnosed
- Whether you sought treatment or medical advice
- Whether a prescription was issued
- Whether a formal diagnosis existed before coverage began
A condition that qualifies as pre-existing in one plan may not qualify in another, which is why we recommend referring to your policy directly for more information.
If you’re having trouble reviewing your disability benefits policy, please contact our lawyers for assistance. These insurance policies tend to use complex legal language, but we can help simplify it for you.
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Why Disability Claims Get Denied for Pre-Existing Conditions
When a disability claim is filed, insurers typically conduct a review of the claimant’s medical history. This may involve requesting records from your family doctor, specialists, and pharmacies. The information requested can go back as far as several years.
If the insurer concludes that your disabling condition was present, symptomatic, or being treated before your coverage began (or within the policy’s look-back window), they may apply a pre-existing condition exclusion to deny or limit your benefits.
This denial does not always mean the matter is final or without question. In some situations, the insurer’s interpretation of the medical evidence may not accurately reflect the clinical picture. In others, the policy language itself may be more limited in scope than the denial letter suggests.
How Pre-Existing Condition Clauses Work in BC
Most group LTD policies issued through employers in British Columbia include some form of pre-existing condition limitation. Pre-existing conditions aren’t defined by severity, but rather timing.
- The look-back period refers to a window of time before your coverage start date. It varies by policy, but anywhere between three to twelve months is common. If you had symptoms, sought treatment, or were diagnosed with a condition during this period, the insurer may classify it as pre-existing.
- The exclusion period is the amount of time you must be continuously covered before a pre-existing condition becomes eligible for benefits. Many policies provide that once you’ve been covered for a certain period (commonly 12 months) even a pre-existing condition may be covered if you remained treatment-free or symptom-free during that window.
The interplay between these timeframes can be complex, and whether an exclusion applies may depend on a careful reading of the policy alongside your treatment history.
Does a Prior Diagnosis Automatically Disqualify You From Disability Benefits?
A prior diagnosis alone does not automatically mean your claim will be denied or that an exclusion applies. What matters is how the policy defines a pre-existing condition and whether your situation actually meets that definition.
Here’s an example: Jackson is diagnosed with anxiety several years before starting a new job. He received treatment, stabilized, and had no active treatment or significant symptoms for an extended period before his coverage began.
If he later became disabled due to anxiety, whether the pre-existing condition exclusion applies would likely depend on:
- The specific look-back period in their policy
- Whether they were actively receiving treatment during that window
- How the policy defines treatment or consultation
- The medical records available
What to Do After a Disability Claim Denial
- Get legal advice from a Dyson Law lawyer: It’s important to get legal advice as soon as you can. In BC, you have 2-years after you were first notified of the denial to sue. Failing to meet this deadline means your claim is lost forever. We recommend getting a lawyer involved to start building your case as soon as possible.
- Read the denial letter carefully: The letter should specify the reason for denial and reference the policy language being applied, which is helpful information for your case.
- Obtain a copy of your full policy: If you don’t already have a complete copy of your disability insurance policy, request one. Pay particular attention to how “pre-existing condition” is defined and what look-back and exclusion periods apply.
- Request your claim file: In many situations, you have the right to request the information the insurer relied on for making the decision, including the medical records it reviewed.
- Gather your own medical records: Collect and document your treatment history to assess whether the insurer’s characterization of your medical background is accurate.
FAQ: Common Questions About Pre-Existing Condition Denials
Can you get LTD benefits if you have a chronic illness?
In some situations, yes. Whether a chronic illness affects your eligibility depends on when the condition became active, when your coverage started, whether you’ve satisfied the exclusion period, and the specific language of your policy.
Can an insurer deny a claim because of past treatment?
Yes, this is one of the most common bases for pre-existing condition denials. Insurers often examine prescription records and physician visit history to determine whether treatment occurred during the look-back period.
Every claim is different, and the right starting point is understanding your specific situation. If you have questions about a denied LTD claim or want to better understand your options, consider reaching out to Dyson Law Corp for a consultation.