There are some long term disability exclusions because long-term disability doesn’t necessarily cover every possible disability condition. When you purchase long-term disability insurance, you may believe you understand the coverage and your policy will cover you for most disability scenarios.
In fact, nearly all long-term disability policies have specific exclusions for certain conditions. Before you go through the process of applying for long-term disability benefits, carefully review your policy and understand what is and is not covered. You will want to understand the long term disability exclusions in your policy. If you are not sure, then you may want to consult with the Herren Law office in Houston, Texas.
What Is An Exclusion?
This is a clause in your policy that you probably agreed to when you purchased it, or you accepted the policy from your employer. An exclusion details a specific situation where the insurance company does not pay you any monthly income. The idea is to exclude coverage for claims that result from or are related to a pre-existing medical condition, or exclude coverage of any claim that could result from any potentially hazardous activities that can lead to the increased risk of potential disability.
Common exclusions include:
• Pre-existing conditions, which is a condition you already know you have prior to application. This may include some or all pre-existing conditions, depending on your policy.
• Work-related conditions, especially if your occupational injury or illness would otherwise be covered by worker’s compensation benefits.
• Specific health conditions such as cancer, heart disease, lung disease, or diabetes, are detailed in the policy.
• Hazardous or high-risk activities, such as injuries and conditions related to things like bungee jumping and other extreme sports
• A normal pregnancy and delivery
• Acts of war and conflict, such as a riot, insurrection, or another incident of violence
• Other criminal activities
• Self-inflicted injuries. Most policies do not cover any injuries that are self-inflicted or related to a suicide attempt.
Policies with more exclusions generally cost less. The more exclusions you reduce, the higher your premiums. Meaning if it covers more conditions, it will be more expensive as the chances of a claim will also increase.
Mental Health Conditions
Many long-term disability policies also limit or exclude mental health or nervous conditions. This means that if your disability is caused by or contributed to by a mental or nervous condition that’s in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), you may have no benefits or strict limitations on the benefits you can receive.
For policies that do allow for mental health condition claims for disability, the standard limitation is 24 months or two years. Depression, anxiety, stress, and even dementia have a strict 2-year limit in most policies for long-term disability benefits. If you are still disabled because of a mental or nervous condition following the two-year period after your benefit period ends, you will unfortunately no longer be eligible to receive benefit payments.
Alcohol And Substance Abuse
Similar to mental health conditions, many long-term disability insurance policies limit or exclude coverage for any disabilities related to alcohol and substance abuse. Some policies do not cover them at all, but other plans include limitations on how long you could receive benefits.
Handling A Denial
If you think your condition is not a long term disability exclusions, then you apply for benefits. But even if you are confident your condition is covered under your long-term disability policy, you may be surprised to receive a denial letter from your insurance company. Unfortunately, this is a common occurrence with long-term disability applicants. The good news is you have the right to appeal, so take advantage of it.
Read the letter carefully, and make sure that you understand why your claim was denied. It may be that you did not submit enough medical evidence, or there was something else missing from your claim application. The denial letter will tell you why, and what you need for your claim. However this may also be time to consult an experienced long term disability attorney like Bill Herren. Herren Law Office is a Houston, Texas-based law firm serving clients throughout the greater Houston area. With almost 30 years of experience, they’ve helped over 4,000 people with their disability claims. If you are trying to obtain SSD, LTD, or VA disability benefits, it is beneficial to get help as soon as possible from an experienced disability attorney.
The letter will also let you know about the deadlines for appealing the company’s decision. It is critical to make sure that you meet these deadlines or you’ll lose your right to appeal altogether.
If you believe your insurance company is acting in bad faith, this is also a reason to engage the services of an experienced disability attorney who can help you file your appeal. A good disability attorney understands how insurance companies work, particularly for claims where they will have to pay out money.
Your Houston Long Term Disability Attorney
If you need help filing a long-term disability claim, or are having trouble with the insurer paying your benefits, or need help preparing an appeal to a denial of benefits, we’re here to help.
We’ve helped over 4,000 Houstonians have received the LTD benefits they need. The Herren Law Firm can help you with your application, appeals and help you through the process, and give you one less thing to worry about. Contact us today at 713-682-8194 (or use our online contact form) to schedule your free consultation. There’s no obligation and no up-front fees. We only collect if we win your case.
