LTD Policy

nryanh94

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Not sure if anyone on here is legal minded:

my Group long term disability policy reads as this: “No benefit is payable for any disability that is caused by or contributed to by a pre-existing condition and that starts before the end of the first 12 months following your effective date of initial coverage.”

to me that reads that if I claim benefits after 12 months of work then the preexisting condition is covered, though I wanted to see if others concurred
 

nryanh94

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Could mean that if your condition arises during the first 12 months of the beginning of your coverage you cant claim. So if your health problem started 12 months after your policy started you can claim.
Thanks, I assumed if that was the intent it would say OR rather than AND. I’m not certain though. Guess I’m just trying to see if I’m screwed in regards to disability :)
 

Gingergrrl

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my Group long term disability policy reads as this: “No benefit is payable for any disability that is caused by or contributed to by a pre-existing condition and that starts before the end of the first 12 months following your effective date of initial coverage.”
I read the word "and" as meaning that BOTH issues must exist in regard to the timing for your LTD policy to deny your benefits.

What I mean is that:

1) They will not pay a benefit for any illness/disability that existed PRIOR to getting the LTD policy, so it must be a new issue (or they must believe that it is a new issue).

AND

2) Your medical claim that you submit to the policy cannot start within the first 12-months that you have the policy. Meaning that if you (hypothetically) got the policy on Jan 1, 2020 and submitted your first claim in LESS than 12 months, they would deny it. So you could not submit a claim prior to one year which would be Jan 1, 2021 (with the hypothetical dates that I just made up).

I could be totally wrong, and I would actually consult with a disability attorney if I were in your shoes, but I read it as it must be a NEW medical condition AND it must be at minimum 12-months after you got the policy.

Also, if you are going to discuss specifics of your LTD policy, I would switch this to a members only thread (for your privacy and protection).
 
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I would read the policy as follows: No monetary outlay can occur under the policy for a disabling condition if BOTH of the following conditions are satisfied: (1) the disabling condition can be attributed in whole or in part to a condition that existed prior to the policy’s inception date, AND (2) the disabling condition arose during the first twelve months of coverage

Example: I purchase the policy of January 1st 2021. I become disabled on March 1st 2021. I am covered as long as the disability isn’t due to some condition that existed prior to my coverage under the policy.

Disclaimer: This is not legal advice and should not be construed as such. I am not licensed to practice law in any jurisdiction. Any decisions regarding legal recourse should be made in consultation with a properly credentialed member of the bar whose membership status is active.
 

minimus

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I interpret the language the same way you do, @nryanh94. That language probably exists so the insurer does not have to pay claims to new employees.

As far as applying for disability, I recommend contacting disability lawyers familiar with ME/CFS, as some will give you a free phone consultation to review your policy and your case and depending on the lawyer, try to sell their services. You can also talk to Linda Nee, who is a disability consultant, but I found her to be incredibly pessimistic, saying my application would be denied if my diagnosis is ME/CFS (which was not correct.)

I personally hired Andrew Kantor of Kantor & Kantor, who offered to charge a fixed upfront fee to act as the go-between with my insurer throughout the initial disability application process. He and his paralegal helped retrieve all my medical records, reviewed all required documents before they were submitted to the insurer, submitted them to the insurer on my behalf (which signaled to my insurer that I had "lawyered up" and that rejecting my claim would likely lead to further legal action), and listened in on phone interviews by insurance company claims managers. I don't know if he is willing to charge a one-time application fee with every client, but he was worth the money in my case.

Unfortunately, I found that some lawyers used the phone consult to argue that my application for disability due to ME/CFS would be doomed unless I hired them on a contingency basis, at a cost of 33% to 40% of all payments and awards obtained from the insurance company. Personally, that seems usurious. This was true of Stuart Sandhaus and Steven Krafchick. Scott Reimer has a combination of upfront fees and contingency fees, which make him quite expensive.

Finally, if you haven't read it, the attached paper by Dr Richard Podell and Barbara Comerford, a disability lawyer, describe the ins/outs of the disability application process for disabled ME/CFS patients.
 

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@minimus do you plan to or did you do a cpet test? I talked with Barbara Comerford and of course she really recommended this. Like others am concerned about how it will worsen my condition. Also I’m in MS, so I don’t know if I could even make it to Workwell or NY to have one done anyway.
 

minimus

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@minimus do you plan to or did you do a cpet test? I talked with Barbara Comerford and of course she really recommended this. Like others am concerned about how it will worsen my condition. Also I’m in MS, so I don’t know if I could even make it to Workwell or NY to have one done anyway.
@Breagjam - Every disability lawyer I spoke to recommended undergoing the 2-day CPET except Andrew Kantor. I didn’t and couldn’t do it, as I had become too severe. But as my health was heading downhill from mild/moderate to severe/housebound ME, I did get an iCPET done by David Systrom. This was right around the time I had to stop working. I later talked to Betsy Keller, who does 2-day CPETs for ME patients at Ithaca College, and she said that in her limited experience, the iCPET provides even more convincing medical evidence of disability than the 2-day CPET because some insurers still try to dismiss the results of 2-day CPETs by arguing they reflect deconditioning.

I guess I would advise getting a neuropsych evaluation from an ME-literate psychologist, a tilt table test, and a skin biopsy for small fiber neuropathy first. Personally, I will not be getting a 2-day CPET in the future. I hope that if my insurer terminates my benefits, my existing medical records will help me either get them reinstated on appeal or win a lawsuit. As for you, it might make sense to apply for disability and see what happens. If you get approved, there is no need in the near term for a CPET. If you get denied, then decide whether the CPET is worth it. My sense is that if you have mild/moderate symptoms and are stable, the CPET won’t permanently make you worse. But if you are not stable and on the more severe end of the spectrum, it’s a tough decision and one to make down the road.
 
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@Breagjam - Every disability lawyer I spoke to recommended undergoing the 2-day CPET except Andrew Kantor. I didn’t and couldn’t do it, as I had become too severe. But as my health was heading downhill from mild/moderate to severe/housebound ME, I did get an iCPET done by David Systrom. This was right around the time I had to stop working. I later talked to Betsy Keller, who does 2-day CPETs for ME patients at Ithaca College, and she said that in her limited experience, the iCPET provides even more convincing medical evidence of disability than the 2-day CPET because some insurers still try to dismiss the results of 2-day CPETs by arguing they reflect deconditioning.

I guess I would advise getting a neuropsych evaluation from an ME-literate psychologist, a tilt table test, and a skin biopsy for small fiber neuropathy first. Personally, I will not be getting a 2-day CPET in the future. I hope that if my insurer terminates my benefits, my existing medical records will help me either get them reinstated on appeal or win a lawsuit. As for you, it might make sense to apply for disability and see what happens. If you get approved, there is no need in the near term for a CPET. If you get denied, then decide whether the CPET is worth it. My sense is that if you have mild/moderate symptoms and are stable, the CPET won’t permanently make you worse. But if you are not stable and on the more severe end of the spectrum, it’s a tough decision and one to make down the road.
Thank you so much! I am scheduled to speak with Andrew Kantor today and this gives me some additional questions to discuss with him. The iCPet is a good option to pursue. I’ve applied for disability and am waiting the initial decision, but getting a sense of what my game plan will be (I’m fairly certain I’ll be denied) helps me feel more prepared.