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Thread: Pre Existing Conditions on Long Term Disability Policy HELP

Created on: 09/06/11 01:09 PM

Replies: 12

DisabledPgh


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Joined: 09/06/11

Posts: 6

Pre Existing Conditions on Long Term Disability Policy HELP
09/06/11 1:09 PM

I am recently disabled, and have applied for long term disab thru my prior employer.

Company is Sun Life. (Insurer)

My current diagnosis is 300.02 (Generalized Anxiety Disorder) and 296.33 ( Depression)

Spoke w/ Sun Life today, they are saying they can go back 1 year prior on pre existing conditons to deny me, they are currently underwriting the file, no decision made yet.

One year prior from January 1, 2011.

I last saw my PCP December 2009, she diagnosed me with 300.00 (Anxiety state) and 401.9 (hypertension).

She prescribed Xanax, which I am presecribed now from my current psychiatrist treating me.

In the insurance clause : It states " Pre Existing Conditon means during 12 months prior to your Effective Date of Insurance, you received medical treatment, consultation, care or services, or took prescribed drugs or medicines for the disabling condition.

MY QUESTION: Do you think they can call this a pre-existing condtions: GIVEN the AXIS CODES are DIFFERENT, but I am taking and took Xanax.

Need some major help/insight here....

Thanks

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nursingangel


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Joined: 06/14/03

Posts: 1,918

Pre Existing Conditions on Long Term Disability Policy HELP
09/07/11 6:44 AM

It is my (nonprofessional) opinion that anxiety is anxiety and that the LTD company will likely argue that anxiety is, in your case, a pre-existing condition. It would be pretty hard for you to argue that a diagnosis of anxiety is not related to a diagnosis of Generalized Anxiety Disorder. Even the codes would support their position: one code is just a subset of the other.

However, rather than take their word for your contract conditions, have you read the LTD plan yourself? If you don't have a copy of the complete plan, you should obtain one right away and see for yourself what the pre-existing conditions clause says.

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DisabledPgh


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Joined: 09/06/11

Posts: 6

Pre Existing Conditions on Long Term Disability Policy HELP
09/07/11 10:20 AM

Thanks for the reply:

Here's what the clause basically says:

For the PreExistiting condition: If I saw a doctor or clinical person etc, in the 12 months prior, it would disqualify me. I DID NOT see or have an appointment with anyone in that time period.

However: Prior to the 12 months, my doctor had prescribed light drugs (Lexapro/Xxanax), but this was prior to the 12 months......

Any thoughts?

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DIclaimsguy


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Joined: 06/11/02

Posts: 364

Pre Existing Conditions on Long Term Disability Policy HELP
09/07/11 10:54 AM

If you had no treatment, etc. as defined by the policy's pre-ex language from January 1, 2010 to January 1, 2011 then it would appear your claim would not fall under the pre-ex exclusion. If I'm understanding your post(s) correctly your treatment and medication management occurred prior to January 1, 2010.

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nursingangel


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Joined: 06/14/03

Posts: 1,918

Pre Existing Conditions on Long Term Disability Policy HELP
09/07/11 11:08 AM

Did you take the Lexapro and Xanax as prescribed for anxiety during that 12-month period?

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DisabledPgh


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Joined: 09/06/11

Posts: 6

Pre Existing Conditions on Long Term Disability Policy HELP
09/07/11 11:10 AM

Correct:

From Jan 1 2010 thru Jan 1 2011: I did not see my PCP with whom they are requesting records from.
My last visit was December of 2009. So, technically during the 12 month period there were no office visits for anxiety.

I'm just concerned, this will be my only source of income for awhile. And,the verbage is very vague in the contract.

Even though she prescribed medications, I was not seen by the PC.

I also have multiple diagnosis: Depression, Panic Disorder with Agoraphobia, etc.. At that time it was General Anxiety, I was not housebound as I am now.

Any other thoughts? THANKS for the input, I appreciate it.

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DisabledPgh


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Joined: 09/06/11

Posts: 6

Pre Existing Conditions on Long Term Disability Policy HELP
09/07/11 11:13 AM

I did take Xanax and Lexapro during the 12 month period: but again: my condition at that time was general anxiety.

Current Diagnosis is Panic Disorder with Agoraphobia: I could leave my house and work at that time, I cannot at this time. Plus depression was not listed as a diagnosis as it is now.

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nursingangel


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Joined: 06/14/03

Posts: 1,918

Pre Existing Conditions on Long Term Disability Policy HELP
09/07/11 12:20 PM

I do not want to add to your anxiety level, but since you are asking, I must say that I think you are in for a battle with your claim. You may want to engage some counsel in filing your claim. An attorney with disability insurance claims experience; ERISA experience, if your claim falls under ERISA.

To deny that you were being treated for anxiety in the prior year simply because you did not physically set foot in the Dr's office will likely not hold much water, given that you were taking the prescribed "treatment" during that year. Again, your diagnoses are inter-related, even the depression. As you likely know, depression and anxiety go hand in hand in most cases. And what you describe as your current diagnoses and symptoms can logically be seen as the worsening of your initial diagnosis. An analogy could be a person who is diagnosed with multiple sclerosis based upon numbness and tingling in their lower extremities. A year later, the numbness and tingling might have progressed into difficulty with ambulation, but all symptoms are arising from the initial diagnosis.


And again, this is simply my nonprofessional opinion, which is why I urge you to seek professional help with your claim.

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DisabledPgh


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Joined: 09/06/11

Posts: 6

Pre Existing Conditions on Long Term Disability Policy HELP
09/07/11 12:35 PM

Thank you for your input.

I'm awaiting a decision now, and I do believe the policy falls under ERISA, they have 45 days to render a decision, so I will have to wait and see. I guess depending on the outcome, I'd have to seek legal advice and counsel.

My employer just moved me from a Disability Leave to a FMLA Leave.
I applied for Unemployment benefits but was denied, because I am "unsuitable" for work.
I don't know if I should appeal that decision either.

I have made appliation for SSDI, but we all know how long that does take as well......

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DisabledPgh


New Member


Joined: 09/06/11

Posts: 6

Pre Existing Conditions on Long Term Disability Policy HELP
09/07/11 12:37 PM

Also: Does anyone know : Can the Dis Insurance company contact my PRIVATE Health Insurance for records?
I have a personal paid policy, that I pay on my own, company never did, I was self employed for years and kept it.

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CatsRGreat


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Joined: 09/23/09

Posts: 38

Pre Existing Conditions on Long Term Disability Policy HELP
09/08/11 10:15 AM

my social worker says that her clients who worked thru the Lucinda Bassett program had great results for reducing their anxiety. You can get it cheap on ebay, used, if you can find a cassette player. You have to be sure the seller includes the workbooks. It won't fix the depression problems, but if you can get out of your home again, maybe the depression will improve enough that you can return to work.

You might be eligible for help from social services,depending on the generosity of your state and local government. There are other programs like food stamps and fuel assistance and weatherization that might help you financially until you get SSDI. Social workers know these programs. You have to ask about social workers for mental health problems to get the correct department to see if you can get one.

when I applied for LTD, my insurance company made a lot of assumptions about what was in my policy, without ever actually reading it. So they would say stuff like there is a 12 month disability exclusion, when my contract said 6 months, and stuff like that. Their assumptions were always in the company's favor.

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DIclaimsguy


Member


Joined: 06/11/02

Posts: 364

Pre Existing Conditions on Long Term Disability Policy HELP
09/08/11 6:52 PM

Based on your additional responses, IMO your claim may be denied due to pre-ex as you were taking medication (assuming you filled the RXs) for an anxiety condition that existed prior to the policy's effective date. I say this given the pre-ex language noted in your initial post. If you signed an authorization allowing the carrier to obtain records, etc. then they might obtain records from the health carrier. As NA previously suggested make sure to obtain the actual LTD policy from your employer.

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destroyer


Member


Joined: 05/01/08

Posts: 63

Pre Existing Conditions on Long Term Disability Policy HELP
09/10/11 7:00 PM

I don't think the appeal on Unemployment will work. My wife just applied for unemployment and one of the things is that you are available to work RIGHT NOW. It sounds like you are not. Your state may have disability benefits though.

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