Pre-existing Conditions and Mental Health Claims

A pre-existing medical condition is one which you experienced prior to becoming covered by insurance. If you become disabled within a specified period after becoming covered for long term disability benefits, and your disability was one for which you were receiving treatment at the time you became covered, your claim may not be payable. For a general discussion on pre-existing condition exclusion clauses, please see our post on that topic.

This post addresses special considerations regarding mental health claims and pre-existing condition clauses. The reason for this clause is best illustrated by comparing a physical and mental disability and the way some insurers will consider pre-existing conditions.

The Physical Disability and Pre-existing Condition Clauses:

Fact Situation:

Sarah starts work on March 1, 2024. After a waiting period of 3 months, she becomes covered for long term disability benefits on June 1, 2024. Sarah had a badly sprained ankle when she became insured and was taking Tylenol 3 for pain. On November 20, 2024, Sarah falls down the stairs and breaks her shoulder. She is prescribed Tylenol 3 for pain. The insurer completes a pre-existing condition investigation because Sarah becomes disabled within the first 12 months of coverage. The insurer reviews Sarah’s medical records at the time she became covered and quickly concludes that Sarah’s long term disability claim is not related to her ankle injury. The insurer and pays her disability claim.

Key points:

• Sarah is taking the same medication for two unrelated conditions at different times.
• There is no reason to exclude the shoulder injury as a pre-existing condition.

The Mental Health Disability and Pre-existing Condition Clauses:

Fact Situation:

John starts work on March 1, 2024. After a waiting period of 3 months, he becomes covered for long term disability benefits on June 1, 2024. John has suffered from depression for many years which is controlled by an antidepressant medication Cymbalta. John’s depression is not disabling and he has never missed work as a result of the condition. On November 20, 2024, John experiences shortness of breath, difficulty focusing and cannot sleep. John is diagnosed with a generalized anxiety disorder. He continues to take Cymbalta and is referred for Cognitive Behavioural Therapy. He makes a claim for disability. The insurer completes a pre-existing condition investigation because John became disabled within the first 12 months of coverage. The insurer reviews John’s medical records at the time he became covered and concludes that John’s long term disability claim is caught by the pre-existing condition exclusion. John’s disability claim is denied.

Key points:

• John is taking the same medication for two unrelated conditions at different times.
• There is no reason to exclude the generalized anxiety disorder as a pre-existing condition.

 Why would an insurer exclude the mental health claim?

If we examine the following clause and the above fact situations, it seems obvious that both John and Sarah have pre-existing conditions which do not cause the disability. Therefore, both claims should be payable.

“No benefits will be paid for:

Disability arising from a disease or injury for which the person obtained medical care before he became insured. Medical care is considered to be obtained when he consults a doctor, uses medication on the advice of a doctor, or receives other medical services or supplies.

This exclusion does not apply if disability starts after:

• He has been continuously insured for 1 year; or
• He has not had medical care for the disease or injury for a continuous period of 90 days ending on or after the date his insurance took effect.”

The reason an insurer would exclude John’s claim is simply this:

• No effort is made to differentiate the disabling mental health diagnosis from the pre-existing health condition.
• The insurance adjudicator reviews the literature for the medication in the mental health claim (Cymbalta) and sees that the medication is used to treat both depression and generalized anxiety disorder and denies the claim.

Conclusion:

Sadly, while mental health claims should be given the same care in adjudication as physical health claims, many claims are denied unfairly. A more careful, thoughtful examination of John’s claim would have revealed two entirely different conditions with different symptoms and impact on his ability to work. This is the type of analysis that an experienced disability lawyer like those at Burn Tucker Lachaine PC will undertake when you consult with us.

For advice please text 613-777-0992 or contact us through our website to schedule a meeting with one of our lawyers.  We provide a free consultation, in French or English, to ensure that your rights are protected.   In most cases, we can offer to represent you on a contingency fee basis.  This means that you do not pay legal fees unless you win or achieve a settlement on your case.

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