“Pre-Existing Conditions” Exclusions Live on In Disability Law

“Pre-existing conditions” clauses exclude coverage when a medical condition that manifested prior to the beginning of coverage causes disability soon after coverage starts. These clauses usually apply for the first 90 days to 12 months of coverage. While the 2009 Affordable Care Act outlawed these exclusions in health insurance plans they remain a feature of disability insurance.

What gets defined as a pre-existing condition can vary:

• Some policies focus on the existence of symptoms, defining a pre-existing condition as one “which caused symptoms within three months before the effective date of [the applicant's] insurance . . . for which a prudent person would usually seek medical advice or treatment . . . [and which] caused or substantially contributed to" the disability.” Roeder v. Guardian Life Insurance Co. (9th Cir. 2024).

• Others focus on the actual receipt of treatment, defining a pre-existing condition to mean “any condition for which you have done 3 months just prior to your effective date of coverage: [r]eceived medical treatment or consultation[,] [t]aken or were prescribed drugs or medicine[,] or [r]eceived care or services, including diagnostic measures." Tunkle v. ReliaStar Life Insurance Co. (M.D. Fla. 2024).

• Some have a version of both. Burleson v. Guardian Life Insurance Co. of America (C.D. Cal. 2024).

Common plan language states that disabilities “caused or contributed to” by pre-existing conditions are excluded from coverage.

• In Dowdy v. Metropolitan Life Insurance (2018), the Ninth Circuit held that “in order to be considered a substantial contributing factor for the purpose of a provision restricting coverage to "direct and sole causes" of injury, a pre-existing condition must be more than merely a contributing factor.”

• Applying Dowdy, the court has consistently held that “[t]o apply an exclusion for a disability that is ‘caused or contributed by’ a preexisting condition . . . the insurance provider must show that the disability was ‘substantially caused or contributed by’ the preexisting condition.” Haddad v. SMG Long Term Disability Plan (2019). There, evidence of a claimant’s pre-existing right-sided herniated disc was not established as a substantial cause of left-sided disabling symptoms.

Pre-existing condition exclusions are an all-or-nothing fight for coverage and often turn on ambiguous medical records focused on different problems. The exact wording of the clause matters in crafting an effective appeal or challenging a denial in court. If you’re facing a pre-existing conditions denial get legal help to understand and best defend your right to benefits.