What is the pre-existing condition exclusion in an LTD policy?

Pre-existing condition exclusions are a primary tool insurers use to deny claims in the first year or two of coverage. The exclusion typically works in two parts: a “look-back” period (usually 3 or 6 months before your coverage start date) and a “benefit-waiting” period (usually 12 months after coverage starts). If you received treatment for a condition during the look-back period, and that condition becomes the basis for a disability claim during the benefit-waiting period, your claim will be denied.

The legal fight is almost always over the word “caused.” Insurers routinely argue that a new, acute condition is “caused by” a previously diagnosed chronic condition even when the connection is tenuous. A lumbar herniation treated before coverage begins is not necessarily the cause of a new cervical disc injury after coverage starts, but insurers will make that argument aggressively in the administrative record.

Your treating physician’s records are the battleground. Medical notes that use language like “exacerbation of pre-existing condition” or “chronic history of” can inadvertently support the insurer’s position even when the treating doctor does not intend to suggest a causal connection to the disability claim.

If your claim was denied on pre-existing condition grounds, you have 180 days under 29 CFR 2560.503-1 to submit a written appeal challenging the causal nexus. We handle ERISA LTD appeals on contingency. No fee unless we win.