Here is a very frequent reader question, “Does short-term disability insurance cover pre-existing health conditions?”
The people most likely to ask this question do not presently have coverage in force.
Therefore, the first part of our answer addresses whether you qualify to buy a new policy when you already have a medical disorder. Some people can, but many more cannot.
The second part of the answer relates to when you can file a claim for benefits, provided you qualify to purchase short-term disability, given your pre-existing condition. Most policies also contain a 12-month exclusion period.
Buying Short-Term Disability with Pre-Existing Conditions
People sometimes can purchase short-term disability insurance to cover a pre-existing health condition. It often depends on where you obtain the coverage, and the type of medical problem in question.
Group policies sold at the worksite offer the greatest flexibility. Carriers sometimes agree to guarantee-issue coverage. This means they will approve all takers, regardless of any predated disorders. They may make this offer when a certain percentage of employees enroll or log into the carrier’s enrollment system.
Apply for a short-term loan for help paying bills until you can return to work. Plans sold directly to individuals often have much stricter underwriting criteria.
Many people will be unable to purchase individual short-term disability when they have a pre-existing illness – although some can if they have minor issues. You must be healthy enough to qualify for new coverage. The agent will ask a series of medical questions. Expect the most intrusive questions for the highest level of coverage.
- Shortest elimination period
- Longest payment duration
- Highest monthly benefit amount
Every company utilizes different underwriting criteria. One company may reject an application from a person already suffering with an illness while another might approve a limited policy. Here is a sample application question that “knocks out” any “yes” response.
In the past 5 years have you received medical advice,
sought treatment or taken medication
for any of the following.
|Heart Attack||Heart Surgery||Heart Disease|
|High Blood Pressure||Stroke||Transient Ischemic Attack|
|Emphysema||Lung Disease||Liver Disease|
|Multiple Sclerosis||Chronic Fatigue Syndrome||Fibromyalgia|
|Intestinal Disease||Alcohol or Drug Abuse|
Request a health insurance quote if you already have one of these medical issues. You do not qualify for short-term disability. However, under Obamacare, you may be able to obtain immediate coverage with no waiting period. If you lost your job because you are unable to work, you may be eligible for a special open enrollment period.
The same logic applies when buying short-term disability with a pre-existing injury. You will not meet the underwriting criteria if you missed more than five consecutive days of work in the last 12 months because of an accidental injury – whether it occurred on or off the job.
You also will not meet the underwriting criteria if you received medical advice, sought treatment, or took medication for any accidental injury causing problems with your muscles, back, or joints.
Nothing prevents you from purchasing short-term disability with a pre-existing pregnancy. Most carriers do not ask any pregnancy-related questions on the application – although some might. Every company is different. Shop around.
The policy will cover future accidents, illnesses, and your next conception – but not your existing pregnancy. Expect to find specific limitations language similar to this.
- We will not pay benefits for normal labor and delivery, including Cesarean in which conception occurred prior to the 30th day after the effective date.
- Complications of pregnancy will be covered to the same extent as any other covered sickness.
As you will soon read, “any other covered sickness” is excluded if the loss begins during the first 12-months of the policy effective date. Every gestation resolves itself about 3 months shy of this critical limitation date.
Applying for Benefits with Pre-Existing Health Conditions
Applying for short-term disability insurance benefits to cover a pre-existing health condition occasionally works. Of course, the information in this section pertains only to those readers who have an active policy already in force. This means you completed an application form, answered the medical questions, and the company agreed to issue the contract before you file a claim.
Read the policy exclusion period legal wording to determine if the issuing company is likely to approve or deny your claim for benefits.
The short-term disability pre-existing condition exclusion period legal language determines when you can file a claim for benefits. In most cases, you can file when the loss begins 12 months after the coverage effective date.
Patients with pending elective surgeries sometimes find the timing constraints acceptable.
Here is a sample exclusion period legal clause. You may find a similar statement in your contract. Read your outline of coverage carefully. Look for a similar two-part prohibition.
- If you become disabled because of a pre-existing condition, we will not pay for any loss if it begins during the first 12 months the policy is in force.
- A pre-existing condition means having a sickness or physical disorder or which you were treated, received medical advice, or had taken medication within 12 months before the effective date.”
Short-term disability claims denials are commonly related to pre-existing conditions. Many people become very motivated to purchase coverage when they become symptomatic, or their doctor starts ordering follow-up diagnostic tests, or when a diagnostic test comes back positive, or when the surgeon suggests they undergo the knife.
This very human tendency to wait until we already have a medical problem results in two very common forms of denials.
- The company denies a new policy application because the applicant is not healthy enough to pass underwriting standards.
- The company denies the claim for benefits because the policyholder’s loss begins within 12 months of the effective date.