Complex Situation re: Pre-Existing Conditions Clause

[Byram_Patrik]

I have a group policy. I was on short-term disability first and was unable to return to work after the 12 weeks were up, so my claim turned into a long-term claim. For long-term it was initially approved but then they came back under reservation of rights a few months later and denied it, citing pre-existing conditions. I didn't think that the pre-existing conditions clause applied, however, because the date of my long-term claim was post the 1-year policy holding period requirement. But they said that they could use the date of my short-term claim as the date of my disability, which was within the 1-year period (complex, I know...) Anyway, my question is: can they do this? How could they know that my short-term application date was definitively my disability date? Said another way, how could they know that I wasn't disabled long-term until the "transition date" from short-term to long-term? It seems to me that they can't, and they are only claiming this in order to cite the pre-existing condition clause and deny my claim.

I have an attorney who says appeal could go either way (gee, thanks for the expert insight), says policy language is ambiguous. Recommends going back to work for a period of time to negate the ambiguity altogether but that's FAR easier said than done. Further, I fear I'll be termed if I return to work, in which case I'll have no policy whatsoever. So, I'm learning towards appeal but want to know how much I should stress this point relative to other salient points.

Help?

I greatly appreciate any help anyone can provide - it really means a lot to me.

 

[leevena]

My initial reaction is the carrier is correct, but I would need much more information to make definitive answer, such as actual dates of disability, what pre-ex occurred and when, copy of plan documents, and more. Lacking that I would tell you to find an attorney if you believe you are right and appeal.

 

[Byram_Patrik]

My initial reaction is the carrier is correct, but I would need much more information to make definitive answer, such as actual dates of disability, what pre-ex occurred and when, copy of plan documents, and more. Lacking that I would tell you to find an attorney if you believe you are right and appeal.

I do have an attorney, please re-read my post. And re: "date of disability" ...that's the whole question. How do you determine that when you're dealing with a window of time? It's not like a light switch that toggles from off to on at a specific point in time.

 

[leevena]

I read that you discussed with an attorney. My point is that this situation is too complex to be discussed in this type of forum, there is too much information needed for any of us to give you a definitive answer. And since you already discussed with an attorney, whom you clearly do not have respect for, I suggested getting another one.

When these determinations are made they use information and dates of services. They appear to have information confirming a pre-existing condition that would allow for the declination of benefits. Did you have any type of expense or consultation during that time, because the carrier believes you did.

 

[somarco]

Have you discussed this with HR or just immediately went the attorney route?