Can I fight a pre-existing claim denial?
Pre-existing claim denials are something that should never happen. Most ERISA provisions contain the “3/12” pre-existing condition provisions. This provision states that if an employee goes out on disability within 12 months of the EDOC (Effective Date of Coverage), there is a three-month look back to determine whether the person took prescribed medications or consulted with a physician for the claimed disability. The EDOC of the Plan is not necessarily the Date of Hire, so people should look very carefully in their Plan to adjudicate what it actually says. The biggest mistake people make with pre-existing conditions is that they use Date of Disability not Effective Date of Coverage to determine whether they have a pre-existing condition.
Employees should be aware of what the pre-existing condition in their Plan says. If it is in fact the “3/12” provision, for example, employees should wait until they have worked 12 months beyond the EDOC of their Plan before filing. Then, there would be no danger of incurring a pre-existing condition investigation.
Pre-x can usually not be fought and won by any insured because the determination is generally “objective” and not “subjective.” It’s not a matter of someone’s opinion. Either there is medical proof of treatment or taking prescriptions during the three-month look back, or there isn’t. (Objective determination.) What are you going to fight?
Employees should just wait out the 12 months before filing a disability claim.
Attorneys have always shunned pre-x cases because they are very difficult to win. I can only think of two reasons why pre-ex denials could possibly be overturned. One is if the “ore-x period was miscalculated. When corrected there is no proof of treatment within the three-month look back period.
Pre-x situations can often become very complicated such as in the occurrence of a “Continuity of Coverage” situation when an employer switches to another insurer. In this case, there is usually a “Continuity of Coverage” provision describing who is pre-x and when. I’m not going to go into how the provisions are calculated, but it is possible to NOT be considered pre-x if an error was made.(I have no confidence whatsoever that the new untrained, non-English speaking claims handlers are capable of managing a “Continuity of Coverage” claim.)
Bottom line? Try to wait out the required 12-months after the EDOC before filing a disability claim. You won’t have any pre-x problems.
