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LTD preexisting condition,Please post
Jul 18, 2001

Hello, Thanks for all your help and information. I have been on STD since feb,2001 for treatment of Hep C. The side effects are difficult for me and I'm unable to work. I have been employed with the same company since Aug,1998. When I first chose benifit options in 98,I had to elect a higher rate for STD to get close to what I make weekly. LTD was offered at 3 different options. Option 0 was no coverage, option 2 is 50 pay, option 3 is 60 pay. Option 2 was offered at no cost to the employee. This is the election I made. I received a comformation form from the benifits department and at first glance all my choices were listed. You can only change coverage once a year and if you don't make any changes by the cut off date, then your current options are enforced. I made no changes in 99 and last year 2000 I did go online to their secure web site and elect some vision and life policy changes. When you go through this on line process each aspect of the offered benifits are shown and you have a choice. I again chose to get the LTD option 2,(still at no cost to me.) and received notice that all my option and changes would be in effect on Jan.01,2001. The insurance company sent me a letter today authorizing my STD through the end of the july. This will be 17 days shy of the 180 days required to switch to long team disabilty. The insurance company is requesting information about my medical history 6 months prior to Jan.01,2000 taking the position that since the LTD was effective on Jan,01,2001 that any doctor visits, treatments, consultations,ect. related to my current disabilty between the months 8/01/2000 thru Jan,01,2001 would excuded me from LTD under the preexisting condition clause. When I reveiwed the conformation records sent to me for my initial enrollment in 98, the dollar amounts listed for LTD were enclosed in Quotations. I contacted the benifits department today and they explained that I was given a credit for those amounts as I did not elect the coverage. I tried to make the case that why would'nt I chose the covered option as the company was paying 100 of the cost, to no avail. My question is since I have been with the company for several years and have satisfied all probation and other waiting periods. Can they preclude my LTD benifits base on this start date of Jan.01,2001 for the LTD. My condition has been existing for the last 13 years. I treated in 95 with interferon and had not seen a Doctor about the Hep c until November of 2000 when I became ill. Also during my medical intake with the company I had to inform the company nurse of all preexisting conditions.( This may have something to do with the Quotation marks around the LTD coverage option I swear that I requested. just a side thought)Do you think I have any hope of security for the LTD. One other point. The LTD, if denied, would then require a 24 month waiting period to elapse before the Hep c condition could be picked up. At this point I'm hopeful that the doctor will give me good news in July and the treatment will be over. I'll then be able to get off the STD and return to work. But if the Geno type shows I need another six months of treatment, and the LTD is disqualfied for the above reasons, what can I do to support my wife and children during this final phase of treatment? Any advice you have is welcome. Thank you

Response from Mr. Berg

Yes, the coverage effective date is the all important factor in avoiding a denial of benefits due to a pre-existing condition. So, unless your company will admit their error and correct the date retro-actively, the insurance carrier can not pay your claim. Even if your employer tried to correct the date (unless they are self-funded), the insurance company probably would fight them on it. It's tragic that the benefits confirmation form is so vague. I really don't know if you have any legal grounds to fight on, but you might run it by a legal services organization. Did you keep a copy of your initial enrollment application showing that you attempted to circle or check or mark acceptance? Why was it that your benefit administrator ignored it? In terms of financial assistance, I suggest you apply for Social Security Disability Insurance benefits as soon as possible. Unfortunately, it can take 3 to 6 months for them to make a determination, but they pay retroactively back to the 6th month of disability (based on their disability onset date determination).



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