Pre-existing health conditions affect short-term disability when you buy insurance and when you file a claim.
Expect denials at both stages.
Pre-existing health conditions are still a thorny issue. The Affordable Care Act does not regulate income insurance.
Avoid exclusions by getting coverage before you fall ill, hurt yourself off the job, or become pregnant.
Take action today. Once you get sick or hurt, your options are limited to mandatory coverage and large employer groups, which are not available to everyone.
Obtaining The Insurance Policy
A pre-existing medical condition can lead to denials when buying a short-term disability insurance policy. The severity of the ailment and the coverage type determine whether you might qualify.
Government benefits can help low-income families reduce expenses if they cannot insure their income due to poor health history.
Individual Policies
Individual short-term disability policies are hard to buy with a pre-existing condition. The insurance company cannot pool risks with a large group. Expect the strictest underwriting guidelines with two policy types.
- Individual coverage obtained outside of employers
- Personal policies bought at the worksite through payroll deduction
One insurance company uses knock-out questions for individual policies, looking back five years. A yes answer means automatic denial. Have you received medical advice, sought treatment, or taken medication for any of these conditions:
| Heart Attack | Heart Surgery | High Blood Pressure |
| Heart Disease | Stroke | Transient Ischemic Attack |
| Cancer | Kidney Disease | Diabetes |
| Emphysema | Lung Disease | Liver Disease |
| Hepatitis | Cirrhosis | Neurological Disorder |
| Multiple Sclerosis | Chronic Fatigue Syndrome | Fibromyalgia |
| Intestinal Disease | Alcohol or Drug Abuse |
Group Policies
Group policies are easier to get with a pre-existing condition. The insurance company can pool risks with hundreds of your co-workers. The more employees insured, the more lenient the criteria will be.
One insurance company asks fewer knock-out questions for small-group policies. A yes answer leads to immediate denial.
- Have you missed five or more consecutive work days in the past 12 months for any injury or illness other than cold, flu, or maternity?
- Have you ever been treated for or diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or tested positive for Human Immunodeficiency Virus (HIV)?
- In the past 12 months, have you received medical advice, sought treatment, taken medication, or been hospitalized for cancer (except basal cell skin cancer), insulin-dependent diabetes, or cirrhosis?
Some insurance companies offer guaranteed issue coverage to large groups with thousands of employees. Sign up during the first available period at work. The guarantee expires after the initial enrollment period. Do not wait until you get sick, hurt, or pregnant.
Mandatory Programs
Mandatory programs are the easiest to get with a pre-existing condition because millions fund the premiums. However, these programs have significant gaps even though everyone gets coverage, regardless of health history.
- Only nine states require temporary disability benefits, and people working in the forty-one other states cannot enroll.
- States require employers to fund Workers’ Compensation on behalf of all employees. However, the insurance covers only on-the-job accidents and illnesses.
- The federal government requires workers to fund Social Security disability benefits through payroll taxes. However, the disability must last at least twelve months.
Filing Claims For Benefits
Pre-existing health conditions affect individual and group short-term disability claims. People covered by mandatory programs are unaffected.
Each insurance company has a unique legal language, but your individual or group policy might include these similar statements.
- Definition: A pre-existing condition means having a sickness or physical disorder for which you were treated, received medical advice, or had taken medication within 12 months before the effective date.
- Exclusion: If you become disabled because of a pre-existing condition, we will not pay for any disability period if it begins during the first 12 months the policy is in force.
Here are some examples of how these statements work for individual and group policies.
Pregnancy
Many women can buy short-term disability with a pre-existing pregnancy. Most companies do not ask maternity-related questions on new applications and often approve coverage.
However, two exclusions cause pregnancy-related claims denials:
- There are no benefits for a pre-existing pregnancy during the first twelve months of the policy.
- Normal childbirth has no benefits during the first nine months of the policy.
Joint Problems
Older adults with pre-existing joint problems can sometimes buy short-term disability coverage. Group policies often approve new applications.
However, you may need to wait twelve months before filing a claim for elective joint replacement surgery for an ankle, knee, or hip.
The policy should cover your recovery after you satisfy the elimination period, determining how quickly claim payments start.
Mental Health
Policyholders with pre-existing mental health issues will have different claims experiences based on their short-term disability policy type.
Most individual policies do not cover mental health problems, even after the exclusion period. Drug and alcohol rehab or losses from anxiety, depression, schizophrenia, and other disorders are not covered.
However, most state-mandated and many group policies include mental health coverage. Contact the agency or insurance company to verify.
Kidney Disease
People with pre-existing kidney disease need state-mandated or group short-term disability to get benefits while recovering from transplant surgery or on dialysis.
Kidney disease is a knock-out question for many individual policies, so people with nephropathy cannot get coverage. You cannot file a claim if you are uninsured.
Kidney disease does not stop employees from buying group coverage during the initial enrollment period. But if you decline the first chance, you may need to show good health later and will fail the criteria.
