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What Are Some Common Disability Coverage Limitations?

Coverage Limitations

Many disability insurance policies exclude or limit coverage for certain types of conditions.  The applicability and impact of a limitation on your disability claim requires careful analysis of the policy language, facts of your case, and the applicable law.  Still, the following information may help you identify whether you have a potential coverage limitation issue.

Pre-existing condition limitation

A pre-existing condition limitation can exclude coverage for disabilities caused by conditions that you had, or for which you received treatment, before you were covered under the policy.

Mental Illness limitation

Commonly, long-term disability benefits for mental illness, such as depression or anxiety, are limited to 12 or 24 months. Exceptions are sometimes made for certain types of mental illnesses such as schizophrenia, dementia, and Alzheimer’s – if your policy exempts such conditions from the 12 or 24-month limit, you may be able to collect long-term disability benefits for much longer.

These restrictions are almost always included in group (ERISA) policies, as well as in many individual policies. With individual policies, however, you may be able to get this mental illness limitation removed if you pay a higher monthly premium.

Mental illness limitations can vary greatly.  Your claim may be wrongly denied or limited if you are disabled from a physical illness, but also suffer from mental illness.  If you are disabled due to a physical illness and also suffer from mental illness, you should consult with an experienced ERISA attorney as soon as possible.

Appropriate care and treatment

Most policies will not pay benefits unless you are receiving appropriate care and treatment for your disabling condition(s).  While that usually does not mean that you must engage in all possible therapies, you should be engaged in a course of therapy that is reasonable and expected to help your condition.  Failure to do so can result in a benefit denial or termination.

The terms of both group and individual disability insurance policies can vary greatly from policy to policy, so it is important to review your long-term disability insurance policy documents to determine what terms apply to your claim.