Guidance Needed for Potential Appeal of Lincoln Financial LTD Claim Denial in Nevada
I am seeking assistance with appealing the denial of my long-term disability (LTD) claim. My policy includes a Pre-Existing Condition Exclusion that outlines:
A “Pre-Existing Condition” is defined as a condition resulting from an Injury or Sickness for which the Covered Person was diagnosed or received Treatment within three months prior to the effective date of coverage. Any Disability or Partial Disability caused by, contributed to by, or resulting from a Pre-Existing Condition within the first 12 months post-coverage initiation is not covered.
During the lookback period, I was pregnant, but the complications I experienced post-C-section were due to a surgical error (an OB accidentally nicked my small intestine), not the pregnancy itself. My disability stems from complications resulting from the surgery, which began after the C-section and did not exist during the three-month period before my coverage started.
I am worried that my insurance provider might incorrectly label my situation as pre-existing due to my pregnancy, despite the fact that the complications arose from the surgery.
With this context in mind, I would like to know if I have a compelling case for appeal based on the following points:
- Pregnancy alone does not qualify as a “sickness or injury” as specified in the policy, and my disability is not directly linked to pregnancy.
- The complications leading to my disability occurred after my C-section and were due to a surgical error rather than any pre-existing condition from the pregnancy.
- I did not receive treatment for any pre-existing conditions (such as bowel issues or surgeries) during the three-month period prior to my coverage beginning.
I would greatly appreciate any advice on my chances of successfully appealing this decision and any important steps I should take to enhance my likelihood of a favorable outcome.
Thank you for your help and insights!
It sounds like you have a compelling case for appealing the denial of your long-term disability (LTD) claim, particularly based on the specific facts you’ve provided. Here are some key points and steps you may consider to help maximize your chances of a successful appeal:
Clarify the Definition of “Pre-Existing Condition”: You’re correct in emphasizing that your disability stems from complications resulting from a surgical error rather than a pre-existing condition linked to pregnancy. The definitions within your policy seem to support your position. Clearly state this in your appeal, backed by any medical documentation that describes the nature of your complications.
Gather Medical Evidence: Collect comprehensive medical records that document your pregnancy, C-section, and subsequent complications. Ensure there’s clear evidence from healthcare professionals stating that your surgery and its complications are distinct from any pre-existing pregnancy-related issues. Look for and include statements from multiple doctors, if possible, to bolster your claims.
Document the Timeline: Create a timeline that outlines your pregnancy, the surgery, and when complications arose. Highlight that all the complications post-surgery occurred after the effective date of your LTD coverage and were not present during the lookback period.
Consult with a Medical Professional: If possible, get a detailed statement from your surgeon or another relevant medical expert that explains how the complications were a result of a surgical error rather than a natural consequence of pregnancy. This professional insight can lend significant weight to your appeal.
Review Policy Language: Thoroughly review your LTD policy, focusing on the definitions and exclusions. Ensure that the insurance company’s interpretation of “Pre-Existing Condition” aligns with the actual wording of your policy when making your appeal. Look for any ambiguities that could be interpreted in your favor.
Cite Relevant Precedents: If possible, research any similar cases where appeals were successful in your state, particularly those involving complications from surgeries. Highlighting successful cases may provide further substantiation for your appeal.
Consult an Attorney: Since dealing with insurance claims can be complex, especially with pre-existing condition clauses, you might want to consider consulting with an attorney who specializes in insurance law or disability claims. They can guide you on how to navigate the appeals process and additional legal avenues should they become necessary.
Keep Accurate Records: Document all communications with your insurance provider. Take notes on phone calls, send letters via certified mail, and keep copies of all correspondence.
Follow Up Promptly: After submitting your appeal, monitor progress regularly. If you haven’t heard back in a reasonable timeframe, follow up with the insurance company.
By approaching your appeal with a well-documented case and a clear argument based on your circumstances, you increase your chances of a successful outcome. Good luck!