Important Notice Concerning New York Disability Claims and Pre-existing Conditions
January 14, 2008
Notice Concerning New York Disability Claims
Because of a recent court decision, Aetna, like many other group insurers, is identifying and reviewing disability claims that were denied based upon pre-existing conditions going back two years from June 27, 2007 (or three years depending on the applicable policy language.)
By April 30, 2008, Aetna will attempt to notify all affected claimants in writing of the result of this review and, where appropriate, will pay benefits due under the policy with interest. The court decision and this review apply to claimants under group disability insurance policies issued or issued for delivery in New York.
If your disability claim was denied based on a pre-existing condition, you may contact Aetna at 1-800-726-7777, Monday through Friday, 9:00 a.m. to 5:00 p.m. Eastern Time to find out if your claim is subject to re-examination.
In a recent Circular Letter, the New York Insurance Department provided important guidance on how New York's pre-existing condition statute 3234(a)(2) should be administered in light of the Court of Appeals decision in Benesowitz v. Metropolitan Life Insurance Company.
In Benesowitz, the court interpreted the New York pre-existing condition statute to mean that an insurance policy may impose a 12-month waiting period during which no benefits will be paid for a disability resulting from a pre-existing condition and arising in the first 12 months of coverage. The policy, however, may not permanently deny benefits because of a pre-existing condition. The court's interpretation has changed the way many insurers, including Aetna, will apply pre-existing condition clauses in their disability insurance policies.
Additional Details for Re-Examined Claims
Re-examined claims will be subject to a pre-existing condition waiting period and claimants will be required to furnish adequate proof of loss. In addition, all applicable policy provisions, limitations and exclusions will apply for any re-examined claim to the extent not prohibited by the Benesowitz decision.
Those insureds unable to demonstrate adequate proof of loss retroactively may nevertheless be eligible for disability benefits on a prospective basis, subject to the insured still being covered under the policy, providing adequate proof of loss and meeting all of the otherwise applicable rules and requirements for claims review under the policy.