Legal Guide

Can Pre-Existing Conditions Void Your Disability Coverage?

Many Albertans are shocked to learn that their disability claim was denied because of a 'pre-existing condition.' You've paid premiums for years, but your insurer suddenly says your medical history makes you ineligible for benefits.

Pre-existing condition clauses are among the most misunderstood and misused parts of disability insurance policies. Insurers rely on them to reject legitimate claims — often unfairly. But not every prior symptom or doctor visit voids your coverage.

As Alberta disability lawyers who once defended insurance companies, we know how these clauses work, when they apply, and how to challenge wrongful denials.

This article explains what pre-existing condition clauses mean, when they apply, and what to do if your insurer uses one to deny your claim.

This guide covers:

What pre-existing condition clauses mean

When they apply and when they don't

How insurers investigate pre-existing conditions

How to challenge wrongful denials

Alberta-specific rules and deadlines

What evidence strengthens your case

What Is a Disability Claim?

Disability insurance provides income replacement when illness or injury prevents you from working. In Alberta, most people are covered through:

Types of Disability Coverage:

Short-Term Disability (STD)Covers temporary medical absences (usually 3-6 months). Managed by your employer or insurer directly.

Long-Term Disability (LTD)Begins after STD or Employment Insurance (EI) sickness benefits end. Can pay monthly income until age 65 if you remain disabled.

Private or Individual Disability PoliciesPurchased directly by professionals or self-employed individuals. Often offer better protection but still contain pre-existing condition clauses.

Common Insurance Challenges in Alberta

Pre-existing condition clauses are a leading reason disability claims are denied. Typical insurer justifications include:

You received treatment for the same condition before coverage began

Insurers may claim any prior treatment makes the condition pre-existing.

Symptoms existed prior to your policy's effective date

Even minor symptoms can be used to deny claims.

Your current disability is related to a pre-existing illness

Insurers often stretch connections between past and present conditions.

You failed to disclose medical history on your application

Non-disclosure can be used to deny claims, even if unintentional.

Key point: These statements sound conclusive — but they often oversimplify or misrepresent your medical history.

What Is a Pre-Existing Condition Clause?

A pre-existing condition clause limits coverage for disabilities connected to a medical condition that existed before your policy started. Typical wording: "No benefits will be payable for a disability arising from a sickness or injury for which the insured received medical advice, diagnosis, care, or treatment within the 90 days prior to the effective date of coverage, unless the insured has been continuously insured for 12 months." This means that if your disability relates to a condition you were treated for within the look-back period, your claim may be excluded — but only under specific conditions.

The Look-Back Period

This is the period before your insurance coverage began (commonly 90 days, sometimes up to 12 months). If you sought treatment, medication, or medical advice for your condition during this window, the insurer may label it 'pre-existing.'

The Coverage Waiting Period

Once your insurance starts, the exclusion usually lasts for 12 months. If you become disabled from a related condition within this period, the insurer can deny benefits. After 12 months of continuous coverage, the exclusion typically expires.

Common Scenarios Where Pre-Existing Clauses Apply

New Employee Coverage: You start a new job and become disabled within your first year. The insurer checks medical history from 90 days before the start date. Lapsed or Restarted Coverage: If coverage ended and was reinstated later, the 'look-back period' for pre-existing conditions may reset. Change of Insurers: When an employer switches group plans, the new insurer reviews pre-existing medical history before assuming risk. Private Disability Policy Applications: You must disclose full medical history. Omitting information may lead to denial of future claims based on 'non-disclosure.'

What Counts as a Pre-Existing Condition?

Insurers interpret 'pre-existing' broadly. It's not just about diagnosed illnesses — even mild or unrelated symptoms can be cited. Examples insurers may classify as pre-existing: doctor visits for headaches before later developing chronic migraine disorder; occasional back pain before a herniated disc diagnosis; mild anxiety before a major depressive episode; minor knee pain before a significant joint injury. Alberta courts often reject denials where the insurer stretches the connection between past symptoms and the disabling condition.

When Insurers Wrongfully Apply the Clause

Pre-existing condition exclusions are strictly interpreted by Alberta courts, with any ambiguity resolved in favor of the insured. Situations where the clause shouldn't apply: the past condition was different from your current diagnosis; you hadn't been treated for that condition during the look-back period; the insurer's connection between old and new symptoms is speculative; your disability arose after the 12-month exclusion period; the insurer didn't properly disclose the clause when you enrolled. A lawyer can identify whether the denial was legitimate or based on overreach — and gather medical and legal evidence to challenge it.

When Pre-Existing Clauses Don't Apply

Even if you had prior health issues, you can still qualify for coverage if: you were symptom-free or treatment-free during the look-back period; your new disability stems from a different condition; you've had continuous coverage for more than 12 months; your insurer failed to disclose the exclusion clearly; the denial violates Alberta's Insurance Act or human rights legislation (e.g., disability discrimination).

How Insurers Investigate Pre-Existing Conditions

When you file a claim, the insurer will: review medical records from before coverage began; contact your doctor for prior appointment notes; search for prescriptions or test results during the look-back period; compare your past symptoms with current diagnoses. If they find any reference to a potentially related issue, they may deny the claim. But their conclusions are often medically inaccurate or legally unsupported.

Alberta-Specific Rules and Deadlines

Two-Year Limitation Period: You must start legal action within two years of the denial. Proof-of-Loss Requirement: Most policies require claim forms within 90 days of disability onset. Pre-Existing Clause Duration: Usually applies for the first 12 months of continuous coverage. Court Interpretation: Alberta courts interpret ambiguities in favour of claimants. Bad-Faith Denials: If an insurer knowingly misapplies a clause, additional damages may apply.

Evidence That Strengthens Your Case

To successfully overturn a pre-existing condition denial, you'll need clear and consistent evidence: Medical records – confirming the timing of onset and progression; Specialist reports – distinguishing new symptoms from prior issues; Functional assessments (FCEs) – quantifying work limitations; Treatment timelines – showing no connection to the look-back period; Doctor's opinion letters – clarifying that the disability began after coverage took effect.

Has your insurer denied your claim over a 'pre-existing condition'?

How to Respond if Your Claim Was Denied for a Pre-Existing Condition

Following these steps can help you challenge a wrongful denial and secure the benefits you're entitled to.

Get the Denial Letter in Writing

Insurers must explain the reason for denial and reference the policy clause they're relying on.

Request the Full Policy and Claim File

Ask for your group policy booklet, master policy, and any internal medical reviews the insurer used.

Review Your Medical Timeline

Identify whether you received treatment or advice during the look-back period — and whether it was truly related to your current disability.

Get Updated Medical Reports

Ask your treating physicians to clarify that your current condition is new, unrelated, or worsened after coverage began.

Consult an Alberta Disability Lawyer

We can determine if the clause was applied correctly, coordinate medical evidence, and challenge the denial through negotiation or legal action.

How a Lawyer Challenges Pre-Existing Condition Denials

A disability lawyer ensures the insurer's reasoning is examined under both medical and legal standards. Here's how we help:

Review Policy Language

Many clauses are ambiguous or inconsistently applied. We analyze the exact wording and how it should be interpreted.

Coordinate Medical Opinions

Doctors can clarify that your current condition is distinct or worsened after coverage began.

Challenge Insurer Assumptions

Insurers often overreach, linking unrelated symptoms to current disabilities. We challenge these connections with evidence.

Negotiate or Litigate

If needed, we pursue settlement or court action for wrongfully denied benefits.

Frequently Asked Questions

Conclusion

A pre-existing condition doesn't automatically void your disability coverage. Insurers often misapply these clauses or stretch them beyond their legal limits. If your insurer has denied your disability claim due to a pre-existing condition, you may still have a strong case — and we can help you prove it.

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"Pre-existing" means recently treated or related — not anything in your medical past.

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Alberta courts interpret ambiguous clauses in your favour.

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After 12 months of continuous coverage, most exclusions expire.

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Strong medical and legal evidence can overturn a wrongful denial.

Denied due to a pre-existing condition?

Call or text us today for a free consultation. No fee unless we win.

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