Tuesday, August 15, 2017

Is Pregnancy a Pre-Existing Condition for Short Term Disability?



A common question I get from women at open enrollment time is if pregnancy is a pre-existing condition for short term disability. Usually, this question comes from women who are already pregnant and who aren't currently enrolled in the STD plan. So in this article, I'm going to talk about how pregnancy is treated under most plans.




Pregnancy and the Pre-Existing Condition Limitation


Most group disability plans are guaranteed issue at every enrollment. This means you can enroll without any medical questions and will be approved regardless of health. However, in exchange for the guaranteed approval, any claims may be subject to what's called a pre-ex, or a pre-existing condition clause.

The most common pre-ex clauses are 3/12, 6/12 and 12/12.

Here's is what the numbers 3/12, 6/12 and 12/12 mean:

(Number of Months Look Back Period)  /  (Number of Months Look Back Applies)

A 3/12 pre-ex means that if you file a claim within the first 12 months the policy is in effect, the insurance company will look back 3 months before the policy took effect to see if it was caused by a pre-existing condition. If it's a 6/12, then the insurance company will look back 6 months for a pre-existing condition for any claim filed in the first 12 months.

If the condition was pre-existing during the look back period, then the insurance company can deny the claim.

Keep in mind that if you are enrolling in the disability plan in November but the plan takes effect on January 1 that the 12 months begins on January 1 and the look back period would be the three, six or 12 months before the effective date and not the date you enrolled.

If you are pregnant when you enroll, your claim for short term disability will most certainly come in the first 12 months the plan is in effect and therefore, your claim would be denied.

However, if you enrolled in October and got pregnant on January 10th after the effective date, then your pregnancy would not be considered pre-existing since it occurred after the effective date.

The Difference Between Group and Voluntary Disability Plans


One factor that may come into play is whether the disability plan you are being offered is a group disability plan or a voluntary one.

The difference between a group plan and a voluntary plan is underwriting. While group disability might be guaranteed issue at every enrollment, a voluntary disability plan might only be guaranteed issue when you are first eligible.

If it's a voluntary plan, if you don't enroll the first time you are eligible and want to enroll later, you might have to answer the medical questions to get in. If you are pregnant, this could possibly prevent you from being approved for the short term disability.

In addition, if you have to answer medical questions to qualify for your disability plan, if you have any other medical conditions outside of being pregnant, those conditions might prevent you from getting disability insurance as well.

The best time to enroll is when you are first eligible under those plans.

Options If You Are Already Pregnant


If you are already pregnant, you'll want to check out how much vacation and sick time you have available that you could use doing your maternity leave.

Alternatively, there are some companies that allow you to allow you to buy, sell and donate vacation time. If your company does that, a possible solution to not having short term disability insurance is to buy it or get some one to donate it to you.

As far as donations go, most donations are made for people with serious illnesses and so I wouldn't really count on that as an option.

The other option is to take your maternity leave unpaid.

Sign Up the Year Before You Get Pregnant if Possible


If you are trying to get pregnant, you might consider signing up at the enrollment period prior to the year you want to get pregnant.

If your employer's plan looks back for any claim filed in the first 12 months after the effective date and you satisfy that 12 month time period in the year prior, then your pregnancy won't be considered pre-existing.

If this is a planned pregnancy, that might help you out to remember to do that.

Conclusion


Pregnancy is considered a pre-existing condition if you are a newly enrolled in your disability plan and most likely will be excluded. Try and plan ahead and make sure you enroll when first eligible or the year before to get around the pre-ex clause found in most group disability plans.

As always, in group insurance, every plan may vary in what it covers depending on what your employer negotiated with the insurance company.

Let me know how you handled your short term disability in the comments below to help my readers further understand their options.

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Michael is a champion of guaranteed issue for employees in the workplace. He's been an insurance agent since 1992 and has worked with thousands of employees.

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