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:
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.
You can also check to see if your employer offers some type of hospital indemnity plan. If they do, these plans are often offered on a guaranteed issue basis with no medical questions or pre-existing conditions.
Ask your employer or their insurance representative specifically does hospital indemnity insurance cover pregnancy. If it does, then the cash it pays directly to you might help out.
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.
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.
what if you are already enrolled, have been for more than a year, and the company changes from a voluntary to a group plan. how does short term apply to pregnancy/child birth then?
Michael Kuhn says
It’s possible your employer negotiated with the insurance company what is called a “take-over”. In a take-over situation, previous policyholders are grandfathered in and their pre-existing time period wouldn’t reset. However, it might not be a “take-over” and you may be subject to a new pre-existing time period. To know for sure, you’ll have to check with your employer and the new insurance company. Since it’s going from voluntary to group, I’m inclined to think it won’t be a take-over situation but I’m only guessing. These days most insurance companies have a preference for group products to make filing of products with state insurance departments easier. So, it’s hard to say for sure without being involved. Also, if it’s a true voluntary policy, there’s a slight chance you might be able to keep your current policy. I’d check into that if you are not grandfathered in. Thanks for your comment and good luck.
I enrolled in short term disability November 2017. I found out I was pregnant 1-15-18 with my first OB visit on February 5th 2018. Would that be considered as a pre-ex condition? My claim is currently in a denied status under review.
Michael Kuhn says
I’m assuming that your short term disability plan had an effective date of January 1, 2018. Keep in mind that the effective date might be different than the sign up date which could affect things. In most cases, a pre-existing condition would be one that you received treatment for prior to the effective date. In your case, it doesn’t look like that is the case. A lot will depend on the policy language, the underwriting rules at the time you signed up and also every insurance company handles claims differently. It could be that all the insurance company might need to do is be able to verify you hadn’t received treatment prior to the effective date. Let me know how it turns out.
Hello! My STD policy went into effect on 7/7/19. My husband and I would like to plan a pregnancy as soon as possible.
Here’s what the policy says about the pre-existing conditions:
Pre-Existing Conditions Limitation: Are benefits limited for Pre-existing Conditions?
We will only pay benefits, or an increase in benefits, under The Policy for any Disability that results from, or is caused or contributed to by, a Pre-existing Condition for up to 4 week(s), unless, at the time You become Disabled:
1) You have not received Medical Care for the condition for 3 consecutive month(s) while insured under The Policy; or
2) You have been continuously insured under The Policy for 12 consecutive month(s).
Pre-existing Condition means:
1) any Injury, Sickness, Mental Illness, pregnancy, or episode of Substance Abuse; or
2) any manifestations, symptoms, findings, or aggravations related to or resulting from such Injury, Sickness, Mental
Illness, pregnancy, or Substance Abuse;
for which You received Medical Care during the 3 month(s) period that ends the day before:
1) Your effective date of coverage; or
2) the effective date of a Change in Coverage.
So… does that mean, IF we got pregnant this month…. and I didn’t see an OB until I was 8-9 weeks pregnant (which is the norm), that would put me past the 3 month mark… so does that mean I should qualify for my maximum benefit payout?
Thanks for your help!
Michael Kuhn says
My suggestion is to talk with the insurance company (or your representative) to get a definite explanation of how the pre-existing condition clause will work in your situation. It’s a very difficult pre-existing condition clause to make sense of. The reason it is confusing is because most pre-existing condition clauses state they don’t pay for pre-existing conditions at all. But in this case, it looks like it will pay for a pre-existing condition but limits the maximum benefit to 4 weeks. It looks like if you go on leave for pregnancy in the first year of the policy, the maximum payout will only be a maximum of 4 weeks. So if you got pregnant now and deliver before the year is up, you’d get a maximum four weeks benefit. However, if you get pregnant 6 months from now and go on leave for pregnancy after a year of being on the policy, then the maximum payout could be longer. It looks like the best bet is if you get pregnant and then deliver after you have had the policy for a year. But again, check with your provider. I’d be interested in hearing back from you on how they explain it to you. Thanks for the comment. Good luck!
What if your effective date is January 1, you find out you are pregnant the end of November or beginning of December by a home test, but your first dr apt is in January to actually “confirm” the pregnancy via ultrasound? Will that be accepted or denied? Do they go by weeks pregnant or the date in which an ultrasound confirms the pregnancy?
Michael Kuhn says
Typically a pre-existing condition is one which have received treatment for prior to the effective date. If you didn’t know you were pregnant and didn’t receive treatment until after the effective date, then I wouldn’t think it would be considered pre-existing based on the definition of a pre-existing condition. I would certainly file a claim. However, expect the insurance company to “do the math” and to initially deny the claim just assuming it was pre-existing. You’d probably have to have them review the claim to discover that you hadn’t received treatment prior to the effective date. Even then, I can’t say for certain that all insurance companies would pay a claim under that scenario and if you are signing up for short term disability now, go into it expecting it to be denied.
Corinne Grice says
Hi Michael, My husband, and I recently found out that I am pregnant. A very big surprise! I had a confirmed blood test on 11/13.My first doctors appointment is December 10. I signed up for STD at my new company in September.My effective date for my companies voluntary STD plan is 10/1/18. Do you think my claim will be denied ?
Michael Kuhn says
Congratulations! I would think you’d be ok since it was all after the October 1 effective date. It’ll depend on the insurance company I’m sure. Let us know what happens.
I just signed up for my Short term disability. The effective date will be 2/1/19. I had planned to seek out fertility treatment this December. I had a child previously through monitoring (not ivf). Would this be considered pre-existing?
Would I be able to just go to the consultation appointment? I do not have any intention on getting pregnant before 2/1, however the process is lengthy and I would rather get the basics started right now. Thank you
Michael Kuhn says
If you are not pregnant before 2/1/19 then I’d think you should be fine as far as short term disability for the pregnancy goes. With that said, if you receive fertility treatment that causes an adverse reaction that makes you eligible to file a short term disability claim, that might be denied if it occurs during a pre-existing condition clause time period. For example, my wife had fertility treatments and she had a reaction to the medication that put her in the hospital. In that case, had it had disabled her long enough, then I could see the insurance company denying a claim related to the adverse reaction of the medication had she been treated prior to an effective date but during the pre-ex period. But fertility is a separate condition than pregnancy so each should be separate I’d think. As always, just keep in mind, I’m assuming without reading the contract to be sure but that would be my expectation. Good luck on the process! I know it’s a challenging (and expensive process) to go through.
Danielle M Rivard says
I am currently off work due to birth of my daughter. In October my company was bought by another company. I had short term disability with previous company and signed up with new company. I was very worried that my pregnancy would be considered a preexisting condition with new insurance. I inquired multiple times with new company and was told that since I had previous coverage and was keeping seniority that it would be covered. I have this in emails. I made multiple inquiries because I was worried. Even help off signing job offer letter until I had an answer. Of course now I am off and the insurance company is denying my claim for that very reason. Is there any course of action I cam take since I have emails stating something different? This is a tremendous financial burden. I am not sure what to do.
Michael Kuhn says
I would contact the insurance company, your human resources department and also the insurance broker on the account and let them know the problem you have. They may be able to resolve it quickly for you. If that doesn’t help, I would contact the Department of Insurance in your state and file a complaint. Include the documentation you have. Typically, when insurance companies change, employees already participating are grandfathered in to the new insurance company without a pre-existing clause on what they were already enrolled in (assuming they weren’t still subject to it). Your situation is a little bit different in that both the employer and the insurance company changed. That might affect things here. It could also be that you just need to bring it to their attention to get it resolved. Sometimes insurance companies automatically decline a claim if on the surface it looks like a claim they would decline but then they later approve it. It’s also possible that when the broker was working with the insurance company, they either didn’t know the rules, didn’t inform the insurance company properly about the take over of risk or the insurance company overlooked it. I know it’s frustrating. Let me know what you find out. I hope it all works out for you and congrats on the new child.
Shelly Smith says
My husband and I have been trying to conceive for about 3 years and I just got a new job. At this point, we want a baby – that is the end goal here. My benefits begin Nov 1 and I enrolled last week. We will continue to try this month. If I found out I was pregnant prior to Nov 1 but did not go get my ultra sound confirmed until after Nov 1. What would the status of that STD claim likely be? We have no requirements per the individual I spoke with in terms of the 3/12 6/12 or 12/12. He basically advised it takes effect after Nov 1.
Michael Kuhn says
If there is no pre-ex on the plan, then if you have the baby after the effective date you won’t have to worry about your std claim being turned down. This assumes the person you talked to knew what they were talking about. If so you should be ok. Check the literature that was handed out and read it carefully. You could also double check with the insurance carrier that underwrites the plan just to be sure.
I am currently pregnant and just found out while doing open enrollment that my employer has switched short-term disability companies effective January 1, 2021. Will my pregnancy be considered a pre-existing condition? I hate that this is out of my control. I have no paid vacation with my current job so this really messes things up if the new short-term disability does not provide coverage.
Michael Kuhn says
In most cases the new insurance company “takes over” the prior policies giving you credit for any time you had the old policy towards any new pre-existing condition clause. This is not always the case so you have to check with your employer and the insurance company to know for sure. If it is not a true takeover, you might look into the old insurance company to see if you can keep it after the company terminates the deduction.
J. Reed says
When I asked my STD provider about pre-existing conditions and pregnancy, they responded with this: “We will not pay for any disability that begins in the first 6 months following the effective date of a pre-existing condition.”
Could you put that in layman’s terms for me?
My policy begins January 1. Does that mean that as long as the baby is born after June, they will pay? Or does it mean that we cannot conceive in the first 6 months?
Michael Kuhn says
How they worded it is a little confusing for me to say for sure. I would ask them to send you the pre-existing condition language so you can read it and clarify it with the insurance company directly to be 100% sure.