Important Information
About Group Disability Claims
A recent New York Court of Appeals
decision may impact your disability claim if it was denied
based on a pre-existing condition.
The New York Court of Appeals ruled on June
27, 2007, in Benesowitz
v. Metropolitan Life Insurance Company, 8 N.Y.3d 661,
870 N.E.2d 1136, 839 N.Y.S.2d 706 (2007) that with respect
to disability insurance, the New York pre-existing condition
statute permits a benefit waiting period of up to 12 months
and not an exclusion of the pre-existing condition.
This means that all future benefits for
disabilities arising during the first 12 months of coverage
that result from a pre-existing condition may have only a
12-month waiting period during which no benefits will be
paid for such conditions. A claimant
with a pre-existing condition must be paid benefits once he
or she has been insured under a disability policy for 12 months
and has satisfied the elimination period and other relevant
policy provisions.
What does this mean for claimants?
Claimants
do not need to request re-examination of their claim denials
because Security Mutual Life Insurance Company of New York
(SML) is automatically undertaking a re-examination of group
disability claims denied under a New York policy where the
denial was based on a pre-existing condition. We
will re-examine claim denials going back two years from June
27, 2007. If, however, a claimant’s policy provides
for a period of time to bring legal action to recover on
the policy that is greater than two years, then we will
go back and review all claim denials based upon a pre-existing
condition for that greater period.
We will make a good faith effort to notify
all impacted claimants in writing by April 30, 2008, of
the results of the review and retroactively pay any benefits
due, with interest, from the commencement of the period for
which SML would have been liable had we applied
the Benesowitz interpretation of Insurance Law
Section 3234 (New York’s pre-existing condition statute)
to the claim at the time the proof of loss was first submitted
to us.
If during our re-examination
of the claim we require additional information to determine
whether benefits are payable, we will attempt to request
the information on or before April 30, 2008. We
will make a decision on the claim and retroactively pay
any benefits owed, with interest, no later than 60
days from
the receipt of all information necessary to complete the
re-examination of the claim.
If you have any questions, please contact us at
(800) 346-7171, ext. 232 or 223.
