Disabling Physical Ailments and Mental Impairments

Many of our clients suffer from depression as a result of their disabling physical conditions or they may have other disabling psychiatric conditions such as bipolar disorder. It is important to be aware that most disability policies cut-off disability benefits after 24 months of benefits if the disabling medical condition is considered a psychiatric condition otherwise known as a “mental impairment.” Each policy contains different language on this issue. For instance, the Prudential policy provides

What Disabilities Have a Limited Pay period Under Your Plan?

Disabilities which, as determined by Prudential, are due in whole or part to Mental illness also have a limited pay period during your lifetime.

The limited pay period for self-reported symptoms and mental illness combined is 24 months during your lifetime.

Mental illness means a psychiatric or psychological condition regardless of cause. Mental illness includes but is not limited to schizophrenia, depression, manic depressive or bipolar illness, anxiety, somatization, substance related disorders and/or adjustment disorders or other conditions. These conditions are usually treated by a mental health provider…using psychotherapy or psychotropic drugs.

In the case of Deal v. Prudential:

 Deal saw a host of medical professionals for both physical and psychological conditions out of a knee injury and associated pain.
 Diagnosed with Moderate Major Depressive Order  Two psychologists reports indicating Deal’s disability caused, at least in part, by mental disorders  The Court concluded–“Prudential has not shown that the mental disorder benefit limitation applies.”

The Hartford Mental Impairment Limitation is as follows:

 If an employee is disabled due to a “Mental Illness” benefits will be limited to 24 months total.

 “Mental Illness” defined as “any psychological, behavioral or emotional disorder or ailment of the mind, including physical manifestations of psychological, behavioral or emotional disorders, but excluding demonstrable, structural brain damage.”

In the case of Curtis v. Hartford, 2014 WL 4185233 (N.D. Ill., Aug. 20, 2014), the court found that the plain meaning of the policy language was critical. Specifically, in the Curtis v. Hartford case:

 Hartford argued that Curtis’ cognitive impairments constitute a “mental illness” limiting her to two years of benefits
 Curtis’ cognitive impairments primarily affected her learning, memory, and problem solving skills
 Court: clear that Curtis’ cognitive impairments, are not the sort of mental health disorders Hartford intended the policy to limit. Hartford has provided no evidence to show otherwise. Therefore, the “mental illness” limitation does not apply.

In another case, evaluating mental impairment limitations in a disability policy, Criss v. Union Security Ins. Co., 26 F. Supp. 3d 1161 (N.D. Ala. 2014), the judge pointed out how difficult it can be to dissect a claim according to physical v. mental impairments:

 “It does not take the dean of Johns Hopkins School of Medicine to know that there is a link between the functioning of the human brain and the well-being of the rest of the body, although that connection is not easy to explain or describe. Any person who is in constant pain becomes, at least to some extent, “anxious” (the word from which the word “anxiety” derives). An overly anxious person has a mental problem.”

 “In circumstances involving a myriad of medical problems like those in this case, it may be impossible to draw the line contemplated by this policy language.”

In Criss v. Union Security the 24 month mental impairment limit did not apply to any periods where disabled due to physical conditions. Also, in Criss:

 Union Security paid 24 months + 38 days  “The ultimate question of whether Criss’ physical ailments alone disabled her becomes close to being an academic, theoretical, hypothetical question.”
 “The inquiry is whether the plaintiff’s serious physical problems, divorced from her mental problems that are largely symptomatic of her physical problems, render her unemployable.”

The policy Interpretation is key in these cases because:

 Court will interpret the terms of the policy in the “ordinary and popular sense.”
 Any ambiguity construed in the insured’s favor.

Additionally, the insurance company bears the burden of proving the applicability of a mental illness policy exclusion in an ERISA claim. Deal v. Prudential Ins. Co. of Am., 263 F.Supp.2d 1138, 1143 (N.D.Ill. 2003) citing Hurst-Rosche Eng’rs, Inc. v. Commercial Union Ins. Co., 51 F.3d 1336, 1342 (7th Cir.1995) (“The burden of proving that a claim falls within an exclusion rests squarely on the insurer.”) –“Prudential must show that absent her mental problems, she would have been able to perform work for which she is reasonably fitted.”

If you have a disability claim which has been wrongfully terminated under the 24 month mental impairment limitation, please contact the O’Ryan Law Firm immediately to discuss your claim further.