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Cause or sympton? Two key court decisions define the limitations of mental illness insurance claims.

While most group disability policies include a provision that limits benefits paid for mental and nervous conditions, the definition of mental illness is often ambiguous. Policy limitations for mental illnesses typically limit benefits to 24 months if the disability is "caused or contributed to" by a "mental illness." Yet many policies fail to define the term "mental illness," and even when it is defined in a policy, confusion arises.

Insurers argue that the mental illness limitation applies to any disability in which the insured exhibits symptoms of anxiety or depression, even when these symptoms are secondary to physical conditions such as headache, muscle ache or fatigue.

Most courts, however, disagree.

In Lang vs. Long Term Disability Plan of Sponsor Applied Remote Technology Inc., the 9th Circuit Court ruled the mental illness limitation did not apply to disabilities that include mental conditions resulting from physical disorders. The court found that an insured with fibromyalgia--a type of soft-tissue rheumatism that affects the muscles and is commonly accompanied by fatigue, sleep disturbances, lack of concentration, changes in mood, anxiety and depression--was not subject to the mental illness limitation, even though the insured's initial treating physician was a psychiatrist who diagnosed her with "depressive neurosis."

While the insured suffered from fatigue, lack of concentration, changes in mood, anxiety and depression, the depression and anxiety associated with fibromyalgia are believed to be symptoms of this muscular disease, rather than causes of it.

The plaintiff was insured under a long-term disability policy which included a 24-month limitation for disabilities "caused or contributed to" by a "mental disorder." While mental disorder was defined as a "mental, emotional, behavioral, or stress-related disorder," the policy was silent as to whether the insurer should look to causes or symptoms when determining whether the mental illness limitation applied.

Lang applied for disability benefits, indicating that her inability to work was triggered by stress arising from her job as a contracts manager. She described her symptoms as "uncontrollable crying," "throwing up before work," and "inability to concentrate." Upon receipt of her claim for benefits the insurer informed Lang that the mental illness limitation applied to her claim.

But while Lang was receiving benefits, her family-care physician diagnosed her with fibromyalgia. Armed with her new diagnosis, Lang requested that the insurer reassess its determination to apply the mental illness limitation to her claim. The insurer, however, upheld its initial denial because Lang had "failed to establish that her fibromyalgia, separate from psychological factors, was disabling in and of itself."

The court disagreed, finding that the term "mental illness" was "ambiguous in that it could reasonably refer either to illnesses with nonphysical causes, or to illnesses with physical causes, but exhibiting both physical and non-physical symptoms." Applying the rule of contra proferentem, the court adopted the reasonable interpretation advanced by Lang, which is that the phrase "mental illness" does not include mental conditions resulting from physical disorders.

The court concluded that Lang was trader a disability from the time she originally applied for benefits, noting that there was nothing to indicate the nature of her physical or mental condition had materially changed. Rather, the only change was the diagnosis of the cause of her disability from depression unrelated to any physical disease, to fibromyalgia.

Similarly, in Mongeluzo vs. Baxter Travenol Long Term Disability Benefit Plan, the 9th Circuit Court found that an insured with chronic fatigue syndrome who suffered from fatigue, headaches and muscle weakness and received treatment from a psychiatrist for depression and anxiety did not fall within the policy's "mental illness" limitation because the term was ambiguous.

As the court explained, the policy did not specify whether a disability was to be classified as "mental" by looking to the cause of the disability, or to its symptoms. In addition, the policy did not make clear whether a disability qualified as a "mental illness" when it resulted from a combination of physical and mental factors. The court concluded that "if either a cause or a symptom of the disease were physical and caused the disability in whole or in part, then the 'mental illness' limitation did not apply and benefits were payable."

Both decisions are significant for insureds who may have been misdiagnosed as suffering from a "mental" condition based on symptoms of depression and anxiety. Individuals with fibromyalgia, chronic fatigue syndrome and other conditions with a combination of physical and mental symptoms should cite these decisions if denied disability benefits based on the mental illness limitation,

Frank N. Darras, a Best's Review columnist, is a partner with Shernoff Bidart Darras LLP, Claremont, Calif. He is a plaintiff's lawyer representing disabled insureds. He can be reached at insight@bestreview.com.
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Title Annotation:Regulatory/Law: Legal Insight; Lang vs. Long Term Disability Plan of Sponsor Applied Remote Technology Inc; Mongeluzo vs. Baxter Travenol Long Term Disability Benefit Plan
Comment:Cause or sympton? Two key court decisions define the limitations of mental illness insurance claims.(Regulatory/Law: Legal Insight)(Lang vs.
Author:Darras, Frank N.
Publication:Best's Review
Article Type:Case overview
Geographic Code:1USA
Date:Mar 1, 2006
Words:777
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