Mental and Nervous Disorder Benefits

Benefits Available for Mental and Nervous Disorders

Most long term disability polices covered by the Employee Retirement Income Security of 1974 (ERISA) limit benefits to one or two years for disabilities caused or contributed to by mental illness. Some policies do not define mental illness at all. Those that define the term do so differently. It is therefore important for the disability benefit experts of to analyze both the language of the limitation itself, and the definition of mental illness, if one is contained in the policy.

Language of the Mental Illness Limitation

mental-and-nervous-disordersCommon examples of mental illness limitations are as follows: “Any loss caused by, contributed to, or resulting from Disability beyond 12 months after the Elimination Period if it is due to a Mental Disorder of any type monthly benefits are limited to 12 months during your lifetime if you are disabled due to a: Mental or nervous disorder or disease, unless the disability results from schizophrenia, bipolar disorder, dementia, or organic brain disease. The Company will pay monthly benefits for no more than 24 months during an employee’s lifetime for disability or residual disability caused or contributed to by any one or more of the following conditions:

  • Alcoholism
  • Drug addiction or abuse
  • Bipolar affective disorder
  • Schizophrenia
  • Delusional disorders
  • Psychotic disorders
  • Depressive disorders
  • Anxiety disorders
  • Somatoform disorders
  • Eating disorders
  • Mental illness

Policy limitations for mental illness usually do not apply during any period the participant is confined for more than a certain number of days in a hospital.

Definitions of Mental Illness

As the recognition and understanding of mental illness evolved, most companies added a policy definition of the term “mental illness.” lawyers have successfully argued that a mental illness limitation is ambiguous when such a definition is not provided, or if the definition is ambiguous as applied to the facts of a particular case. For example, “A disorder found in the current Diagnostic Standards Manual of the American Psychiatric Association (DSM-IV-TR) or 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” is insufficiently vague and should not be enforced.

Courts addressing the issue have taken three basic approaches. They have either focused on the infirmity’s (1) symptoms; (2) cause; or (3) method of treatment (whether medical or psychiatric).

The most challenging cases for clients of involve the interplay between physical and mental conditions. Often, a physical condition can lead to a psychological condition, such as depression. Sometimes, the physical condition itself will manifest both physical and psychological symptoms. Separate physical and mental conditions may also combine to create an inability to return to work. Under these circumstances it becomes most important for our attorneys to research and argue the case law of your federal circuit.

In one recent case the claimant was disabled as the result of chronic fatigue syndrome. The court noted that the plan language was ambiguous because it did not address the question of whether a disability presenting mixed physical and mental components could be considered a “mental illness”. The court concluded that “[b]ecause of the rule that ambiguities are to be resolved in favor of the insured, if either a cause or a symptom of the disease were physical and caused the disability in whole or in part, then the benefits are payable.”

In another case the plaintiff claimed that her inability to work was triggered by stress arising from her job. She allegedly suffered from symptoms of “uncontrollable crying,” “throwing up before work,” and “inability to concentrate.” During the two-year limitation period, the plaintiff was later diagnosed with fibromyalgia. The court described the plan language as presenting “an almost classic ambiguity,” pointing out that earlier cases construing similar language “held that it was ambiguous in that it could reasonably refer either to illnesses with non-physical causes, or to illnesses with physical causes, but exhibiting both physical and nonphysical symptoms.” The court therefore reinstated the claimant’s long-term disability benefits.

The attorneys at will make themselves available to discuss your long term disability claim at your convenience. Contact us at 1-888-843-1261.