Benefit Limitations – “Mental/Nervous” or “Self Reported Conditions”

Benefit limitations and how to handle them.

In the typical claim for Long Term Disability benefits governed by the federal statute commonly referred to as ERISA (Employee Retirement Income Security Act), if benefit limitations are initially approved and you remain disabled, the next important point in your claim will come, typically, after receipt of benefits for 24 months. I say typically because the Plan Documents governing the benefits vary from employer to employer. The following is written based on the standard policies which the law firm of Herbert M. Hill, P.A. reviews. That experience extends to claims arising out of employment throughout the southeastern section of the country. In any event, in all cases, your situation must be tailored to the terms of the governing Plan Documents.

If you have questions about the contents of the “Plan Documents,” please see my writings on that subject found elsewhere on this website.

In any event, after 24 months, two (2) important issues may arise. First, at the 24-month point in time, there typically is a change in the definition of the term “disability” relative the occupation to which it applies. Second, there are typically certain medical conditions for which benefits are limited to a 24-month entitlement. I will address the second issue in this writing. The first is addressed elsewhere on this website under a writing entitled Benefit Limitations – “Own Occupation” v. “Any Occupation.”

In any event, most Plan Documents (but certainly not all) provide for a limitation on the period benefits are paid, usually 24 months, for disability involving mental or nervous conditions. As to what constitutes a mental or nervous condition, there may or may not be a definition of the meaning of this term. As far as that definition is concerned, the legal maxim of Contra referendum, which stands for the proposition that vague or ambiguous documents will be construed against the author, would result in a narrow construction and application of any such limitation.

The specific language of the Plan Documents needs to be carefully reviewed because there are two (2) types of clauses currently in use in the industry. The first is a clause which provides for the limitation in benefits is the disability “is caused by” or “due to” a mental or nervous condition. The approach here would be to ensure that any underlying medical or physical problems are properly addressed so as to make it clear that, if it can be done, the mental or nervous condition is secondary to or an adjunct of the truly disabling condition, the underlying physical condition. Of course, the medical evidence may not lend itself to this proposition but the point must be carefully explored and presented to the party charged with rendering the benefits determination.

The second type of clause in relation to benefit limitations, which might be found in Plan Documents is more problematic. This is a clause which provides for the limitation if the mental or nervous condition “causes, or contributes to,” the disability, or words that effect. However, the undersigned would suggest that every disabling physical condition is, at first, a medical problem. Then it becomes an economic problem when it prevents us from working. Working goes at the core of our self-identification. It is how we support ourselves and our loved ones. When we are unable to do so because of a medical condition it almost always becomes an emotional issue as well. If so, the insurance company might use this as a way of limiting benefits under this second type of clause. Indeed, just about every employee who is off work because of a physical medical condition might end up falling under this clause. Now, please understand that I am not suggesting that you not seek treatment for mental or nervous conditions in this circumstance. It is just that it will be necessary to carefully present the claim in a manner which makes it clear that the mental or nervous would not be present but for the underlying physical problem or that the employee could work if the mental or nervous condition were the only problem.

Either way, claims involving mental or nervous relating to benefit limitations must be approached very carefully to avoid these tender traps laid by the insurance companies for the unwary.

There are other conditions which might also fall under a similar type of benefits limitation clause. The undersigned has seen Plan Documents limiting benefits in a similar manner to claims involving fibromyalgia, chronic fatigue syndrome and other conditions which insurance companies think to involve only self-reported symptoms. Again, the Contra preferendum legal maxim would apply but the approach on such claims must, nonetheless, be made very carefully.

Please keep in mind that the foregoing is not intended as legal advice applicable to any individual person’s unique legal situation. Its sole purpose is to give a general idea of the existing status of the law as it applies to the point of law addressed above. You cannot rely on the foregoing as legal advice. You cannot make legal decisions based on its contents. If you have questions arising out of this point of law, you should contact an attorney who routinely handles claims involving policies of disability insurance. The law offices of Herbert M. Hill, P.A. handles such cases and would welcome the opportunity to discuss your case with you, at no charge. You can contact me at 407-839-0005 or at hmh@herbertmhill.com.

If you would like, after discussing your case, we can set a conference. That conference would be free of charge and you would be under no obligation to hire me nor would you feel any pressure from me to do so.

Herbert M. Hill, P.A. is a law firm located in Orlando, Florida with a practice extending throughout the state of Florida and the southeastern part of the United States. Areas of practice include disability and employee benefit claims of all sorts. The firm handles any claims arising under the Employee Retirement Income Security Act (known and referred to as “ERISA”) for disability benefits, medical benefits, retirement benefits of any sort, including pension, 401k, termination agreements or the like as well as claims arising under private disability policies.