Billings v. Unum Life Insur. Co. of America

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Billings v. Unum Life Insur.Co. of America, 2006 U.S.App.LEXIS 20244 (11th Cir. 8/8/2006)( Issue: Mental versus Physical Disabilities; Judgment) .  The plaintiff, a pediatrician, was diagnosed in 1996 with obsessive compulsive disorder (OCD) and major depression, which caused him to cease practicing in 1997 and apply for benefits.  The insurer approved the claim, effective July 21, 1997 (following a 180 day elimination period).  In 1999, Unum informed Billings that his benefits would be ending due to a 24 month limitation on the payment of benefits for mental disorders; however, Billings contended he also suffered from Meniere’s disease and that his benefits should continue.  Unum did not deem that condition of sufficient severity, though, and benefits ceased, leading to litigation of the claim.  One of the issues raised by the complaint had to do with whether the mental limitation even applied to OCD, which was determined to be a physiological condition, albeit one that presents with psychiatric symptoms.

The court first examined the mental illness limitation which the district court had found ambiguous.  The court looked at several approaches.  For example, Unum asserted the court should follow the reasoning of the Eighth and Fifth Circuits which apply a “plain meaning” to a mental impairment limitation, focusing on the symptoms of an illness to determine whether the mental illness limitation applies.   See, Brewer v. Lincoln Nat'l Life Ins. Co., 921 F.2d 150, 153-54 (8th Cir. 1990);  Delk v. Durham Life Ins. Co., 959 F.2d 104, 105 (8th Cir. 1992); and  Lynd v. Reliance Standard Life Ins. Co., 94 F.3d 979, 983-84 (5th Cir. 1996).  The plaintiff, however, argued the provision was ambiguous because the policy fails to state whether an illness is classified as “mental” based on cause or symptoms.  That argument follows the approach taken by the Seventh and Ninth Circuits in both  Phillips v. Lincoln Nat'l Life Ins. Co., 978 F.2d 302, 311 (7th Cir. 1992) and  Patterson v. Hughes Aircraft Co., 11 F.3d 948, 950 (9th Cir. 1993).  As the court explained, “Construing the ambiguity against the drafter under the applicable state law doctrine of  contra proferentem, these circuits have held that the limitation does not include organically based illnesses.  Phillips, 978 F.2d at 311;  Patterson, 11 F.3d at 950.” *13.

In the Eleventh Circuit, the law regarding ambiguities in insurance contracts provides that if the policy is susceptible to multiple reasonable interpretations, one of which results in coverage and the other in exclusion, the policy is deemed ambiguous.  Under that reasoning, the court ruled the policy was ambiguous in the absence of a definition or explanation of the term “mental” disorder and without any “illustration of the conditions that are included or excluded.” *15.  The court added that it was unpersuaded by the Eighth and Fifth Circuit’s “plain meaning” analysis because it fails to “resolve the ambiguity…[it] merely adopts one reasonable interpretation over the other.”  *17.  Hence, Billings’s OCD did not fall within the mental illness limitation.  The court also affirmed the lower court’s finding that Billings was disabled due to Meniere’s disease and ruled that benefits were due through the date of judgment even though judgment was not entered until 22 months after the trial.  As the court explained, “although there was no evidence in the record that Billings continued to suffer a disability during the period between the last day of trial and the day the district court entered judgment, there was also no evidence before the district court indicating that Billings's condition had improved during such time period.”

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