Most disability insurance policies distinguish between disabilities that are due to medical conditions and those that result from behavioral health disorders. For the latter category, benefit payments are typically limited to a maximum of 24 months, while payments for disabilities resulting from medical conditions can continue until the claimant reaches Social Security retirement age.
In many instances, courts have had to determine when benefit limitations for psychiatric conditions should apply. The most recent example is the U.S. Court of Appeals for the Sixth Circuit’s Nov. 13 decision in McEachin v. Reliance Standard Life Insurance Co., where the Sixth Circuit reaffirmed its prior precedent and collected other cases from around the country, holding that the limitation applies only where a behavioral health condition is the “but for” cause of the claimant’s disability.[1]
The McEachin ruling prevents disability insurers from overreaching in their application of policy limitations for mental illness and offers claimants guidance on how they might challenge misapplications of the limitation.
The first critical point made in McEachin is that the insurance company bears the burden of proving the applicability of the policy limitation.[2] The decision also reinforced the Sixth Circuit’s determination that behavioral conditions must be the but-for cause of disability before the limitation applies by citing rulings from other circuits that have come to the same conclusion.[3]
Thus, if a disability benefit claimant is disabled due to a medical condition irrespective of any coexisting mental health condition, the limitation is inapplicable. Adding a belt and suspenders to that proposition, the court added that “a mental-health disability does not ’cause or contribute to’ a ‘total’ ‘disability’ if existing physical disabilities suffice by themselves to cause it.”[4]
The Sixth Circuit’s view of mental health limitations, which are ubiquitous in disability insurance plans, is critical, especially in situations where a benefit applicant is claiming disability due to conditions such as long COVID, chronic fatigue syndrome or fibromyalgia. Since those impairments lack specific objective diagnostic markers,[5] they may be mistaken for a psychiatric disorder, also known as a somatic symptom disorder,[6] due to the patient’s focus on symptoms, which appear out of proportion to the clinical findings.
A recent article published in Psychology Today by Dr. Yochai Re’em raised concern about the classification of medical conditions, such as long COVID, as behavioral health disorders due to mental health professionals’ lack of knowledge concerning the patient’s physical illness.[7] Re’em wrote that “one who is uneducated about the vast array of potential Long COVID symptoms may view almost any increased concern about one’s own health following Covid-19 as ‘excessive’ or ‘disproportionate.'”
While the diagnostic criteria for a somatic symptom disorder do not exclude the presence of a medical condition, the label of a psychiatric condition carries the risk that a disability insurer will apply a policy limitation even though the claimant’s disabling symptoms are exactly those that are produced by the medical condition.
Especially in situations where disability insurance policies define conditions subject to the limitation as any condition listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM, it is easy to see how insurers could potentially manipulate the evidence to limit their liability.
The fourth edition of the DSM cautions against that possibility by pointing out: “[T]he term mental disorder, unfortunately, implies a distinction between ‘mental’ disorders and ‘physical’ disorders that is a reductionistic anachronism of mind/body dualism. A compelling literature documents that there is much ‘physical’ in ‘mental’ disorders and much ‘mental’ in ‘physical’ disorders.”[8]
Although the fifth edition of the DSM does not include that specific language, the authors caution:
When DSM-5 categories, criteria, and textual descriptions are employed for forensic purposes, there is a risk that diagnostic information will be misused or misunderstood. These dangers arise because of the imperfect fit between the questions of ultimate concern to the law and the information contained in clinical diagnosis. … Nonclinical decision makers should also be cautioned that a diagnosis does not carry any necessary implications regarding the etiology or causes of the individual’s mental disorder.[9]
Thus, labeling a patient with a DSM diagnosis raises the risk of triggering a disability insurance policy’s limitation for disabilities due to a behavioral health condition.
The Wall Street Journal recently reported that over 1 million Americans are out of the workforce due to long COVID, and added that “[r]researchers don’t know how long symptoms can last. Few people with long Covid have fully recovered within two years,” and “[s]ome people might live with the condition for the rest of their lives.”[10] Limiting disability benefits for long COVID sufferers by characterizing their disability as a psychiatric condition is manifestly unfair.
Thus, the lessons offered by the McEachin decision are critical in preventing policy limitations from being unjustly imposed. McEachin’s holding that a mental illness limitation is not properly applied when a medical condition accounts for a claimant’s disability, irrespective of a coexisting psychiatric diagnosis, ensures that disability benefits are not arbitrarily limited.
Hence, so long as disparate treatment of mental health claims by disability insurers persists, the McEachin ruling is a valuable precedent that claimants can utilize when faced with a misclassification of their disabling impairments.
Mark DeBofsky is a shareholder at DeBofsky Law Ltd.
This article was first published by Law 360 on November 20, 2024.
[1] McEachin v. Reliance Standard Life Insurance Company, 2024 U.S. App. LEXIS 28746, 2024 WL 4759527 (6th Cir. November 13, 2024).
[2] Citing Okuno v. Reliance Standard Life Ins., 836 F.3d 600, 609 (6th Cir. 2016).
[3] See, Michaels v. Equitable Life Assurance Soc’y, 305 F. App’x 896, 901, 904 (3d Cir. 2009); George v. Reliance Standard Life Ins., 776 F.3d 349, 355 — 56 & n.9 (5th Cir. 2015); Krolnik v. Prudential Ins. Co., 570 F.3d 841, 844 (7th Cir. 2009); Weyer v. Reliance Standard Life Ins., 109 F.4th 1072, 1077 (8th Cir. 2024); and Gunn v. Reliance Standard Life Ins., 399 F. App’x 147, 153 (9th Cir. 2010).
[4] Citing Okuno (internal quotations omitted).
[5] See, e.g., Mitchell v. Eastman Kodak Co., 113 F.3d 433, 443 (3d Cir. 1997) (finding it improper for disability claimant to be required to provide “clinical evidence of etiology” to establish the existence of a condition for “there is no ‘dipstick’ laboratory test.”).
[6] See, “Somatic Symptom Disorder” at https://www.psychiatry.org/patientsfamilies/ somatic-symptom-disorder#:~:text=Somatic%20symptom%20disorder%20is%20diagnosed,relating%20to%20the%20physical%20symptoms. The American Psychiatric Association defines a Somatic Symptom Disorder as a condition that
is diagnosed when a person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning. The individual has excessive thoughts, feelings and behaviors relating to the physical symptoms. The physical symptoms may or may not be associated with a diagnosed medical condition, but the person is experiencing symptoms and believes they are sick (that is, not faking the illness).
A person is not diagnosed with somatic symptom disorder solely because a medical cause can’t be identified for a physical symptom. The emphasis is on the extent to which the thoughts, feelings and behaviors related to the illness are excessive or out of proportion
Also see, Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition (DSM-V) at 311.
[7] “Why So Many Doctors Doubt Patients With Long Covid” by Yochai Re’em, M.D., which was published on September 29, 2022 (available at https://www.psychologytoday.com/us/blog/long-covid-lessons/202209/why-so-manydoctors-doubt-patients-with-long-covid).
[8] DSM-IV at page xxi.
[9] DSM-V at 25.
[10] “Long Covid Knocked a Million Americans Off Their Career Paths,” Wall Street Journal, August 26, 2024.
