If you suffer from chronic pain, fatigue, and other symptoms severe enough to interfere with work, there is a good chance you also suffer from depression, anxiety, and other mental health problems. The connection between chronic pain and depression is well-established, with up to 85% of chronic pain patients reporting severe depression. That makes intuitive sense, since living in chronic pain and losing one’s income due to disability are likely to cause feelings of sadness and loss. Therefore, it should not be controversial that a disability claimant should suffer from depression and anxiety in addition to his or her physical impairments.
Unfortunately, however, most long term disability policies limit benefits for mental/nervous conditions to 24 months. While our firm opposes this practice and has advocated for legislation prohibiting mental/nervous limitations in disability insurance policies, as of this writing only the state of Vermont has abolished them. Thus, the vast majority LTD claimants live under the threat of having their LTD benefits terminated after 24 months if their disability is deemed to be caused by a mental/nervous condition.
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How Courts Approach Physical vs. Mental Disabilities
According to Krolnik v. Prudential Ins. Co. of Am., 570 F.3d 841, 843-44 (7th Cir. 2009), a disability plan administrator may not terminate benefits due to a mental/nervous limitation if the claimant can establish that he or she is independently disabled due to a non-limited condition. However, distinguishing physical from mental disability is not always easy. Consider the following examples:
- Chronic pain has been known to cause depression that then intensifies the pain, in a vicious cycle.
- Fibromyalgia is a physically painful condition that can produce symptoms of anxiety and depression; it is thought to originate in the central nervous system; it is treated with anti-depressants; and it has been statistically correlated to PTSD.
- A conversion disorder, or functional neurologic disorder, is a type of somatoform disorder characterized by physical and sensory problems (such as paralysis, numbness, blindness, deafness, and seizures) for which there is no underlying physiologic explanation.
Whose Burden of Proof for Physical or Mental Disability?
In these cases, how can a disability plan administrator or court parse out whether the patient’s disability is physical or mental in nature? As a preliminary matter, the burden of proving the applicability of a policy exclusion or limitation rests on the insurer. See Deal v. Prudential Ins. Co. of Am., 263 F. Supp. 2d 1138, 1143 n.2 (N.D. Ill. 2003) (“The burden of proving that a claim falls within an exclusion rests squarely on the insurer.” (quoting Hurst-Rosche Eng’rs, Inc. v. Commercial Union Ins. Co., 51 F.3d 1336, 1342 (7th Cir. 1995))); see also Okuno v. Reliance Standard Life Ins. Co., 836 F.3d 600, 609 (6th Cir. 2016) (“Reliance bears the burden to show that the exclusion on which it based denial of benefits, the Mental and Nervous Disorder Limitation, applies in this case.”). However, the claimant retains the burden of proving he or she remains disabled within the meaning of the policy.
Given this tension, some courts have refused to apply a presumption in favor of either party and instead adopted a preponderance of the evidence approach to determine which party has the more compelling case. See, e.g., Watson v. Reliance Standard Life Ins. Co., No. 14 C 4990, 2017 U.S. Dist. LEXIS 187488, at *27-28 (N.D. Ill. Nov. 14, 2017) (ruling claimant who suffered from fibromyalgia and chronic fatigue syndrome had sufficiently proved by a preponderance of the evidence that she was disabled due to a physical, as opposed to mental, condition).
Cause vs. Symptoms-Based Approaches
People have argued that mental illnesses such as depression, bipolar disorder, and schizophrenia have physical causes like chemical imbalances in the brain, so they shouldn’t be subject to mental/nervous limitations. Three federal courts of appeal (the Seventh, Ninth, and Eleventh Circuits) have agreed and ruled that the “mental/nervous” limitation does not apply where the mental impairment has a physical cause. Those courts relied upon the principle of contra proferentem, which means that unclear terms in an insurance contract be interpreted against the person who wrote it.
In contrast, two other federal courts of appeal (the Fifth and Eighth Circuits) have ruled that the “mental/nervous” limitation applies even if the illness has a physical cause, so long as the main symptoms are mental. Those courts reasoned that focusing on the cause of the illness would remove the difference between mental and physical disabilities (since nearly all illnesses arguably have some physical origin). Those courts further ruled that a symptoms-based approach better reflects how a regular person would understand the insurance policy.
Physical vs. Mental Disability in Disability Claims: An Unsettled and Case Fact-Specific Inquiry
In disability claims, the distinction between physical and mental disabilities can be complex and fact-specific, and the law in this area is unsettled. Each case demands a fact-specific inquiry. Depending on the jurisdiction, you may have success arguing that the mental disability is caused by an underlying organic process such that the mental/nervous limitation should not apply. However, parsing out the cause of disability remains difficult in the case of comorbid physical and mental impairments. If your disability benefits have been denied pursuant to a mental/nervous limitation, or you are concerned about a future denial, contact the attorneys at DeBofsky Law today to discuss your rights.