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Cognitive and Mental Health Conditions Are Not Always Subject to a 24 Month Maximum Benefit Cap

Many group Long Term Disability policies limit the payment of benefit to 24 months if the disability is "due in whole or part to mental illness." However, insurance companies can be quite liberal with this language and apply it to claims where there are cognitive limitations that may have an organic basis or to claims where depression and/or anxiety are a reaction to an insured's physical illness but not actually the disabling medical condition. In a recent 9th Circuit case from California, the Court found that Prudential should not have applied the mental illness limitation to John Doe's claim and ordered Prudential to reinstate benefits retroactively and ongoing.

In John Doe v. Prudential Insurance Company, the Court considered all of Mr. Doe's medical conditions as a whole in order to determine if the 24 month mental/nervous cap applied to his claim. It was not disputed that Mr. Doe had problems with attention, memory, focus, and executive function and that these limitations contributed to his inability to perform his job. He also suffered from physical conditions related to HIV, asthma, migraines, hypertension, bundle branch block, and osteoporosis. When Mr. Doe applied for benefits he asserted that his physical conditions made him unable to sustain focus and that, in part, was why he could not perform his job duties. Prudential determined that it was only his mental health issues (depression, anxiety, and related symptoms) that disabled him and awarded benefits based on those issues only. Subsequent neuropsychological evaluations showed that Mr. Doe's cognitive deficiencies may be caused by brain damage, likely resulting from HIV. As such, there may likely be a physical etiology behind the cognitive issues and they are therefore not attributable to mental health issues. After reviewing the medical evidence and numerous physician reports submitted by both the Plaintiff and Prudential, the Court held that the Plaintiff established that he is disabled under the terms of the Prudential LTD Plan and that Prudential incorrectly relied on the Plan's mental illness limitation to terminate benefits.

If you have questions about your disability claim, are applying for disability benefits, need to appeal a denial of benefits, or plan to sue your disability carrier for a wrongful denial of benefits, please feel free to contact DI Law Group for a free consultation. You can visit our website at www.dilawgroup.com or contact us by telephone at (866) 363-3628.

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