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CIGNA’s attempt to limit claimant to a maximum of 2 years of long-term disability benefits limitation for an organic brain disorder such as bi-polar is reversed by the District Court

Cigna attempted to deny lifetime disability benefits for a claimant suffering from a psychiatric organic brain disorder, but the district court of Colorado disagreed. Following a remand from the court of appeals, which ruled the district court had erred by considering evidence outside the “administrative record,” the district court nonetheless reaffirmed its ruling in plaintiff’s favor after carefully considering all of the evidence in the record and analyzing each of the medical opinions presented.

The specific issue was whether Jewell was disabled due to a functional psychiatric disorder or on account of an organic disorder. The court began its discussion by rejecting the insurer’s argument that the policy provision limiting benefits to 24 months for conditions “caused” or “contributed to” by a psychiatric condition was applicable to co-morbid organic and functional organic illnesses. The court found the insurer’s interpretation would mean that an employee whose sole affliction is a disabling organic brain dysfunction would be entitled to lifetime LTD benefits, while an employee who suffers from a disabling organic brain dysfunction plus a non-organic psychiatric illness would be limited to only to 24 months of LTD benefits. The latter employee thus would be penalized for his or her additional condition. This is not a reasonable interpretation of the Plan language. *31-*32

Turning then to the evidence, the court next explained that even the absence of objective test results such as an EEG, MRI or CT scan did not rule out the possibility of an organic brain dysfunction. However, if such evidence had existed, the issue would have been more clear-cut. Nonetheless, the court found the preponderance of the evidence favored the plaintiff.

Ultimately, however, the Court is persuaded by the well-supported opinions of Dr. Peters, the only neurologist who offered an opinion in this case, and Drs. Caster and Maiman, Plaintiff’s psychiatrist and psychologist. Each of these doctors believed that a diagnosis of organic brain dysfunction was not dependent upon positive objective test results. The Court has been given no cause to doubt the experience, expertise, and integrity of these doctors. Certainly, positive objective test results would have made Plaintiff’s condition easier to diagnose. However, based on the documents in the record, the absence of positive objective test results is not dispositive. The Court finds and determines that the preponderance of the evidence establishes that an organic brain dysfunction “caused” or “contributed to” Plaintiff’s disability as of October 18, 2000. Thus, the LTD mental illness limitation does not apply to Plaintiff. *41-*42

Jewell v. Life Ins.Co. of North America, 2009 U.S.Dist.LEXIS 27982 (D.Colo. March 20, 2009)



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