Reliance Standard limits disability insurance benefits to 24 months for mental nervous disorder, despite claimant’s diagnosis of multiple sclerosis

This case is an example of how a diagnosis of a disabling condition such as multiple sclerosis (“MS”) does not always mean the claimant is disabled by the medical condition. In this case, while the claimant had MS, the disabling condition was depression and not MS. Unfortunately, the Reliance Standard disability policy limited benefits to 24 months for a mental nervous disorder.

Igor Gunn participated in the Paine Webber Long Term Disability Plan (“the Plan”) which was administered by Reliance Standard Life Insurance Company (“Reliance”) during his course of employment for UBS/Paine Webber (“Paine Webber”). Gunn suffered from multiple sclerosis and was unable to work due to a mental or nervous disorder, namely, severe depression. Gunn was initially awarded long-term disability benefits by Reliance. Reliance later determined that Gunn was not eligible for benefits beyond the initial 24- month period because the policy precluded an award of benefits beyond the initial 24-month period for total disability “caused by or contributed to by” mental or nervous disorders.

The “Disability Plan” booklet prepared by Gunn’s employer differed from the policy language in that it precluded benefits for disability “due to” mental illness. Reliance argued that the language of the mental illness exclusion in the policy required Gunn to show that he was totally disabled solely due to his physical condition stemming from his multiple sclerosis, without taking into account the disabling effects of any mental or nervous disorders. The District Court interpreted the language as allowing benefits so long as Gunn’s disability was not due solely to mental illness and thus ruled in favor of Gunn by holding that Reliance’s denial of benefits was an abuse of discretion. Defendants appealed against the District Court’s order.

The Court of Appeals for the Ninth Circuit noted that the booklet informed employees including Gunn that the insurance policy was the controlling document, and an integration clause in the policy precluded the application of the language in the “Disability Plan” booklet to the extent that it differed from the language in the policy.

The records of Gunn’s treating physicians showed that Gunn’s multiple sclerosis alone was not disabling. Further, an independent medical examination of Gunn by a board-certified neurologist and psychiatrist recorded that Gunn had physical impairment in the form of mild gait instability, which was not in itself a disabling symptom, and opined that Gunn would not be prevented from working at a sedentary job by his multiple sclerosis.

Although some medical records stated that Gunn was disabled “both” as a result of multiple sclerosis and depression, the Court noted that such record was not sufficient to avoid the policy limitation precluding benefits where mental or nervous disorders caused “or contributed to” the applicant’s disability.

The question was whether Gunn could meet the definition of total disability based solely on his multiple sclerosis without considering his severe depression. Gunn argued that even if his disability must be due solely to multiple sclerosis, his mental symptoms of depression and cognitive dysfunction were attributable to multiple sclerosis, a physical disease; therefore, these mental symptoms could be considered in establishing disability without violating the limitation for mental and nervous disorders. The Ninth Circuit however noted that the medical records failed to establish that Gunn’s depression and cognitive dysfunction were solely attributable to his multiple sclerosis or attributable to a degree sufficient to result in disability based on the symptoms of multiple sclerosis.

The medical records indicated that Gunn’s multiple sclerosis was “mild” and Gunn’s “severe depression” was not solely a symptom of his multiple sclerosis. There was also additional evidence in the record which supported a finding that Gunn suffered from severe depressive and anxiety disorders of psychiatric origin which were independent of his multiple sclerosis. The record also included several reports indicating that Gunn had a documented history of depressive episodes long before he was diagnosed with multiple sclerosis, including one severe episode with suicidal thoughts while in his teens, which also supported a finding of a separate origin for his psychiatric problems.

The Ninth Circuit therefore concluded that Reliance’s decision to deny benefits was grounded on a reasonable factual basis for concluding that Gunn’s multiple sclerosis alone was not disabling because Gunn would be able to work, but for his psychiatric mental and nervous disorders.

Gunn argued that Reliance should have mentioned the mental illness limitation in its letter to Gunn which referred specifically to the new definition of “disability” applicable after 24 months but excluded Plan’s limitation for mental illness. The Ninth Circuit opined that Reliance’s failure did not give rise to an inference that Reliance acted in bad faith because Gunn was given a full and fair review of his claim. Gunn was given notice of the mental illness limitation in the initial denial letter which quoted the Plan provision concerning the limitation for mental or nervous disorders. Finally, the Ninth Circuit held that the conclusion that Gunn’s disability was attributable to his mental illness, severe depression, rather than to multiple sclerosis, did not establish that Reliance simply ignored the evidence relating to his multiple sclerosis or reached a biased result.

Mental nervous limitations in ERISA group disability insurance policies are found in almost every group policy. These clauses usually limits benefits to either 12 or 24 months. If a claimant has a mental as well as a physical disability, they need to work with their physician in order to provide sufficient medical evidence of the physical disability.

DISABILITY INSURANCE COMPANY INFORMATION
Videos, Questions, Resolved Cases, Lawsuit Summaries & Company Reviews

disability insurance companies complaints

Leave a comment or ask us a question

FAQ

Do you help MetLife claimants nationwide?

We represent MetLife clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a MetLife disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from MetLife. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by MetLife.

How do you help MetLife claimants?

Our lawyers help individuals that have either purchased a MetLife long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with MetLife:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Reviews   *****

Brett C.

I have been on LTD, since Aug 2016, and Cigna is my LTD Insurance Company. I received a couple of payments from Cigna, without any issues, but then the payments stopped in Oct, at which time I was informed by Cigna that they were “looking into” my claim. Cigna stopped contacting me, would not even return calls or emails, but finally contacted me in mid-December to inform me that they would not be continuing with my claim.

I contacted Dell & Schaefer in January, at which time I began working with Attorney Alex Palamara, Disability Appeal Specialist Randa Escayg, and Legal Assistant Kathy Bordes. These folks were always kind, professional, understanding, did a great job of explaining everything to me, and most importantly I could tell that they truly cared about the situation my wife and I had unfortunately found ourselves in.

I fully understand the feeling of being overwhelmed, when you are first denied, that David vs Goliath feeling of you against some huge conglomerate, that powerless and helpless feeling that overcomes you when you are sick and injured and at your most vulnerable. The only things that you are able to focus on are saving your family’s home, doing whatever you can to take care of them, all while you should be focusing your energy on getting better, as much as you are able, so that you can recover your life to what it once was, returning your current life of overwhelming stress and chaos to some semblance of normalcy. Well, as soon as I began working with Alex, Randa, and Kathy, I immediately felt better, like I finally had someone in my corner fighting for me, somebody who cared, and somebody who would stand up to that giant corporation, and make things right.

Alex won my appeal for me, and Cigna is in the process of restoring my full benefits, retro back to October. I cannot describe to you the feeling of joy and elation the moment my wife and I were notified we had won. To those currently dealing with a LTD company, and all of the madness that entails, just know that there is a light at the end of the long dark tunnel. You do still have hope, and you can certainly do no better than to have the wonderful folks at Dell & Schaefer in your corner fighting for you!!!!

Read 424 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us