Long term disability applicants in Chicago are discovering that their employer sponsored long term disability insurance policies often have clauses which place a 24-month limit on disability benefits caused by any mental or psychiatric conditions, including depression, anxiety, ADHD, etc. For years, insurers would argue that a 24-month limitation applies any time a claimant's list of conditions included depression or anxiety. Claimants have been able to overcome those benefit terminations by showing that even if any mental or psychiatric conditions are ignored, they are nevertheless physically disabled. More recently, though, Prudential terminated benefits after a claimant developed severe cognitive impairments following a car accident in which he was injured. The court did not allow Prudential to get away with this one in White v. Prudential Insurance Co. of America, No. 11-3394 (E.D. Pa. Nov. 9, 2012).
After a 2007 auto accident, White was diagnosed with post-concussion syndrome--a traumatic brain injury--and experienced emotional and psychological strain, anxiety, and depression. Prudential denied White's initial claim, but after two appeals overturned the denial. After 24 months, Prudential terminated the payments, claiming the cognitive impairments were subject to the limit for mental illnesses. White appealed, but Prudential never responded to his appeal. White sent several letters following up with Prudential to try to spur a determination, but nothing happened. Almost a year later, White just filed his lawsuit. After White filed the lawsuit, Prudential produced a letter upholding the benefit denial. The letter was dated 10 months after White submitted the appeal, clearly in violation of ERISA's 45-day deadline for an insurer to respond to an appeal.
The judge awarded a judgment in White's favor. The judge determined that while ERISA does not require an insurer to give special weight to treating physicians' opinions over its own retained physicians' opinions, Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), Prudential improperly ignored all the opinions which concluded White's disability was caused by the head trauma suffered in the 2007 auto accident. Though the disability is due to a mental illness, if the mental illness is caused by a physical injury, then the 24-month limitation does not apply.
If your long term disability benefits have been terminated pursuant to a limitation on mental illnesses, and you believe the disability relates to a physical injury, call an experienced ERISA lawyer.