The Interplay Between Physical and Mental Disabilities in An ERISA Disability Claim

Welcome to Season 5, Episode 8 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "The Interplay Between Physical and Mental Disabilities in An ERISA Disability Claim."

Join attorney Nancy L. Cavey, a leading expert in disability claims, for an insightful discussion on the complexities of mental nervous condition limitations in ERISA disability policies - especially when they intersect with physical disabilities. In this episode of Winning Isn't Easy, Nancy unpacks two key limitations insurers use to deny or terminate claims, including the notorious "Monty Python" limitation, which cuts off benefits if a mental condition contributes to a disability, no matter how minimally. Through real-world cases - from post-surgical depression to fibromyalgia - she reveals how insurers exploit these clauses to restrict benefits. Don’t miss this essential conversation on protecting your rights and navigating these restrictive policies. 

In this episode, we'll cover the following topics:

One - Case Study: McEachin v. Reliance Standard Life Ins. Co.

Two - What Constitutes Disability in the Context of a Mental Nervous Claim?

Three - The Interaction between Physical and Mental Health Disabilities

Four - What Happens if You Become Disabled Sequentially by Physical and Mental Illness?

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Navigating Your Social Security Disability Claim. Give it a listen: https://wiessdpodcast.buzzsprout.com/


Resources Mentioned in This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


Need Help Today?:

Need help with your Long-Term Disability or ERISA claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

Review, like, and give us a thumbs up wherever you are listening to Winning Isn't Easy. We love to see your feedback about our podcast, and it helps us grow and improve.

Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Nancy Cavey [00:00:15]:
 Hey, I'm Nancy Cavey, national ERISA and IDI disability attorney. Welcome to Winning Isn't Easy. Before we get started, I've got to give you a legal disclaimer. This podcast is not legal advice. The Florida Bar association says I have to say it, so now I've said it. I will tell you that nothing is going to ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that carriers play, and what you need to know to get the disability benefits you deserve. So off we go now. Many ERISA disability insurance policies or plans have mental nervous policy limitations and they come in two different forms, forms or flavors.
 
 Nancy Cavey [00:00:55]:
 The most common is one that will limit benefits to just two years if the policyholder or plan beneficiary's disability is caused by the mental nervous condition, as that term is defined by the policy or the plan. And that's the more common one that we see. But the one that always causes me the greatest concern is what I call the Monty Python mental nervous policy limitation, and it's much more problematic. It restricts benefits to just two years if your disability is caused or contributed to, regardless of how small, by a mental nervous condition. And I think that this distinction is very critical. So, for example, you may have undergone spine surgery and experienced post operative pain that will lead to depression or anxiety, and your benefits could be limited to just two years if your doctor says that your disability is due to depression or a combination of back pain or depression, even though that underlying physical problem with your back caused the depression. Now, I also represent a lot of folks who have multiple sclerosis and as their condition progresses they'll experience increased physical, cognitive and even psychological issues if after two years the Ms. Specialist says, look, the disability is due solely to depression, which I've never seen, benefits are going to be limited to just two years.
 
 Nancy Cavey [00:02:20]:
 But if the specialist attributes the disability to a combination of the Ms. Symptoms and depression, for example, benefits are still going to be limited to two years if you have this caused or contributed to language in your disability insurance policy or plan, and that minor psychological condition can trigger that two year limitation. In this podcast, what we're going to talk about in greater detail is a case study and I'm going to talk about the McEachin versus Reliance standard case. I'm also going to talk about what constitutes a disability in the context of a mental nervous claim. I'm also going to talk about the interaction between physical and mental health disabilities. And lastly, I'm going to talk about what happens if you become disabled sequentially by a physical condition and a mental illness. So we've got a lot to cover today. But before we do that, let's take a quick break and be sure to come back with a pad and a pen so that you can take notes.
 
 Nancy Cavey [00:03:18]:
 Got it. Let's take a break. Welcome back to Winning Isn't Easy. We're going to be talking about a case study involving the issue of mental nervous policy limitations. And it's McEachin versus Reliance Standard Life. I'm going to use this case to set the stage for our discussion, and it's a decision that was reached in November of 2024. So it's a recent decision. Now, McGeechen was a human resource manager at a company called Perceptron.
 
 Nancy Cavey [00:04:02]:
 And In February of 2017, she was involved in an automobile accident sustaining serious injuries, including spinal injuries. In that year, she had a second auto accident. It was almost like there was a bullseye on the back of her vehicle. Over the next three years, she underwent three major spinal surgeries, spinal injections, multiple rounds of physical therapy, and pain management, all without relief. And as you can imagine, that pain caused sleep disturbance and depression and anxiety. Now, her employer offered her a disability insurance plan that was insured by Reliance Standard. After her 2017 accident, she submitted a disability claim and RS approved a claim, Reliance Standard, in June of 2017. They paid benefits for over three years.
 
 Nancy Cavey [00:04:51]:
 Unfortunately, in 2019, her son tragically died as a result of suicide and she developed post traumatic stress disorder. Now, you need to understand that disability carriers will routinely review claims that have been accepted because they're always looking for a reason to deny or terminate the benefits. And McEachin's case was no exception. In October of 2020, they terminated her benefits, saying she wasn't disabled anymore. She appealed, and then Reliance Standard reinstated her benefits to saying, look, there's no mental health barriers that prevent you from working. Remember that. Keep that in mind here. This meant that Reliance Standard didn't believe her depression, anxiety, or post traumatic stress disorder were disabling, and they were focusing on her physical ability to work.
 
 Nancy Cavey [00:05:38]:
 Now, Pikachin provided updated medical records and Reliance Standard determined that they supported her continued physical disability. So they rescinded the termination and reinstated the benefits. But as I've said, disability carriers and plans are not in the business of paying benefits out for the life of the period of benefits that you might be eligible for under the policy of the plan. And so Reliance Standard had her records reviewed again and concluded that she was now physically improved enough to go back to work. Her medical records show that there had been a decrease in her migraines. She had improved strength through physical therapy. There were positive MRI and X ray results. She even told the doctors that she was feeling better.
 
 Nancy Cavey [00:06:22]:
 She was participating in activities like rafting. That sounds significant. Now, based on this, Reliance Standard determined that she wasn't physically disabled. And at this point, however, Reliance Standard then changed their position and said, look, you're disabled because of the psychological issues and they're independently disabling. Guess what? This plan had a two year mental nervous policy limitation. And since she had psychological issues dating all the way back to 2017, Reliance Standard terminated her benefits, saying, look, you've exhausted the maximum duration for your mental health related disability, 2017-2019. She appealed, but Reliance Standards stood firm. This case proceeded to federal court which ruled that while she wasn't physically disabled anymore, she was entitled to an additional 24 months of benefits beginning in April of 2021 when her benefits were terminated because of her psychological condition.
 
 Nancy Cavey [00:07:23]:
 Now, I will tell you, in my many years of practice, that was an unusual decision because courts rarely restart the benefit clock. Now, both parties appealed to the 6th Circuit and later in this episode, I'm going to discuss what happened next. But I'm really kind of baiting the hook here. So let's take a break while you think about this narrative that I just gave you. That's going to set the stage to our further discussion.
 
 Speaker B [00:07:54]:
 Have you been robbed of your peace of mind by your disability insurance carrier? You owe it to yourself to get a copy of Robbed of your peace of mind, which provides you with everything you need to know about the long term disability claims process. Request your free copy of the book@kvlaw.com today.
 
 Nancy Cavey [00:08:28]:
 Welcome back to Winning isn't Easy. What constitutes disability in the context of a mental nervous disability claim? Now, the term disabled is commonly defined as a condition that limits a person's movements, senses or activities. That's the common definition of disability that you and I use in our everyday life. But that's not the definition of of disability in an ERISA case. You've got to get out your policy or plan because there's no uniform ERISA disability policy or plan. The definitions of disability will vary among plans and carriers. I've seen multiple versions offered to one class of employees. So you need to understand that plans have different definitions of disability for benefit eligibility and for even waiver of premium.
 
 Nancy Cavey [00:09:20]:
 So we want to start out obviously by getting a copy of your policy or plan. And the first thing we want to look at is the definition of disability. What is it? Write it down. Now the second definition that's important here is the definition of occupation. And the occupation definition is really crucial. Remember, you haven't insured your job, you've insured an inability to do your own occupation. So we need to understand how is that term defined. And many times you can see a definition of disability that could be how your occupation is performed for your employer, how it's performed in the local economy, how it's performed in the national economy, how it's performed according to the Dictionary of Occupational Titles.
 
 Nancy Cavey [00:10:07]:
 So this definition is really crucial in assessing whether or not you can perform your occupational duties not only from a physical standpoint, but or from a cognitive standpoint. So write down that definition. Then we're going to get to the definition of mental illness in the policy or plan. And again, no uniform policy or plan. But I will tell you that most policies or plans will define mental illness as a psychiatric or psychological condition regardless of the cause, such as schizophrenia, depression, bipolar disorder, anxiety, personality disorder, or adjustment disorders typically treated by a mental health provider using psychotherapy, psychotropic drugs or similar treatment. Now I will tell you that bipolar disorder, even though it has an organic cause, is often classified as a psychiatric condition, leading to challenges in disability claims. But that's a digression. Now with those fundamental concepts, we are going to go back and figure out whether a back pain caused by lumbar radiculopathy qualifies as a somatic system disorder, justifying prudentials termination of long term benefits.
 
 Nancy Cavey [00:11:22]:
 So the case I'm going to talk about now I think is a good example of games that disability carriers or plans play. They often use these policy limitations, such as the mental nervous policy limitation, to restrict benefits to just two years. And they apply this limitation even when the disabled policyholder or plan beneficiary has a physical condition that leads to psychological problems. So let's talk about the case of Cherry versus Prudential Insurance. It's a 2002 case out of the state of Washington. Cherry was a former Microsoft software engineer and he became disabled as a result of chronic and unremitting lumbar radiculopathy. Think of it like lighting a match, if you will, and having this burning pain going down your leg that doesn't stop. Now, he was part of an elite team responsible for developing new Microsoft products, and that obviously required prolonged sitting while solving complex coding problems.
 
 Nancy Cavey [00:12:20]:
 He worked 50 to 60 hours per week and was on call every six weeks, which required immediate availability as you can imagine he developed severe back issues. He underwent unsuccessful spine surgery, and despite that procedure, he continued to have this lumbar radiculopathy, this burning pain down his leg that radiated from his buttocks down to his toes. Now, he filed a disability claim and Prudential initially approved it on the basis of his back condition. However, during the claims process, they had him undergo a not so independent physical and psychiatric evaluation. Prudential's psychiatrist diagnosed him with having a moderate somatic symptom disorder characterized by excessive thoughts, feelings and behaviors that disrupted his daily life and interfered with completing tasks. The diagnosis did not discount a possibility of an underlying medical condition, but that made it difficult to prove that his symptoms were inconsistent with the medical abnormalities. And by that we mean that there could be a medical basis for his symptoms. But the complaints may not necessarily have had objective findings on examination or diagnostic studies.
 
 Nancy Cavey [00:13:40]:
 So you've had back pain, you've got surgery, you still have the back pain with leg pain, but maybe the testing or the exams are still normal. Certainly his psychiatric test results were consistent with somebody suffering from chronic pain. The diagnosis conveniently set the stage for Prudential to invoke the two year mental nervous policy limitation. And as expected, the Microsoft Disability plan had such a limitation in its policy and plan. So what happened here was when Cherry's claim transitioned from own occupation to any occupation, Prudentials said, hey, look, we think that you are disabled because of the somatic symptom disorder, and we're not going to pay benefits any further under the two year mental nervous policy limitation. And the only way we're going to pay benefits is if you are physically disabled. Now, despite unanimous opinions from Cherry's physicians confirming it couldn't work, including an FCE that demonstrated he couldn't even work part time, Prudentials still denied the claim. So what was the reason, the justification that they came up with? Well, the physical exam they arranged suggested he could work part time and gradually increase his hours.
 
 Nancy Cavey [00:14:54]:
 And they further claimed that his physical limitations stemmed from this somatic symptom disorder. I call it the pain that's in your head rather than an actual physical condition, which obviously is. This case, as you can imagine, ends up in front of a federal judge. Now, in the state of Washington, there's something called a ban of discretionary clauses. A discretionary clause lets the judge substitute their own judgment for that of the disability carrier or plan. That's the preferred standard of review because the other standard of review is called arbitrary and capricious. And normally there's A very high burden that we have to prove to establish that the carrier plan's denial or termination was arbitrary and capricious, and it serves as a golden handcuff on the hands of a judge trying to do what's right. Now, fortunately for Cherry in this case, there were no discretionary clauses, so the judge was able to do a de novo review and substitute their own judgment for that of the carrier.
 
 Nancy Cavey [00:16:00]:
 So what the judge did in this case is said, look, excuse me, Cherry's symptoms are consistent with what chronic pain sufferers will suffer. Number two, this diagnosis of somatic symptom disorder doesn't invalidate the medical basis of the symptoms. And lastly, the judge said, look, there's no evidence that Cherry's disability was due in whole or part to mental illness. The judge reinstated Kerry's benefits and dismissed Prudential's attempt to justify the denial. Now, I'll tell you that won't always be the case, particularly if there is an arbitrary, capricious standard of review. But you can see how the judge went about looking at this. The judge looked at the definition of disability, occupation, mental illness, and went through basically the gyrations that Prudential had gone through to try to create and justify the denial and took them apart one by one. You can see case by case basis.
 
 Nancy Cavey [00:17:00]:
 And of course, the standard of review is really important. Let's take a quick break. Welcome back to Winning Isn't Easy. Let's talk about the interaction between physical and mental disabilities. And in particular, I'm going to talk about Unum and how Unum used a mental nervous policy limitation in a fibromyalgia claim to create a reason to deny a claim. Fibromyalgia is a condition that's characterized by widespread pain, joint pain, fatigue and fibro fog. And many fibromyalgia sufferers develop depression because of that chronic pain, pain, fatigue and sleep disturbances. Unfortunately, that can make them vulnerable to an ERISA claims denial based on a subjective medical condition or mental nervous policy limitation.
 
 Nancy Cavey [00:18:00]:
 So what is that mental nervous limitation? Many disability policies will limit the payment of benefits to just 24 months if the policyholder is disabled due to mental illness. Let's talk about that definition. There's no uniform one, but again, this is sort of an example of a definition that is used and one that of course you should check in your policy. It is a psychiatric or psychological condition regardless of cause, such as schizophrenia, depression, bipolar disorder, anxiety, personality disorder, or adjustment disorders typically treated by psychotherapy, psychotropic drugs rather or similar methods. Now that's A basic mental nervous policy limitation. But remember, we've got the second form, the second flavor, which is the cause or contributed to one. And in that definition, if your psychological condition contributes ever so slightly, ever so slightly to the disability, your benefits are limited to just two years. So they come in two flavors.
 
 Nancy Cavey [00:19:04]:
 And disability carriers would love to use them to limit benefits to just two years. So let's talk about the case of Jennifer CATO in Cato vs. UnumLife. It's a 2022 case. Now, Cato was a principal traffic engineer with Parsons Corporation and she filed a long term disability claim because of fibromyalgia, sleep disorders, migraines, syncopy and anxiety. So Unum initially approves the claim and then later terminates her claim as the two year policy mental nervous limitation period expires. How did they go about that? Well, Unum has their medical reviewers, their in house liar for hires, who concluded that despite all these problems, she had no physical impairments, which of course I have a problem with. But they said, look, you have no physical impairments, you're psychiatrically impaired.
 
 Nancy Cavey [00:20:04]:
 And Unum of course said, okay, you're ineligible for continued period of benefits after the 24 months. You don't have any physical condition that causes a functional limitation. And too bad, so sad. Now, in this instance, Cato appealed and sued, saying, look, Unum cherry picked my records. Amazingly, the court said, look, Unum told you from the very beginning that your primary condition that they were accepting was anxiety and depression. Your medical records really aren't addressing your physical symptoms and your limitations. We have to agree with Unum, and in this case there is what's called the arbitrary and capricious standard of review, which makes it difficult for the judge to overturn the denial. But you can certainly see the games that are played here.
 
 Nancy Cavey [00:20:50]:
 And I want you to understand what the issues are and the lessons that you should be learning from these kinds of cases. The first is that your medical records have to thoroughly document your physical symptoms and the physical basis for your complaints and limitations. Similarly, if you've got problems with depression or anxiety or any other psychological condition, your records and the opinion of your physicians should clarify that your disability is caused by the physical problems that not the psychiatric problems. And if you have one of these policies where we have the caused or contributed to language, you definitely need to have your physician, your psychologist and psychiatrist, and your doctor who's treating you for your physical conditions clarify that your disability is caused by the physical conditions and that there is no contribution to your disability because of psychological issues. And the other lesson you need to learn, quite frankly, is how to give a history to both your physicians who's treating you for your physical problems, and your psychologist and psychiatrist. If you make yourself out to be psychologically impaired as part of the history that you're giving to the doctor, that's one thing, and you certainly need to be truthful with them. But as you approach approach this two year mental nervous policy limitation or own occupation to any occupation stage, you really have to, I think, moderate the nature of your complaints and have an off the record discussion with your physician and your psychologist or psychiatrist about the import of the mental nervous policy limitation and what impact any psychological problems are having literally in your ability to do your own occupation or any occupation. And of course, another lesson here is don't give statements to the disability insurance carrier plan without legal representation.
 
 Nancy Cavey [00:22:51]:
 Because even in the most innocuous phone call with the carrier or the representative, you can say things that will lead them to conclude that there's a basis for denying this claim at the end of two years on a mental nervous policy limitation. In my office, we don't allow our clients to talk to the disability carrier without representation and preparation. Got it. Hopefully you don't have to deal with a fallout of these kinds of experiences or lessons. Let's take a break.
 
 Speaker B [00:23:27]:
 Are you a professional with questions about your individual disability policy? You need the Disability Insurance Claim Survival Guide for Professionals. This book gives you a comprehensive understanding of your disability policy with tips and to dos that will assist you in submitting a winning disability application. This is one you don't want to miss. For the next 24 hours, we're giving away free copies of the Disability Insurance Claims Survival Guide for Professionals. Order yours today@disabilityclaimsforprofessionals.com.
 
 Nancy Cavey [00:24:19]:
 Welcome back to Winning Isn't Easy. What happens if you become disabled sequentially by a physical illness and then by a mental illness or a combination? This is the case of McEachin vs Reliance Standard and we started this podcast episode talking about this case. So let me refresh her memory. She had two severe auto accidents in 2017 leading to major spinal surgeries, physical therapy, pain management. She developed depression and anxiety and post traumatic stress. Reliance initially terminated her benefits in October of 2020, claiming she was no longer disabled. She appealed, sent them additional information. They reinstated her benefits, saying, you're physically disabled, but your mental health is not preventing you from working.
 
 Nancy Cavey [00:25:08]:
 So when Reliance reinstated the benefits, everything seemed to be going fine until they looked at her records again and they decided to terminate her benefits. After claiming that her physical condition had improved, they argued that she was independently disabled as a result of the mental illness triggering the 24 month limitations. So in the case, the 6th Circuit ruled that the mental health limitation didn't begin until April of 2021, when Reliance first terminated the benefits. They rejected Reliance's arguments that the mental health symptoms earlier in her claim had triggered that limitation. So concurrently, they were running the physical and the psychiatric limitations. You know, 24 months own occupation, 24 months mental limitations. The court said, no, we don't buy that, and found that McEachin was entitled to an additional 24 months of benefits for mental disability from the time they had cut off her benefits from a physical standpoint. So I think some of the key takeaways from this particular case is going to be your medical records.
 
 Nancy Cavey [00:26:22]:
 What story does your medical records tell about both your physical condition and your psychiatric condition? Now, from a physical standpoint, she had reported that she had had improvement in terms of her pain. She was more functional, including even going rafting. The physical exam findings and the diagnostic studies showed improvement. And the court agreed that the carrier was right, that there had been physical improvement and that therefore no benefits could or should be paid as a result of her multiple spine surgeries. But we also have to look at the mental health issues. What is it in the medical records that addressed her functional restrictions and limitations? And more importantly, remember, they had determined that she wasn't disabled as a result of her psychiatric problems when they reinstated her benefits. And it wasn't until October of 2020 that they had now taken the position that her mental problems from the very beginning were also a contributing factor to her disability. And I think in part that was an issue for the court because the carrier was switching gears.
 
 Nancy Cavey [00:27:37]:
 At one point they're paying benefits based on the physical issues and then they're reinstating them based on physical and saying, no, no, no, no mental. And now all of a sudden we want to terminate benefits. And while you're not physically disabled, we're going to apply the mental nervous condition limitations, even though we didn't think you were disabled because of those conditions. So that's an example of some of the dumb games the carriers can play is not clear from the decision what was in the medical records about her mental condition and her symptoms and functionality. But again, you've got to be cognizant of the definition of disability, occupation and psychiatric mental nervous limitations. So you understand the parameters, if you will, the box, if you will. You're in in this game, so you have to understand that you've got to understand what's in your medical records. You've got to also understand that the forms that you fill out, that you're required to fill out by the carrier's request, your activities of daily living form are going to be closely scrutinized together with social media.
 
 Nancy Cavey [00:28:45]:
 So if you're doing something that is, you know, inconsistent with what it is you're claiming, you're going to be, you're going to have a problem. Now, you can also see it in this case that the court was analyzing when the mental health limitation period started. So you really do have to think this out. If you've got a policy limitation that's contributed to, you certainly don't want to emphasize the mental health issues as being the cause for the disability. You need to understand that you've got to sort of play is not the right word, but you got to understand the parameters of the policy in developing your medical history, your report of activity. And if you have a situation like this, the court obviously is going to say, look, we're going to look at these medical records. At what point in time was the physical condition resolved? At what point did the mental health issues become disabling? Ah, well, it's as of that date. Well, then that's the date upon which the mental health limitation period is going to start.
 
 Nancy Cavey [00:29:56]:
 You can see that this is a complex area and it's going to depend on the policy wording, the facts and federal court interpretations. I can't tell you that every court is going to follow the 6th Circuit. There are some that do and there are some that don't in this analysis. So it really is important. If there is a mental health issue in your case and you've got the cause or contributed to language or you've got a straight mental nervous policy limitation that you could really consult with an experienced ERISA disability attorney, kind of sort all this out so you understand the games that are going to be played at each stage, the proof that you are required to submit, and that you can anticipate what kinds of defenses or arguments that the carrier is going to use to justify a denial or termination of your benefits. Got it. Well, I thank you for tuning in to this week's episode of Winning Isn't Easy. Please leave a review, share it with your family or friends, and subscribe to this podcast.
 
 Nancy Cavey [00:30:57]:
 I also want to hear from you at the beginning of each episode description. You can find a link where you can send us your questions or comments and I might even feature them in a future episode. So join us next week for another insightful episode of Winning Isn't Easy. Thanks for listening.