Does A Mental And Nervous Limitation Apply To My Long-Term Disability Claim?

According to the Mental Health Foundation, nearly one in three people with a long-term physical condition also has a mental condition. Claimants with both mental and physical conditions may be concerned that their insurance company will apply a mental and nervous limitation to their long-term disability insurance claim.

A mental health limitation should not apply to claims where a mental health condition is secondary to a physical disability. However, insurers may attempt to misclassify these cases in order to deny or limit benefits. This article examines situations in which long-term disability insurers commonly misapply mental health limitations and offers strategies to protect your claim.

The Role of Policy Language in Determining Limitations

The specific language in your policy is critical. Key terms to look for include:

• “Due to”: Insurers must prove that your disability was caused solely by a mental condition.
• “Caused by” or “Contributed to”: These terms give insurers more leeway to impose restrictions.

Understanding your policy is important. A careful review by you or your attorney can help identify potential misapplications of mental health limitations. This issue often arises in cases involving conditions with invisible symptoms, or where a physical condition leads to secondary mental health problems.

Common Tactics Insurers Use to Misclassify Claims

Insurers often use several strategies to misclassify physical conditions as mental health conditions, including:

• Emphasizing Diagnosis Over Symptoms: Insurers may argue that the lack of a precise diagnosis invalidates a claim, even if the symptoms are clearly disabling.
• Exploiting Symptom Overlap: Chronic pain or migraines can lead to depression or anxiety. Insurers may focus on secondary mental health symptoms to justify a claim denial.
• Biased Medical Exams: Independent medical examinations (IMEs) conducted by insurer-selected physicians may downplay physical conditions.
• Cherry-Picking Medical Records: Insurers often highlight minor notes that support their position while ignoring substantial evidence in your favor.

Proper documentation of symptoms and proactive communication with your treating physician are essential to counter these tactics.

Conditions Often Misclassified Under Mental Health Limitations

By classifying physical conditions as mental, insurers limit benefits under many policies to 24 months. Medical conditions that may trigger a mental and nervous limitation include, but are not limited to, the following.

Lyme Disease

Lyme disease presents with neurological, musculoskeletal, and cardiac symptoms. Insurers may argue that residual effects such as cognitive impairment or mood disorders are psychological. However, medical research directly links these symptoms directly to physical causes. Sheila Statlender, PhD, states in the article, Why Lyme Disease Gets Misdiagnosed as Depression, Bipolar, and More, that Lyme disease is sometimes called the great imitator because it can mimic several mental health disorders.

Related Post: Unum Denies Disability Claim for Lyme Disease

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Insurers often mislabel ME/CFS as a mental illness. For example, in Easter vs. Hartford, Hartford concluded that “the evidence does not support that you suffer from a physical condition such as chronic fatigue syndrome”.

This decision was supported by an independent review doctor, who concluded that:

“CFS is typically only diagnosed after other causes of fatigue have been eliminated. In this case, Ms. Easter appears to have ongoing significant psychiatric issues, including severe depression and anxiety, which may also cause similar symptoms as CFS.”

However, research supports physical causes such as immune dysfunction and energy metabolism abnormalities. Proper documentation by medical professionals can help counter insurers’ attempts to classify it as a mental health disorder.

Fibromyalgia

While the exact cause of fibromyalgia is not fully understood, it is widely recognized as a legitimate physical condition with a biological basis. Despite this, insurers often classify fibromyalgia as a psychological condition and use vague policy language to improperly limit benefits under a mental health limitation.

For example, the Ortiz Law Firm successfully appealed a denial of long-term disability benefits for fibromyalgia. The claimant, who was originally on disability for anxiety, depression, and PTSD, also suffered from fibromyalgia. The Standard terminated the claim, citing a mental disorder limitation and arguing that the claimant’s physical conditions did not prevent her from working.

Prior to the appeal, we ordered a Functional Capacity Evaluation (FCE). The results of the FCE indicated that the claimant could not perform any work due to her physical condition, so the Standard reinstated the claim and paid benefits.

Claimants facing similar challenges with fibromyalgia or other complex conditions should seek professional advice to ensure their rights are protected.

Complex Regional Pain Syndrome (CRPS)

Another condition often targeted by insurers is Complex Regional Pain Syndrome (CRPS). This chronic pain disorder, which usually develops after an injury, surgery, or stroke, involves extreme sensitivity to touch, swelling, and changes in skin color or temperature.

Insurers may question a claimant’s credibility or attempt to misclassify CRPS as psychosomatic in order to limit benefits. However, medical research underscores its physical origins. A comprehensive medical history and detailed evidence can challenge such misclassification.

In Brown vs. LINA, the long-term disability claim was denied in part because Cigna doubted Brown’s reports of severe pain, even though at least three treating physicians confirmed her pain level. Instead, it relied on the results of an FCE and surveillance.

Migraine Headache Disorders

Migraine headache disorder is a complex neurological disorder involving abnormal brain function, such as altered blood flow and imbalances in neurotransmitters such as serotonin and glutamate. Despite being recognized as a true neurological disorder by organizations such as the World Health Organization, insurers often misclassify migraines as a mental health condition.

This can result in the improper application of a mental and nervous limitation, which can significantly reduce the benefits to which a claimant is entitled. If your insurance company has wrongly denied your claim, an experienced long-term disability attorney can help.

For example, we recently represented a claimant in a long-term disability case involving debilitating migraines against New York Life Insurance Company. By presenting strong medical evidence and countering the insurer’s attempts to cherry-pick records, we secured a favorable outcome for our client.

Ehlers-Danlos Syndrome (EDS)

Ehlers-Danlos Syndrome (EDS) is a group of connective tissue disorders characterized by joint hypermobility, fragile skin, and chronic pain. Despite its well-documented genetic basis, insurers often misclassify EDS claims as psychological. However, proper medical documentation can dispute this misclassification.

In Pifer vs. Lincoln, which involved Ehlers-Danlos Syndrome, the court criticized Lincoln Life for potentially failing to consider all relevant medical evidence, including a symptom diary provided by Pifer that detailed her daily pain and functional limitations. The court emphasized the importance of considering all available evidence, particularly when a claimant’s condition involves subjective symptoms such as chronic pain.

Chronic Pain

Chronic pain often leads to mood disorders, creating the false impression that the condition is mental rather than physical. Insurers may also portray chronic pain disorders as psychological when there are observable physical causes. The outcome of such claims depends heavily on the exact policy language and the specific details of the claim.

In Parr vs. Reliance Standard, the court found that Reliance Standard (RSLI) improperly discounted the significance of Parr’s chronic pain and its impact on her ability to function. Reliance Standard did not point to any specific examples in the record that were inconsistent with the reported episodes of high pain levels. In fact, the court found that there were recent treatment notes consistent with Parr experiencing debilitating pain.

Multiple Chemical Sensitivity (MCS)

MCS involves severe reactions to environmental chemicals such as cleaning agents, perfumes, or smoke. Its subjective symptoms make it an easy target for insurers to dismiss as psychological. However, experts recognize MCS as a legitimate physical condition linked to environmental exposures. Proper testing and expert opinions can strengthen your case.

GI Conditions

Conditions like Crohn’s Disease and Irritable Bowel Syndrome (IBS) often result in cognitive and mood changes. The Crohn’s Disease and Colitis Foundation website states that GI problems can lead to cognitive problems associated with depression and anxiety. However, these are secondary to the physical GI symptoms and should not be classified as mental health issues.

Postural Orthostatic Tachycardia Syndrome (POTS)

POTS is a disorder of the autonomic nervous system. Problems with the autonomic nervous system, which controls automatic body functions such as heart rate and blood pressure, can cause symptoms such as dizziness, rapid heartbeat, and extreme fatigue. It is sometimes mistaken for anxiety or another mental health disorder. Medical evidence, including autonomic function tests, can help establish POTS as a physical condition.

Long COVID

Long COVID, also known as Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), refers to a range of symptoms that persist for weeks or months after the acute phase of COVID-19 has resolved. Research supports a physical basis for Long COVID.

For example, studies published in Nature Medicine and The Lancet have identified persistent inflammation, vascular damage, and autonomic dysfunction as underlying mechanisms. Brain imaging studies have also shown structural changes in the brains of Long COVID patients that may explain symptoms such as cognitive dysfunction.

Despite this evidence, insurers may attempt to limit benefits by applying a mental health limitation, citing anxiety or depression as the root cause of Long COVID symptoms.

Autoimmune Encephalitis

Autoimmune encephalitis occurs when the immune system attacks the brain, resulting in psychiatric symptoms, cognitive impairment, and neurological problems. Insurers may misclassify it as a mental health problem. However, advanced diagnostic tools, such as antibody testing and brain imaging, confirm its biological roots.

Functional Neurological Disorder

Functional Neurological Disorder (FND) is a condition that involves physical neurological symptoms—such as limb weakness, seizures, tremors, or difficulty walking—that are not caused by structural damage or disease of the nervous system. While the symptoms are real and often debilitating, they result from a disorder in the way the brain works, not from a physical injury or disease.

Because FND can sometimes coexist with psychological symptoms such as anxiety or depression, insurance companies may attempt to classify it as a mental health condition. Insurers may argue that FND symptoms are “psychological” or “psychosomatic” in order to limit benefits under a mental health limitation. However, research shows that the biological basis is well established.

Mast Cell Activation Syndrome (MCAS)

MCAS is a condition in which mast cells release excessive chemical mediators, causing chronic symptoms such as fatigue, brain fog, and abdominal pain. The symptoms can mimic anxiety or other mental health conditions, leading to misunderstandings by insurers. However, research is demonstrating the neurological causes of MCAS. Extensive testing and expert opinions are critical to supporting your claim.

Central Sensitization Syndrome (CSS)

Central Sensitization Syndrome (CSS) is a condition characterized by an increased sensitivity to pain and other stimuli due to heightened responses in the central nervous system. Insurers may argue that the symptoms associated with CSS are psychological, especially since they often co-occur with mood disorders such as anxiety or depression.

Insurers may attempt to apply mental health limitations to CSS-related disability claims, arguing that the symptoms are rooted in mental health rather than physical changes. However, research suggests that CSS has a clear physical basis. A study in the journal Pain explains how central sensitization alters pain pathways in the brain and spinal cord, increasing the perception of pain.

How to Protect Your Claim

Here are some proactive steps you can take to strengthen your claim and guard against unfair denials:

• Thoroughly document your symptoms with detailed medical records.
• Seek evaluations from specialists who have experience with your condition.
• Challenge biased independent medical examinations or peer review reports.
• Hire an experienced disability attorney to review your policy and build your case.

The Ortiz Law Firm Can Help You Appeal a Wrongful Denial of Your Claim

Facing a denied disability claim can be overwhelming, especially when insurers misapply mental health limitations. At the Ortiz Law Firm, we’ve helped countless claimants successfully appeal disability insurance denials.

Here’s how the Ortiz Law Firm can help:

• Review your policy language and assess whether a mental health limitation has been misapplied.
• Gather and present compelling medical evidence to counter insurer tactics.
• Appealing disability claim denials using our experience from similar cases.
• Fight for the full benefits you deserve under your policy.

Don’t go through this process alone. Call us at (888) 321-8131 for a free case evaluation and let us fight for the benefits you deserve.