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Unum Denies Cognitive Impairment Claim Based On 24-Month Mental Illness Limitation

In Gill v. UNUM Life Insurance Company of America, the U.S. District Court for the Northern District of California decided a dispute over long-term disability (LTD) benefits. The plaintiff, Terrance Gill, was a project manager at Union Bank when he applied for LTD benefits. He received benefits under a UNUM policy governed by the Employee Retirement Income Security Act (ERISA).

Gill’s benefits were terminated after 24 months because UNUM’s policy limited benefits for disabilities caused by mental illness to a maximum period of 24 months. UNUM classified his condition as falling under the policy’s mental illness limitation because his disability diagnosis was primarily bipolar disorder, which had been managed in the past without significant cognitive impairment noted until more recent years.

The disability policy defined disability as follows:

“You are disabled when Unum determines that:

  • You are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and
  • You have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.

After 24 months of payments, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training, or experience.”

Gill argued on appeal that his cognitive impairment disability was a physical condition and was not subject to the mental illness limitation.

He submitted evidence that his cognitive impairment was severe and independent of his bipolar disorder, including an opinion from Dr. Steven McIntire. Dr. McIntire supported the contention that Gill’s cognitive deficits were too severe to be attributed solely to depression or bipolar disorder and could be related to neurological problems.

Unum, however, upheld its earlier determination terminating benefits. Gill filed suit, and both parties presented arguments regarding the termination of benefits based on the policy’s limitation for disabilities caused by mental illness.

Plaintiff’s Arguments

  1. Nature of Disability: Gill argued that his disability, characterized by mild cognitive impairment, was physical in nature and not a mental illness. He contended that it should not be subject to the policy’s 24-month limitation on benefits for mental illness to 24 months.
  2. Ambiguous Policy Language: Gill argued that the language of the policy’s mental illness limitation was ambiguous and therefore should be resolved in his favor.
  3. Cursory Review: Gill argued that UNUM violated the statutory and regulatory requirements entitling him to a full and fair review because it conducted only a “cursory review” of Dr. McIntire’s evaluation and failed to provide his complete file to the independent doctors reviewing his claim.

Defendant’s Arguments

  1. Nature of Disability: UNUM emphasized that Gill’s cognitive impairments were manifestations of his bipolar disorder, citing reports from several physicians who evaluated Gill’s condition and overwhelmingly agreed that his disability was related to his longstanding psychiatric conditions rather than a separate physical cause.
  2. Unambiguous Policy Language: Unum argues that its policy unambiguously defines “mental illness” as “a psychiatric or psychological condition regardless of cause.” Therefore, the focus of the limitation is on whether Mr. Gill’s symptoms constitute a psychiatric or psychological condition.
  3. Compliance with ERISA Guidelines: UNUM contended that it complied with ERISA guidelines and conducted a thorough and fair review process before denying the continuation of Gill’s benefits.

The court ultimately ruled in favor of UNUM, agreeing with the insurer that the preponderance of the evidence did not support Gill’s claim that his cognitive impairments were due to a physical condition separate from his diagnosed mental illness.

The court emphasized that even Gill’s own treating physicians did not conclusively support the notion that his cognitive impairments were independent of his bipolar disorder. Therefore, the LTD benefits were properly limited to the 24-month period specified in the policy.

Struggling with a Long-Term Disability Denial Due to a Mental Illness Limitation?

The Gill claim was not handled by the Ortiz Law Firm. However, we have vast experience with mental health disability claims and in claims against Unum.

At Ortiz Law Firm, we specialize in challenging unfair disability denials and securing the benefits our clients deserve. If your LTD benefits have been unjustly denied based on mental health conditions, we’re here to help. Experienced long-term disability attorney Nick Ortiz understands the intricacies of disability insurance policies and ERISA regulations and is committed to advocating for your rights. Call Ortiz Law Firm today at (888) 321-8131 for a free case evaluation.

Disclaimer: This case was not handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.

Here is a PDF copy of the decision: Gill v. Unum