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Long-term disability insurance: mental impairment limitations on benefits

There are also "older" and "newer" insurance contracts that impose different levels of restrictions on benefits when a patient with a physical illness also has a documented "mental impairment", including depression, anxiety, etc.

The "older" policies—many still in force—restricted disability benefits to two years when the disability was "due to" a mental impairment. A major difficulty for an ME/CFS, FM, or Lyme disease patient under these "due to" contacts was to ensure that the illness was not improperly diagnosed as a mental impairment: depression, etc. Many patients are familiar with being misdiagnosed as having depression instead of ME/CFS or FM. Secondly, many patients with these illnesses do have secondary or reactive depression as a natural response to having an unyielding, chronic physical illness. Still, under these circumstances, the insurance company could claim that the mental impairment was itself a disabling cause rather than a consequence of the physical illness. Then the disability would be "due to" the depression and benefits cut-off after two years.

The remedy to this problem was for a doctor(s) to document that the depression was "reactive" or "secondary"—only a result—of the physical illness. Therefore the disability was only "due to" the physical illness.

However, newer policies developed by the insurance industry (in favor of their own interests) changed the "due to" language to "contributes to". Therefore any medical documentation that indicates or implies that a mental impairment contributes to the overall disability and inability to work could have the effect of cutting off benefits after two years. For example, a person with ME/CFS has, naturally, some ongoing depression actually caused by the illness. However, the medical record indicates that the depression, in addition to the physical illness, would be a likely factor in the person's inability to work. Such documentation, or even an interpretation of the documentation, would likely mean a massive curtailment of benefits.

To combat an insurance company's seizing on any mention of depression or other mental impairment as a reason to curtail benefits, patients, their doctors, and attorneys must document that such impairments do not "contribute to" the disability caused by the physical illness. There should be a clear statement in the medical record by the physician(s) to refute any implication that a mental impairment contributes to the disability—the person's severity of illness and inability to work is entirely a consequence of the physical illness.

Also, it is prudent for patients not to offer, unless required to do so, information on emotional issues in their forms. Consult with a knowledgeable attorney if you are unsure as to what is required. You must answer questions truthfully, but you do not have to offer unasked for information.