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Guide to Limitations for Disabilities in Mental Health Patients

Regardless of your disability insurance coverage, you must file a comprehensive insurance claim form to receive monthly disability attorney benefits. Though similar to insurance claims after property damage or car accidents, a long-term disability (LTD) claim can prove complicated and cause substantial financial consequences.

LTD claims for mental illness are common, but many LTD insurance policies contain language that limits or excludes benefits for nervous and mental conditions.

For instance, one common limitation is the mental illness benefit limitation of 24 months of benefits. Sometimes, the limitation says “due to” or “caused by” and sometimes the limitation states mental disability benefits for disability “contributed by,” or “caused by” a mental condition.

Therefore, the language of the mental limitation is essential in ascertaining whether the limitation applies to a particular case. Working with an experienced LTD claims attorney right at the start of the claims process can help you throughout the maze.

The Need of Mental Disability Benefits

Millions of U.S. citizens struggle with vast emotional ailments. A recent survey compiled by the National Institute of Health found that one in every five adults has a mental condition. The advent of the Coronavirus situation and the resultant economic recession has made the number worsen to about four in every ten adults.

For most people in this category, the severity of their mental illness limits them from work activities. If a mental condition is preventing you from working, you may be eligible for various disability benefits.

The most common disability benefits available are:

  • Long term disability (LTD)
  • Short-term disability (STD)
  • Social Security Disability
  • State Disability

Others include Supplemental Security Income, and disability retirement benefits.

Overview of Mental Illness Limitation

Common LTD benefits for mental illness last only 12 to 24 months. But exceptions are sometimes made for specific conditions like Alzheimer’s, dementia, and schizophrenia. If your policy exempts such conditions from the timeline limit, you can collect your benefits for pretty long.

These limitations are almost always available in group ERISA policies and numerous other individual policies.

Mental illness limitations vary. Your claim may be wrongly limited or denied if your disability results from physical illness and you also have a mental condition. If this is your condition, you should reach out to a reliable ERISA attorney immediately.

An insured generally cannot receive monthly insurance benefits for more than 24 months for a disability (including residual) caused or contributed to by:

  • Alcoholism
  • Bipolar affective disorder
  • Drug abuse or addiction
  • Delusional disorders
  • Schizophrenia
  • Depressive disorders
  • Psychotic disorders
  • Eating disorders
  • Anxiety disorders
  • Mental illness
  • Somatoform disorders

Policy limitations for mental illness usually do not apply if the insured is hospitalized from a mental problem at the end of the mental limitation period.

The Problem with Long-term Disability Policies

Insurance providers often overlook physically disabling conditions and award benefits based on a person’s mental health diagnosis. This limits them to paying only two years (or 24 months) of benefits. Then again, they may attempt conflating a physical condition into a mental one to invoke the limitation in the policy.

The limitation should specifically define mental conditions or illnesses to enforce the policies under the law.

Suppose the insurance policy doesn’t clearly define mental health or mental illness and leaves the determination to the company’s discretion. In that case, the court may find and declare this provision ambiguous and construe it to favor the claimant. For this reason, numerous federal courts have invalidated nervous/mental limitations in LTD insurance policies.

You Need Proof of Physical and Psychiatric Conditions

If your insurance policy covers a mental illness limitation and you have a physical and mental condition, your benefits may cease after the expiration of the maximum allowable period. This is possible when someone develops anxiety or depression after a disabling condition like chronic pain.

In this case, you’re obliged to prove that the condition is serious enough to render you disabled from the physical problem only. In essence, you would still be disabled even if you never had the mental condition.

Your physician’s views can be helpful if you’re struggling with both physical and mental conditions. They may determine the condition that’s preventing you from working. While the insurer isn’t required to consider the opinion as truth, they must consider it.

Medical Qualifying with a Mental Illness

The Social Security Administration (SSA) conducts a comprehensive evaluation of your medical records to ascertain your eligibility. They’ll match your records to a disability listing in the medical guide known as “The Blue Book.”

The listing outlines the condition’s severity level requirements and the specific medical evidence to support your claim.

According to Section 12.00, mental illness includes:

  • Anxiety-related disorders (12.06)
  • Personality disorders (12.08)
  • Affective disorders (12.04)
  • You need extensive medical records to quantify these, including:
  • Psychologist or psychiatrist’s information regarding your diagnosis
  • Brains scans or any other confirmation of physical abnormalities
  • Treatment records highlighting medications used and therapy
  • Comprehensively documented episodes of increased decompensation symptoms

Get Professional Assistance Interpreting Your Policy’s Mental Illness Limitation

Often, your benefits’ future heavily relies on your initial application submission. Therefore, talk to a long-term disability lawyer to ascertain whether your policy contains a mental illness limitation before planning your application accordingly.

Disability benefits attorneys are well-versed in STD and LTD policies that contain these mental health limitations. An experienced Boston disability attorney can interpret your policy, and develop a strong application likely to preserve your future benefits for the longest time possible.

 

DarrasLaw is Americas' most honored and decorated disability litigation firm in the country. Mr. Darras has seen more, evaluated more, litigated more, and resolved more individual and group long term disability and long-term care cases than any other lawyer in the United States.

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