Principal Uses Limitation Provision to Deny Disability Benefits

Certain conditions can be hard to prove up, or even diagnose, and insurers, such as Principal, will key in on this and may seek to deny, or at least limit, benefits.  This can be true of Principal, even when policy language does not explicitly request objective medical evidence.

One such case is that of Gilbert v. Principal[1].  Sharon Gilbert, a biostatistician, ceased working in 2018 and filed a disability insurance claim with Principal, based on a diagnosis of Lyme disease from 2016.  Gilbert’s associated symptoms included fatigue, headaches, chills, chest pain, joint pain, numbness and nausea.  She also indicated that she was seeing a psychologist once a month due to her difficulty in managing her symptoms.

Gilbert’s policy had a 24-month limitation on benefits for mental health conditions and “Special Conditions”, which included headaches, chronic fatigue syndrome, fibromyalgia and musculoskeletal and connective tissue disorders. Principal ultimately determined that Gilbert was suffering from a Special Condition, namely Somatic Symptom Disorder (SSD) and therefore was only eligible for 24 months of benefits.

Principal conducted multiple independent medical examinations (IMEs) and had various physicians do medical records reviews in order to challenge the Lyme disease diagnosis.  Their main argument was that the diagnosis did not fit the CDC guidelines. They also pointed to the fact that several of Gilbert’s own physicians questioned the diagnosis of Lyme disease. The Court decided in favor of Principal.  While Gilbert had other conditions outside of SSD, Principal and the Court found they did not rise to the level of disability.

Despite records and statements from the provider treating her extensively for Lyme disease, and a favorable Social Security determination, Gilbert was unsuccessful in her case.  This case highlights the importance being aware of any limitation provisions in your policy.

If you feel your insurer is trying to apply a limitation provision to your claim for benefits, please feel free to contact one of our attorneys directly.

[1] Gilbert v. Principal Life Ins. Co., Civil Action No. TDC-21-0128, 2022 WL 3369537 (D. Md. Aug. 16, 2022).

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is using any of the tactics above to evaluate your claim, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.


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