Mental vs. Physical Condition Claims: A Case Study
In some instances, it may not be clear whether symptoms are caused by a physical or mental disability. This distinction can be important because many policies have a mental and nervous limitation, which means that benefits for mental conditions will only be paid out for a limited amount of time (typically 24 months). It’s not surprising that insurance companies may try to argue that a condition is a mental health one, even if treating providers say otherwise, in an attempt to limit the amount of benefits they have to pay out.
One such case is that of Radle v. Unum.[1] In this instance, Radle tripped and hit his head while running, which resulted in dizziness, difficulty focusing, headaches, a “buzzed” feeling, and sensitivity to noise and light. A few days after the fall, he went to the ER where he was diagnosed with post-concussive syndrome. A few months later, he was admitted to the hospital after another symptomatic episode. Here, he was diagnosed with a conversion disorder, which is defined as a mental condition where a patient shows psychological stress in physical ways. A few days later, he returned for a second opinion and was again diagnosed with conversion disorder.
However, subsequently, over the course of several years, he engaged in treatment with little to no result (including physical therapy and speech therapy). Because of his progressing symptoms, Radle’s three treating providers re-diagnosed him with delayed post-concussive syndrome. In support of their diagnoses, his providers pointed to the fact that he had an EEG positive for left temporal slowing (which would suggest a brain injury), had testing which showed a visual disability, and had a cyst located near his cerebellum.
Unum’s reviewing physicians, however, disregarded these reports form treating providers and continued to claim that his condition was subject to the mental and nervous limitation of the policy, and as a result, Radle was only entitled to 24 months of benefits.
In response, Radle underwent additional assessments including an independent medical examination (IME) and a Neuropsychological Evaluation, which both concluded that his symptoms were not psychologically based. However, Unum did not accept this evidence, and also claimed that his symptoms did not prevent him from working.
The case remains pending as of this writing, but it illustrates how insurance companies may seek to classify certain conditions as mental health conditions, in order to limit the benefit amount they will have to pay out. If you are worried about how your insurer is classifying your disabling condition and have questions, please feel free to reach out to one of our attorneys directly.
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 not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.
[1] Radle v. Unum Life Ins. Co. of Am., No. 4:21CV1039 HEA, 2023 WL 2474509 (E.D. Mo. Mar. 13, 2023)
