The Mental Health Foundation indicates nearly one in three people with a long term physical condition also has a mental condition. Claimants with mental and physical ailments may worry that their insurer will apply a mental limitation to their claim. This article discusses the importance of understanding your insurance coverage and situations where long term disability insurance carriers commonly misapply mental health limitations.
The Language Used in Your Policy Matters
The specific language used in your policy will determine whether a limitation applies to your claim.
Let’s say you have both mental and physical issues. Your policy says benefits are only payable for 24 months if your disability is “due to” a mental condition. This means the carrier must prove that your disability is solely due to a mental condition. If it said “caused by” or “contributed to,” the insurer would limit benefits to 24 months.
For this reason, it is extremely important that you or your disability attorney carefully review your policy. Understanding your coverage will help you identify – or even prevent – wrongful termination of your claim.
Mental Illnesses Resulting from Physical Injuries
Your claim should not be subject to a mental limitation if your mental illness results from a physical disability. However, your insurer may try to avoid paying your claim by identifying your disability as a mental illness. This issue often arises in claims for Lyme disease, fibromyalgia, migraine headache disorders, chronic pain, and gastrointestinal disorders.
Lyme disease, caused by the bacterium Borrelia burgdorferi and transmitted to humans through the bite of infected black-legged ticks, often presents a wide range of symptoms. While the most recognizable symptom may be the “bull’s-eye” rash, the neurological, musculoskeletal, and cardiac manifestations can significantly impact a patient’s life.
Some patients with Lyme disease experience cognitive impairments, fatigue, sleep disturbances, and mood disorders. Sheila Statlender, PhD, states in the article, Why Lyme Disease Gets Misdiagnosed as Depression, Bipolar, and More, that Lyme disease is sometimes called the great imitator because it can mimic several mental health disorders.
Insurers may argue that the ongoing symptoms after treatment, often called “Post-Treatment Lyme Disease Syndrome” or “chronic Lyme disease,” are psychological. However, many medical professionals and researchers argue that these psychiatric symptoms directly result from a physiological condition, not a primary one.
In another study published in the American Journal of Psychiatry, Lyme Borreliosis and Associations with Mental Disorders and Suicidal Behavior: A Nationwide Danish Cohort Study, researchers found that individuals who received a hospital diagnosis of Lyme borreliosis had an increased risk of mental disorders.
Fallon, lead author of the paper, states that Lyme disease can cause severe mental health problems. The connection between bacteria and mental health symptoms is not new, Fallon said, offering syphilis as one example. Both syphilis and Lyme are caused by a corkscrew-shaped bacterium called a spirochete.
Fibromyalgia is characterized by widespread musculoskeletal pain, fatigue, sleep, memory, and mood issues. While the exact cause of fibromyalgia is unknown, various factors, such as infections, genetics, and physical or emotional trauma, have been suggested. Symptoms sometimes begin after surgery, infection, significant psychological stress, or physical trauma. Because its symptoms are subjective and there isn’t a definitive diagnostic test, insurers sometimes classify fibromyalgia as a psychological disorder.
However, medical professionals recognize it as a distinct entity that causes real and often debilitating pain and fatigue. Ricciotti and Hur assert in their article, Is Fibromyalgia Real, that researchers have used MRIs to examine the brains of people with fibromyalgia. These studies indicate that the brain boosts normal pain signals’ intensity.
Migraine Headache Disorders
A migraine is not just a headache. It is a complex neurological condition involving abnormal brain function, such as altered blood flow and imbalances of neurotransmitters like serotonin and glutamate.
Migraines come with various symptoms, including a pounding headache, nausea, vomiting, and sensitivity to light and sound. Some people may also experience aura — visual and sensory disturbances — preceding the headache. While the exact cause remains a mystery, genetics and environmental factors play a role.
Insurers may attempt to classify migraines as a psychological condition, especially if psychological symptoms like anxiety or depression coexist. However, the World Health Organization recognizes migraine as a genuine neurological disorder, and many neurologists note its physiological basis, such as changes in the brain and imbalances in brain chemicals.
The American Migraine Foundation, in its article, The Relationship Between Migraine and Mental Health, asserts that migraine and psychiatric disorders may share similar mechanisms but are separate diseases.
Insurers often portray chronic pain disorders as psychological despite observable physical causes. The outcomes of such claims depend heavily on the exact policy language and the specific details of the claim. However, there is ample research that supports a connection between chronic pain and mental health disorders:
Dersh and his colleagues assert in their article, Chronic Pain and Psychopathology: Research Findings and Theoretical Considerations, that research findings from the 1980s “document the strong association between chronic pain and psychopathology.” The emerging model at the time explained the connection between pain and mood as a diminished capacity for psychological adaptation:
Chronic pain is a significant stressor. When a chronic pain patient faces mundane, day-to-day stressors, his or her coping strategies are already taxed. Thus, someone coping with chronic pain may be more irritable than he or she would be otherwise. This interaction between pain and mood can diminish the patient’s capacity to interact with people healthily, which can exacerbate the physical pain.
Michael Hooten, MD, points out in Chronic Pain and Mental Health Disorders: Shared Neural Mechanisms, Epidemiology, and Treatment, published by The Mayo Clinic, that pain and mental health issues are strongly correlated.
His findings support a more refined model of pain’s role in vulnerability to mental disorders. Hooten refers to imaging and other data that support the recursive nature of chronic physical pain and the experience of depression, anxiety, and similar diagnoses. He asserts that pain and emotion, which share neurological pathways and brain structures, explain the model of pain as a stressor and the greater likelihood for pain patients to experience depression and similar comorbid psychopathology.
Another article, Impact of Chronic Pain on Patients’ Quality of Life: A Comparative Mixed-Methods Study, published in the Journal of Patient Experience, also points out how chronic pain diminishes the quality of life and mental health. The researchers conclude that chronic pain directly impairs interpersonal relationships, work and professional advancement, and “interference with…social life, sleep, and mood.
Psychological Processing in Chronic Pain: A Neural Systems Approach. Simons, Elman, and Borsook, published in Neuroscience & Biobehavioral Reviews, explore how mood symptoms and conditions can manifest when caused or triggered by chronic pain.
The authors explain that the onset of pain can present in varied ways and remit or flare up depending on variables, including causes, treatment, and other biopsychosocial factors. The associated anxiety and depression will wax, wane, and evolve as the pain condition develops. These mental health issues appear to have had similar nuanced trajectories in many cases.
The Crohn’s Disease and Colitis Foundation website asserts GI issues can lead to cognitive issues associated with depression and anxiety. Public incontinence and other social concerns often trigger and perpetuate anxiety and panic symptoms. The foundation’s assertions are well-supported by scientific literature:
An article from the Journal of Crohn’s and Colitis, Burden of Ulcerative Colitis on Functioning and Well-Being: A Systematic Literature Review of the SF-36 Health Survey retrieved from Oxford Academic, examined responses of people coping with colitis and similar conditions regarding their quality of life. The authors refer to the connection between these conditions and participants’ social functioning and mental health issues.
In their article, Prevalence of Anxiety and Depression in Patients with Inflammatory Bowel Disease, published in the Canadian Journal of Gastroenterology and Hepatology, Byrnes and colleagues assert that patients with GI conditions are particularly prone to symptoms of anxiety and depression. The pathway from ulcerative colitis to anxious and depressive symptoms has been examined in well-structured research.
In their article, The Relationship between Irritable Bowel Syndrome and Psychiatric Disorders: from Molecular Changes to Clinical Manifestations, published in the Journal of Molecular Psychiatry, Fadgya-Stadette, and team looked at the mechanisms behind the connection between IBS and mood and other mental health disorders. The authors highlight the growing literature on IBS and anxiety and depressive disorders. They also explain that generalized anxiety disorder is far more prevalent among people with GI conditions.
In the article, Depression and Anxiety in Patients with Gastroesophageal Reflux Disorder (GERD) with and without Chest Pain. Channa, et. al., The NIH National Library of Medicine. The authors assert, ‘This cross-sectional study suggests a high prevalence of anxiety and depression among patients with GERD.”
Ortiz Law Firm Can Help You Appeal a Wrongful Termination of Your Claim
Contact our office immediately if your insurer has misapplied a mental health limitation to your claim. We assist claimants nationwide in appealing the wrongful denial or termination of their long term disability claims. Call (888) 321-8131 to schedule your free case evaluation with an experienced long term disability insurance attorney.