In today’s evolving healthcare landscape, mental health care has taken center stage and our society continues to better understand the effects mental health can have on peoples’  well-being and ability to function productively in daily life and in their work. In recent years, mental health has emerged as a central focus within the disability insurance claims, highlighting both the necessity for comprehensive care and the challenges claimants face when their conditions extend beyond the typical benefit durations.

For many people, mental health issues such as major depressive disorder, anxiety disorders, post-traumatic stress disorder (PTSD), and bipolar disorder are not only life-altering but also lead to significant, long-term disabilities that interfere with the ability to work. For those covered under employee benefit plans governed by the Employee Retirement Income Security Act of 1974, or ERISA, the pathway to accessing mental health benefits can be complex and can include many challenges to receiving these important benefits. A common hurdle in these cases is that most long-term disability policies limit benefits to 24 or 36 months regardless of whether a person remains unable to perform his job due to his mental health condition.

What Is ERISA?

Understanding ERISA is essential to navigating this complex landscape. ERISA is a federal law that sets minimum standards for most insurance plans offered by private employers. ERISA’s primary stated goal is to protect the interests of plan participants and beneficiaries by ensuring that plan administrators adhere to strict standards of conduct and clearly communicate the terms of the plan. While ERISA does not require employers to offer specific benefits, once a plan is in place, ERISA governs how the plan is administered, including how claims must be processed and disputes resolved. This framework is intended to protect the interests of participants and beneficiaries, but when it comes to mental health disability claims, the interpretation and application of ERISA can become particularly complicated.

ERISA and Mental Health Claims

Disability claims are generally challenging and difficult to navigate, which is compounded when the claim involves a mental/nervous condition. Many physical conditions can be objectively confirmed through physical exams and imaging. If you have a bulged disc in your spine, your claim will be supported with x-rays and MRIs. Mental health conditions typically do not present themselves in a way that can be objectively proven. There is no objective physical evidence that can be reviewed for anxiety, depression, PTSD and other mental health conditions, so it is harder to demonstrate to disability insurers that you have such a condition, and if you do, how severe it is and what are your resulting restrictions and limitations. On top of that, the claims process can be incredibly stressful, presenting an additional challenge to someone living with one or more of these conditions.

As noted above, an important feature of mental health claims is that the benefit period is typically limited to 24 or 36 months, whereas physical disability benefits can be paid until the policy term, as long as you are disabled from the condition(s). This limitation can uniquely impact a claimant with a long-term or chronic mental health condition, given the stress that comes with knowing that even if you get all the benefits available to you under the policy, you will receive them for a relatively short time.

Common Challenges with ERISA Mental Health Claims

Insurance companies have a financial interest in denying disability claims, especially mental health claims. This means they will deny such a claim for many reasons, including for the fact that there is no objective evidence to prove a mental health claim. It is common for them to challenge the severity of mental health conditions. They will downplay the medical evidence and take the position that your symptoms are not severe enough to stop you from being able to work in your occupation.  In addition to the benefit duration limitations, here are other common challenges:

·  Ambiguity in Policy Language: The language in disability policies can be vague, leading insurers to interpret the coverage more narrowly than claimants believe is warranted, especially when defining the extent and duration of mental health impairments.

·  Evidentiary Requirements: Establishing the severity and chronic nature of a mental health condition requires comprehensive and detailed documentation. Insurers often challenge whether the submitted medical evidence—such as psychiatric evaluations, treatment histories, and expert opinions—sufficiently proves the claim.

·  Discrepancies in Treatment Expectations: Insurers may argue that the claimant’s condition has stabilized or improved, even when ongoing symptoms persist, which can lead to disputes over whether continued benefits are justified.

·  Inconsistent Application of Standards: Variations in how different plan administrators interpret and apply policy terms can result in inconsistent outcomes, making it difficult for claimants to predict or understand decisions regarding their benefits.

·  Delays and Administrative Hurdles: The process for reviewing and approving mental health disability claims can be lengthy, with administrative delays that further complicate access to timely care.

What to Do If Your Mental Health Claim Is Denied

If your ERISA disability claim is denied or if the insurance company has stopped paying your benefits before the end of the benefit period, it is imperative to understand the timeline you face and act accordingly. When you receive a denial, immediately consult with an attorney with ERISA expertise, like the attorneys at McKennon Law Group PC. You will have 180 days from receipt of a written claim denial to appeal the denial. Keep in mind the amount of time it can take to get all the necessary evidence for your appeal, like your medical records, doctor certifications, personal statements and preparation of strong arguments in support of your claim. Additionally, you should gather documentation related to the policy and document your communication with the insurance company, including calls and any evidence you send them.

If the insurance company denies your appeal, you will be able to bring a legal action against them in federal court. In many cases, especially in California, the court will decide your case under a de novo standard of review, meaning that it will review the administrative record and determine whether you are disabled as defined by the policy without giving any deference to the insurer’s prior decision. The administrative record is all the evidence available to the insurance company when it made its final determination on your claim. Any evidence that supports your claim should be submitted to the insurance company before a final decision is made on your claim. Therefore, it is crucial to gather and organize all the evidence that supports your claim when your claim is denied.

Conclusion

Mental health claims under ERISA inherently present unique challenges for claimants and can be especially stressful relative to physical claims. By understanding the claims process, challenges involved, and the importance of acting quickly to gather your evidence and consulting with an attorney, you can minimize the stress associated with the process and increase the likelihood that you get the maximum benefits available to you.