Concurrent Causation from "A Medley of Interesting Disability Cases"

Kruk v. Metropolitan Life Ins. Co.,2013 U.S. Dist. LEXIS 35637 (D. Conn. 2013)

Facts and holding: Rita Kruk (“Kruk”), a Human Resources Specialist, was a participant in an ERISA plan provided through her employment that provided disability benefits. Kruk’s Plan stated that if a disability was due to a mental or emotional disease, participants were entitled to monthly long term disability benefits for a maximum of 24 months. If the disability was due to physical injury or illness, then participants were entitled to benefits up to, at most, age 65. The Plan used an “any occupation” definition of total disability.

Kruk suffered from the combined effect of two co-morbid illnesses: one mental or emotional in nature (depression) and one physical in nature (lupus). In December 2000, she submitted a claim to Metropolitan Life Insurance Company (“MetLife”) for long term disability benefits. MetLife paid Kruk’s claim for the maximum 24-month duration pertaining to benefits for disability due to a mental or emotional illness. Kruk challenged this determination, claiming that she was disabled by lupus, a physical cause, entitling her to benefits until age 65. MetLife argued that Kruk’s disabling conditions were actually mental and emotional depression, and not the physical illness of lupus.

 

 

On summary judgment, and under an abuse of discretion standard, the Court found that Kruk was impaired “by a combination of symptoms and ailments: some readily ascribable to mental or emotional disease (severe depression, anxiety, cognitive impairment); others more readily ascribable to physical disease (arthralgias, anemia), still others of less determinable origin (fatigue, sleep disturbances).” Id. at *34-35. The Court held that in order to be entitled to disability benefits after the 24-month limitation period, Kruk had to show that “her physical disease, in and of itself and entirely disregarding her mental and emotional disease, was totally disabling.” Id. at *47. The Court found that Kruk could not make that showing. Despite a report from Kruk’s physician which concluded that Kruk was totally disabled by her lupus and depression, one independent physician determined that Kruk was totally disabled by her psychiatric condition and a second independent physician found that, from a physical standpoint, Kruk was capable of unrestricted work activities. Therefore, the Court ruled that Kruk was not entitled to more than 24 months of disability payments, and MetLife’s decision to terminate Kruk’s benefits after that time did not constitute an abuse of discretion.

The Court found its decision consistent with Sheehan v. Metropolitan Life Insurance Co., 368 F. Supp. 2d 228 (S.D.N.Y. 2005). There, the plaintiff suffered from two co-morbid illnesses – coronary heart disease, a physical illness, and cardiac neurosis, a mental disorder generated by fear of recurrence of a heart attack. The Sheehan court ruled that during the time in which the plaintiff’s co-morbidity existed, he had exhausted his entitlement to benefits resulting from psychiatric disease, and thus he could only receive additional disability benefits if the physical cardiac condition by itself constituted a total disability.

Lessons learned: The issue of concurrent causation can be very complicated, primarily because the same issue can be analyzed in a variety of contexts, or by focusing on different aspects of the dispute. Here, of course, the issue is a disability caused by both a mental and a physical condition. But the issue can also arise in the context of “accident versus sickness.” And more generally (and more commonly), the issue is presented in the property/casualty context when a loss is the result of both a covered and excluded cause. See, e.g., Garvey v. State Farm Fire & Casualty Co., 48 Cal.3d 395 (1989). In the disability context, that same issue can arise when a cause of disability is excluded specifically by rider, or the cause is excluded as a pre-existing condition. See, e.g., Fought v. Unum Life Ins. Co., 379 F.3d 997 (10th Cir. 2004). And many courts divert the focus of the dispute to whether one of the two causes is the primary or proximate cause of the loss or disability, sidestepping the issue of what happens with true independent, concurrent causation. See, e.g., Brooks v. Metropolitan Life Ins. Co., 27 Cal.2d 305, 309-310 (1945). Thus, different states may characterize the dispute differently, leading to different types of analyses, which in turn makes generalizing or predicting an outcome to this kind of dispute difficult. (And the author reminds the reader that this decision was based on a review under the “arbitrary and capricious” standard, and it is often difficult to generalize a legal conclusion based on a ruling from a court using that standard.)

For a review of another concurrent causation (or dual causation) case discussed by the author, see White v. Prudential Ins. Co., 2012 U.S. Dist. LEXIS 161675 (E.D. Penn. 2012), reviewed in the Ensemble of Interesting Disability Cases.

Finally, an entirely separate (and more common) issue may arise in determining whether a psychiatric condition is properly characterized as “mental” in the first place. See, e.g., Patterson v. Hughes Aircraft Co., 11 F.3d 948 (9th Cir. 1993). This issue, too, has been discussed in the author’s earlier annual case summaries.

From A Medley of Interesting Disability Cases

ERISA Long Term Disability Claim Barred By Failure to Exhaust Administrative Remedies

DRI members Martin E. Rosen and Jenny H. Wang, partners with Barger & Wolen LLP in Los Angeles and Newport Beach, California, respectively, recently obtained a summary judgment from the U.S. District Court for the Central District of California.  The court ruled that a plaintiff seeking long-term disability (LTD) benefits under an ERISA-governed employee welfare benefit plan cannot maintain his lawsuit without first exhausting the plan’s administrative remedies and that appeals for help to the Department of Insurance do not constitute the proper exhaustion of remedies.  On that basis, the court summarily dismissed the plaintiff’s lawsuit.

Defendant United of Omaha Life Insurance Company administered plaintiff Richard Carey’s claim for LTD benefits under an ERISA plan established by his employer.  Carey claimed that he was totally disabled as defined by the plan and thus entitled to benefits.  After investigation, United denied Carey’s claim.  In its denial letter, United told Carey that he had the right to administratively appeal the claim denial, as set forth in the plan, and that he had to submit any appeal within 180 days.  The letter also informed Carey of his right to contact the Department of Insurance (DOI) about United’s handling of his claim.

 

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Early Bird Registration for Definitive Disability Conference Expire on 1/31/2013

Early bird registration discounts for the inaugural Definitive Disability Conference are set to expire on January 31, 2013. Fax or e-mail your registration form in today to lock in your discounted rates. 

About the Definitive Disability Conference (DDC)

On May 16-17, 2013, Barger & Wolen will host the inaugural Definitive Disability Conference in Boston, an industry conference designed for in-house counsel and experienced claim personnel. The conference will be chaired by Martin Rosen, who heads Barger & Wolen’s Disability, Life and Health practice group.

The primary objectives for the Definitive Disability Conference are: (1) to create a conference focused solely on disability insurance issues; (2) to design the conference with the experienced disability insurance professional in mind; (3) to limit the conference to industry-related personnel and their counsel; and (4) to ensure that the conference provides great value for the price.

To accomplish these goals, Marty has secured speakers from the following companies, law firms and other entities:

  • Ameritas
  • Berkshire Life Insurance Company of America
  • Cigna
  • Colonial Life Insurance Company
  • CSC Financial Services Group
  • Disability Management Services, Inc.
  • First Mediation Corporation
  • Funk & Bolton, P.A.
  • Kunz, Plitt, Hyland & Demlong PC
  • Metropolitan Life Insurance Company
  • Mutual of Omaha Insurance Company
  • Nawrocki Smith LLP
  • Ogletree, Deakins, Nash, Smoak & Stewart, P.C.
  • Shipman & Goodwin LLP
  • Shutts & Bowen LLP
  • Sun Life Financial
  • Unum Group

We are very excited about the inaugural conference and look forward to seeing you in Boston next spring.

For more information, please click on the following hyperlinks:

Ÿ         Definitive Disability Conference

Ÿ         Conference Program and Agenda

Ÿ         Speakers

Ÿ         Sponsorship Opportunities

Ÿ         Fees

Ÿ         Registration Form

Ÿ         Hotel

Ÿ         FAQs

Barger & Wolen Launches Disability Insurance Industry Conference

We at Barger & Wolen have exciting news to share with you.

On May 16-17, 2013, we will host the inaugural Definitive Disability Conference in Boston, an industry conference designed for in-house counsel and experienced claim personnel. The conference will be chaired by Martin Rosen, who heads Barger & Wolen’s Disability, Life and Health practice group.

The primary objectives for the Definitive Disability Conference are: (1) to create a conference focused solely on disability insurance issues; (2) to design the conference with the experienced disability insurance professional in mind; (3) to limit the conference to industry-related personnel and their counsel; and (4) to ensure that the conference provides great value for the price.

To accomplish these goals, Marty has secured speakers from the following companies, law firms and other entities:

  • Ameritas
  • Berkshire Life Insurance Company of America
  • Cigna
  • Colonial Life Insurance Company
  • CSC Financial Services Group
  • Disability Management Services, Inc.
  • First Mediation Corporation
  • Funk & Bolton, P.A.
  • Kunz, Plitt, Hyland & Demlong PC
  • Metropolitan Life Insurance Company
  • Mutual of Omaha Insurance Company
  • Nawrocki Smith LLP
  • Ogletree, Deakins, Nash, Smoak & Stewart, P.C.
  • Shipman & Goodwin LLP
  • Shutts & Bowen LLP
  • Sun Life Financial
  • Unum Group

We are very excited about the inaugural conference and look forward to seeing you in Boston next spring.

For more information, please click on the following hyperlinks:

Ÿ         Definitive Disability Conference

Ÿ         Conference Program and Agenda

Ÿ         Speakers

Ÿ         Sponsorship Opportunities

Ÿ         Fees

Ÿ         Registration Form

Ÿ         Hotel

Ÿ         FAQs

 

About Martin E. Rosen

Martin E. Rosen is a partner in the firm’s Los Angeles office. He represents insurers and other large corporations in sophisticated litigation matters in both state and federal court. Mr. Rosen’s expertise is in the area of insurance bad faith litigation, with extensive experience in the areas of disability, life and health bad faith law, ERISA litigation, insurance agency law, class action law, unfair trade practice litigation and financial institution and general business litigation. Mr. Rosen practices at both the trial and appellate levels.

Mr. Rosen also often serves as a speaker at national conferences concerning insurance bad faith litigation, and frequently advises insurers on means of minimizing their exposure to bad faith litigation. He also serves in the local community as a Judge Pro Tem. 

Mr. Rosen can be reached by email at mrosen@bargerwolen.com.