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.