You have been receiving long-term disability benefits for severe depression and anxiety for almost two years. Your psychiatrist says you are no better. Then the insurance company writes that your benefits will end at 24 months, not because you have recovered, but because your policy limits benefits for mental health conditions.
This limitation surprises many people. It is common in group LTD policies, and it can end benefits for someone who is still unable to work. But it does not apply the same way to everyone, and sometimes it does not apply at all.
What the limitation says
Many group policies include a clause, often called a “mental illness,” “mental and nervous,” or “mental health” limitation, that caps the total benefits paid for disabilities caused by those conditions. The cap is often 24 months over your lifetime under the policy. Some policies use a different period.
The limit applies even if you remain disabled. When it runs out, benefits stop unless something else in the policy keeps them going.
Individual policies you bought yourself may not have this limitation, or may word it differently. More: ERISA plan or private policy?
Which conditions it covers
That depends entirely on the policy’s definitions. Many policies apply the limitation to conditions such as depression, anxiety disorders, PTSD, and bipolar disorder. Some carve out certain conditions, such as dementia or other conditions with a known physical cause in the brain, so that the limitation does not apply to them. Some policies define “mental illness” in detail; others barely define it at all.
A related clause in some policies limits benefits for conditions diagnosed mainly from self-reported symptoms, sometimes listing conditions such as fibromyalgia, chronic fatigue, or certain pain conditions. And separate clauses may exclude or limit disabilities related to alcohol or substance use.
Read the exact words. Whether your condition falls inside or outside the definition can decide your claim.
Common exceptions
Policies often include exceptions to the limitation. Look for language like this:
- Hospital confinement. Some policies continue benefits past the limit if you are confined to a hospital or facility for treatment of the condition when the limit runs out.
- Excluded conditions. Conditions the policy specifically removes from the limitation, as described above.
The exact exceptions, if any, are in your policy.
The most important question: is there another disabling condition?
Many people on LTD for a mental health condition also have physical conditions: a back problem, heart disease, diabetes with complications, an autoimmune disease, chronic pain, or cognitive problems with a neurological cause. If a condition that is not subject to the limitation independently keeps you from working, it may support continued benefits after 24 months, depending on the policy language.
Example: a claimant is approved for LTD based on severe depression. She also has cervical spine disease that limits how long she can sit and use a keyboard. If her medical records document the spine condition and its limits on their own, she may continue to qualify after the mental health limit runs out, even if the insurer argues the depression is the main problem.
Policies and courts have treated these mixed claims differently. Some policy wording limits benefits when a mental condition “contributes” to the disability; other wording focuses on whether the disability is “due to” or “caused by” the mental condition. The wording in your policy and the law where your case is decided both matter. This is an area where a lawyer’s review of the exact clause is worth it.
How to protect your benefits
Know your date. Find out when your 24 months, or whatever your policy’s period is, will run out. Count from when benefits started, and remember that some policies count all periods of disability from the same condition together.
Document every condition. If you have physical conditions, make sure they are treated and documented on their own, with specific functional limits: how long you can sit, stand, and walk; how much you can lift; how often you need breaks. Records that mention a physical condition only in passing will not carry the claim. More: Why your doctor must describe limitations, not just diagnoses.
Get the right testing. If you have memory or concentration problems, neuropsychological testing can help show whether they stem from a neurological or other physical cause.
Start before the deadline. The insurer usually reviews the file in the months before the limit runs out. The time to build the evidence for your other conditions is before that review, not after the termination letter.
Do not assume Social Security will decide it. Social Security has no mental health time limit, so you may remain on SSDI after your LTD benefits stop. A favorable Social Security decision that relies on physical conditions can be useful evidence, but it does not control your LTD claim. More: Approved for SSDI: what happens to my LTD claim?
If your benefits are ending under the limitation
- Get the policy and read the limitation, its definitions, and any exceptions.
- Ask whether the insurer applied the right clause, to the right conditions, for the right period.
- Gather evidence for every other condition that limits your ability to work.
- If ERISA governs your plan, appeal within the deadline, at least 180 days, and put that evidence in the record.
CTA: Is your insurer applying the mental health limitation to your claim? Call 770-351-0801 or request a free case evaluation. We will review the clause and your medical records with you.
Related: Why your approved claim is being reviewed · LTD for depression, anxiety, and PTSD · Top 5 reasons LTD claims are denied