781 F.3d 623
1st Cir.2015Background
- Plaintiff Mark Dutkewych, a participant in an ERISA-governed LTD plan insured/administrated by Standard Insurance Co., received LTD benefits beginning in 2009 but Standard terminated benefits effective June 1, 2011 after applying a 24‑month "Limited Conditions" cap that includes "Mental Disorders."
- The Plan defines "Mental Disorders" broadly to include cognitive, mood, stress‑related or psychological abnormalities "regardless of cause," and contains two Rules governing overlapping limited and non‑limited conditions.
- Dutkewych has a complex medical record: long‑standing psychiatric diagnoses and substance abuse, positive IGeneX Lyme serologies (not CDC‑conforming), treating physicians diagnosing and treating for chronic Lyme with IV antibiotics, and VA/SSA/other consultants offering conflicting views.
- Standard relied on multiple consulting reviewers who questioned the chronic Lyme diagnosis and concluded mental disorder, fibromyalgia, and substance abuse were the likeliest contributors to disability; Standard applied the Plan’s Mental Disorder Limitation and discontinued LTD after 24 months.
- Dutkewych administratively appealed; Standard’s review reaffirmed the limitation. The district court granted summary judgment for Standard; the First Circuit affirmed under the arbitrary‑and‑capricious (deferential) standard.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether there was substantial evidence that a mental disorder "caused or contributed" to disability as of June 1, 2011 | Dutkewych: contemporaneous records show disability was due to chronic Lyme (physical), not a mental disorder | Standard: record (including treating notes, claimant admissions, and consultants) shows mental disorders contributed to disability; Plan definition covers mental disorders "regardless of cause" | Held: substantial evidence supports that mental disorders contributed to disability; limitation applies |
| How the Plan's two "Rules for Disabilities Subject to Limited Pay Periods" interact with the 24‑month Mental Disorder Limitation | Dutkewych: Rules require paying limited conditions first but then permit continuation after 24 months if a non‑limited physical condition exists, so limitation should not bar continued benefits where physical disease coexists | Standard: Rules require payment order but do not eliminate the underlying 24‑month cap; to continue beyond 24 months claimant must be disabled by a non‑limited physical disease independent of limited conditions | Held: Standard’s interpretation is reasonable and consistent with Plan language; limitation can continue to apply after 24 months unless disability at that date is caused by an independent non‑limited physical disease |
| Whether Standard’s reliance on the Mental Disorder Limitation was a post‑hoc litigation rationale | Dutkewych: Standard only contested Lyme’s validity during admin review; invoking the Limitation was raised only in litigation and should be disregarded | Standard: termination and the administrative review letters explicitly relied on the Limited Conditions Provision and gave claimant notice; not a new litigation‑time rationale | Held: Not post‑hoc; admin decision expressly invoked the Limited Conditions Provision and claimant had notice/opportunity to respond |
Key Cases Cited
- Colby v. Union Sec. Ins. Co., 705 F.3d 58 (1st Cir. 2013) (administrator discretion and substantial‑evidence review)
- Conkright v. Frommert, 559 U.S. 506 (2010) (deference to plan administrator's reasonable interpretation)
- Glista v. Unum Life Ins. Co. of Am., 378 F.3d 113 (1st Cir. 2004) (barring new denial rationales raised only in litigation)
- Schwob v. Standard Ins. Co., [citation="248 F. App'x 22"] (10th Cir. 2007) (applying similar mental‑disorder limitation where mental disorder may be secondary to physical illness)
- Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008) (conflict of interest is a factor in reviewing administrator determinations)