Lynd v. Reliance Standard Life Insurance

was removed to federal pursu- district court GARWOOD, Before EMILIO M. GARZA DENNIS, 1331, § Judges. parties ant 28 U.S.C. and Circuit summary thereafter filed cross motions for GARWOOD, Judge: Circuit judgment. The district court denied ERISA, Bringing this action under and, motion, granting appellees’ motion § seq., plaintiff-appellant U.S.C. et Ed- plan held that administrator had not Lynd (Lynd) alleged ward E. in his com- abused in deciding its discretion to terminate plaint that the receiving benefits he had been benefits. pursuant long-term disability plan to a were wrongfully appeal terminated. In his appeal, Lynd On contends that the district rulings parties’ district court’s on the cross by reviewing plan court erred adminis- summary judgment, Lynd motions for pres- trator’s decision under an abuse of discrеtion ently contends the district court re- Lynd argues standard. plan viewed the administrator’s decision to court plan should have reviewed the adminis- terminate these inappro- benefits under an Furthermore, trator’s decision de novo. review, priate standard of grant that, Lynd regardless maintains of the stan- summary judgment dismissing his suit was employed, long-term dard of review dis- erroneous. ability wrongfully benefits were terminated. Proceedings Facts and Below employed by defendant-appellee Discussion Ford, (FBD) Davis, Bacon & Inc. on Decem- employed Whether the district court

ber September 1989. In appropriate reviewing became unable to began receiving work and standard an eli- thority’ hinges incantation of word by an ERISA made gibility determination ‘magic word.’ law. ‘discretion’ question administrator See Rather, Oil, Supreme directed lower Court Co. v. Chemical Chemical Chevron of the ad- courts to focus on the breadth Local Union Workers Atomic 4-44 Cir.1995). power ‘authority to Therefore, ministrators’ we re 139, 142 —their eligibility or to determine for benefits novo. decision de the district court’s view ’ plan’.... construe the terms of the On Rubber Co. v. Tire and In Firestone hand, discretionary authority the 113-17, Bruch, implied ... ‘an administrator cannot be (1989), 956-57, Supreme the L.Ed.2d 80 eligibility no discretion to determine a of ERISA that denial Court established interpret plan plan unless the lan- should be plan administrator expressly authority on guage confers such unless the de novo the courts reviewed ” (cita- 47 F.3d at 142 the administrator.’ “discretionary gives the plan administrator omitted). tions authority eligibility for benefits to determine however, case, present pretermit we In the plan.” of the How- to construe the terms regarding standard of review the issue which ever, lan- precisely unclear what it remains employed the district court should employed plan in the to con- guage must be reviewing plan eligibility administrator’s discretionary authority upon the fer such because, regard- determination. We do so Texaco, In Duhon v. plan administrator. court reviewed less of whether the district (5th Cir.1994), Inc., this Court F.3d 1302 eligibility the administrator’s determination analysis Bruch to the lan- applied the novo, the nature for abuse of discretion or de plan and held that de guage of an ERISA Lynd’s disability compelled the district because: inappropriate review was novo Lynd’s long-term that ben- court to conclude plan administrator is clear “[I]t properly plan under the were terminat- efits authority discretionary to make has the ed.2 of the final and conclusive determination plan in 8.0 of the instant Section imposed a lin- This court has not claim. “Monthly cludes the limitation that Benefits satisfy requirement this guistic template to Disability to mental or nervous for Total due plan’s plain lan- ... but in this ease the beyond twenty- payable disorders will not be may the administrator guage provides that (24) you Hospital are in a four months unless independent and final determina- make an twenty-four at the end of the or Institution (cita- eligibility.” Id. at 1305-06 tion (24) period.” parties The do not dis month omitted).1 tions Neither, Lynd remains disabled. pute that Additionally, observed that we have however, any suggestion is there discretionary authority grant of requisite hospitalized or institutionalized language of an cannot be inferred from the two-year at the end March Co., su- plan. In Chevron Chemical ERISA long-term during which he received period holding discre- pra, course of abuse of in the Therefore, dispute disability benefits. review, proper we was the standard of tion proper characterization turns on the stated that: it must Lynd’s disability; specifically, be de disability consti whether or not his ‘surely sug- did not termined Supreme Court “[T]he or nervous disorder” within ‘discretionary au- tuted a “mental gest Bruch [in ] that, he is found to be dis- concedes if plan Duhon addressed the dis- 1. The at issue in cretionary authority in two of the administrator disor- a "mental or nervous abled as der,” result of passages: of the Plan Admin- "The decisions plan; under the he then he cannot recover respect shall be final and conclusive with istrator to either the Plan;” absolutely no difference” that "it makes allows relating every question which arise employed to review the admin- standard is which interpretation of this or administration eligibility should.his determination of istrator’s necessary you undergo the “After so characterized. be examination(s) upon of all review case, will in the the Plan Administrator facts deny pay- the decision to authorize or make Id. at 1305. ments.” meaning plan. of this hold that the A: We From a disorder of the central ner- correctly court plan district affirmed the system.” ad- vous ministrator’s determination that dis- Dr. Dumont further testified that: ability was due to a “mental or nervous disor- “Major depression ais disease and it has a der”; therefore, holding the district court’s physiologic every bаsis bit as much as regardless of affirmed the standard of review diabetes, hypertension, cardiomyopathy or employed reviewing court in any other” eligibility administrator’s determina- opinion “every major and that in depres- tion. implicated] sive inefficiency disorder of neu- undisputed sys- rotransmitters evidence before the dis- central nervous tem.” Lynd diagnosed trict court was that 19,1990, September suffering “major as from Dr. regarding Dumont testified symp- the depressive diagnosis, disorder.” This docu- experienced by Lynd toms consequence as a Lynd’s form, mented on benefits claims “major depressive of his disorder”: static

remained since that time.3 “[Lynd] reported symptoms of lack of stamina, physical energy loss of and inter- However, Lynd general contends that this est, unable to pressure, deal with unable to diagnosis “major of his de- —as decisions, disturbance, sleep make he had pressive comports with his claim disorder” — up he would wake in a cold with sweat physical that his condition nature. In apprehension. He had to leave the office position, Lynd of support presented early day or early one went to the office (taken deposition district court the the well day anxiety great one and found so he had denied) after benefits were treating very to leave. He has been mean- anergic physician, psychiatrist Dumont, Dr. in which ing energy no and ahdonia meaning [sic] Dr. Dumont asserted his depres- belief that experience pleasure. unable to He thus “physical” is a sion disorder: Dr. contacted Nichols who then referred “Q: All right, sir. But I guess ques- the him to me.” is, driving itself, tion I am depression Dr. expressed Dumont the view “resolu- that something that physi- caused from a Lynd’s major depressive tion of Mr. disorder cal disorder itself? disability.” would remove his Yes, Yes, it A: is. it is. We think of Dr. Dumont physi- described himself as “a depression being as a chemical imbalance. specializes cian practice psychi- who is a part It malfunction in the of the brain atry.” Lynd He saw on referral from regulation. controls mood And we see regular physician, but received from the re- usually as an inefficiency of the neuro- ferring physician no “documentation” or transmitters or a relative deficit of certain reports.” “medical When asked if his rec- try neurotransmitters and we to treat that ords any reflected “whether Mr. had by utilization of help medications that can physical diseases,” disorder or Dr. Dumont efficiency increase the elevate responded, “not consequences neurotransmitters. this, would been connected with no.” Q: right, ... All depression sir. So Dr. Dumont treated with psychoreac- from a essence results nervous disorder as tive psychotherapy.4 mediсation and When I understand? asked did not “You conduct exami- following (3) 14, 1992, Lynd's January characterizations of dis- In a letter of Dumont Dr. ability were attached to Reliance’s motion for Lynd's disability major described “a as severe summary judgment: disorder”; depressive (1) 22, 1990, 12, 1993, Lynd's In a letter of May October treat- In letter of Dumont Dr. ing physician, psychiatrist Lynd's Dr. Arthur “major Dumont characterized as a de- III, Lynd’s disability "major depres- described pressive as illness.” sion”; Prozac, April Wellbutrin, aIn letter of Dr. 4. The Dumont medication included Lithium, Lynd's disability Anafranil, described Desyrel, Klonopin, Buspar, as "a severe treat- depression"; Zoloft, Depakote, ment resistant Cylert, and Serzone. plan participant complained of de- unqualifiedly ERISA Lynd, Dr. Dumont nation” sleeplessness, impaired “No, pression, concen- I did not.” responded symptoms, con- tration and other the court previously addressed has not This Court participant cluded “suffered allega- raised interpretive issues laypersons would a “men- what consider” “physical” aspects of “mental” tion that disorder).5 tal” or “nervous” necessarily impact the construction illnesses In AND its DIAGNOSTIC STATISTICAL phrases as “mental qualifying of such DISORDERS, MENTAL MANUAL OF plans. in ERISA disorders” used nervous (APA) Psychiatric Association ac- American ap- However, Eighth Circuit’s we find the bright-line dis- knowledges that there is no instructive: proach to be tinction between “mental” disorders and improper unfair to allow “It would be Nevertheless, “physical” disorders. the APA plan] terms that to define experts [ERISA that, much recognizes also while “there is targeted specifically written for were disorders,” phrase ‘physical’ ‘mental’ pro- laypersons. requirement This toward persists “mental disorder” “because we have we fashion a source from which vides appropriate substitute.” Amer- not found rule; law the terms a federal common Association, Psychiatric ican DIAGNOSTIC ordinary, not be accorded their should MANUAL OF MEN- AND STATISTICAL meanings. specialized, (Fourth Edition, TAL xxi DISORDERS 1994). Accordingly, APA has not wa- judgment for of a disease is a The cause from its classification of disаbil- vered laymen and under- experts, while know ity “major depressive disorder” —as a undoubtedly Laymen symptoms. stand — Thus, disorder.” Id. at 339. it is “mental illnesses are aware that some mental are lay not; just population not that holds to the others are organically caused while properly view that certain disorders are however, classify they illnesses do necessarily disor- Instead, characterized as “mental layper- origins. based on their ders,” though even what is thus referred to symptoms to focus on the sons are inclined origin, “physical” aspect a illness; primary of an illnesses whose and/or swings as well. depression, mood symptoms are commonly char- аnd unusual behavior are approach taken the Ninth Circuit The regardless of mental illnesses acterized as Hughes 11 F.3d in Patterson v. Aircraft

their cause. (9th Cir.1993), In is also instructive. Patterson, confronted an ERISA upon the court By focusing ... the disease’s etiolo resulting to which benefits plan pursuant factors gy, the district court considered “mental, nervous or emotional disorders experts not to important that are to but years. be limited to two any type” would court thus failed to exam laypersons. The plan The court observed layper Id. at 949. term “mental illness” as ine ‍​‌​​​​​​‌​​​‌​​‌‌​​‌​​‌‌‌‌​‌‌‌‌‌‌​​​‌​‌​​‌​‌‌​​​‍the disorder,” and held “mental have, not define which is the examination did son would be re- ambiguities plan were to that and federal common we conclude ERISA plan participant. Id. at in favor of the National solved require.” law Brewer v. Lincoln Cir.1990), (8th that the term reaching In its conclusion 950. 921 F.2d Life denied, ambiguous in this con- disorder” was “mental rt. ce that, text, (1991); view when the court asserted its see also 115 L.Ed.2d 1038 1054, 1056 by “depression,” then disability was caused Unisys Corp., 24 Stauch Cir.1994) disability properly charaeter- that would be (observing that when an and stems from "symptoms” imbalance” identifying sents a "chemical In the “causes” and illnesses, always argument inefficiency seems that an could ..." of the neurotransmitters "an that, itself should be be fashioned that viewed as a the illness reasonably Eighth Circuit concludes underlying “symptom" of some framework, laymen analytical will within this cause; "physical” particularly true if one this is “symptom" order to of an illness in look to the origins willing of the illness ad to trace the illness, symptom “de- and the characterize provided this is An illustration of infinitum. Dr. Dumont's illness. pression” of a “mental" is indicative testimony depression repre- resulting illnesses, exist, ized as from a “mental disorder”: those if which have no disability solely “If Patterson’s “physical” was caused If manifestations. the exclusion of depression, ... then his condition is disability, lasting twenty-four more than subject two-year by any to the limitation months, due to “mental or nervous disorders” possible meaning of the Plan’s term ‘mentаl anything is to mean we think it must— —and ” disorder.’ Id. at 951.6 principled then there is no basis on which to Lynd’s “major depressive exclude disorders” ultimately The court remanded the case to from the reach of that exclusion. court, that, concluding “[I]f Pat- terson’s headaches contributed to his total “major depressive suffers from dis- disability, they are either a cause or order”. suggestion There has been no symptom depression, of his then Patterson’s Lynd’s major depression inis some relevant disability does not fall within the ‘mental unusual, aspect disability nor that his interpreted disorder’ limitation in his favor.” by anything caused than this disorder. added). (emphasis Id. at 951 The court noted, As Dr. Dumont testified that “resolu- reached this conclusion because the cause of Lynd’s major tion of Mr. depressive disorder disability Patterson’s had not been deter- Instead, disability.” would resolve his However, mined. language quoted Id7 maintains that his condition falls outside the apparently above would sanction the conclu- phrase “mental simply or nervous disorder” that, sion even if it were established that the “every major disorder,” because depressive cause of “depres- Patterson’s according Lynd’s psychiatrist, “physi- sion”—and that Patterson’s headaches were origins symptoms. cal” Based on this only symptom depression of his Pat- —then evidence, the compelled district court was terson’s would nevertheless fail to affirm eligibility administrator’s de- constitute a “mental disagree disorder.” We termination, regardless of the standard of view, with particularly if the court in- employed by review the district court in re- analysis tended that apply only this to viewing this determination. headaches, Patterson’s but “physical” to all Accordingly, judgment of the district symptoms of “mental” disabilities. If we be- court is gin premise with the the cause of a AFFIRMED. disability Eighth is “mental” —and the and Circuits, Ninth Psy- as well as the American DENNIS, Judge, dissenting. Circuit Association, chiatric “depres- characterize required This court is to review de sion” as a novo “mental” disorder —then to find grant court’s decision to sum- disability thаt a falls outside of the term mary (as judgment company to the “mental disorder” in insurance used an ERISA employer, and the plan) applying the disability “physical” because the same criteria symptoms employed by would the court in the first render the term instance. “mental Texas, Harper County, disorder” v. obsolete this Harris 21 F.3d context. As the 597 (5th Cir.1994). plan Thus, panel ERISA pointedly instant case should re- disorders,” refers to “mental verse pleadings, depositions, or nervous unless “the an- would inappropriate effectively be collapse interrogatories, swers to and admissions on file, the term only “mental disorder” to together affidavits, include any, with the if show Second, by Thе court's view that disabilities caused the Plan does not make clear wheth- depression fall disability qualifies within the classification of "men- er aas ‘mental disorder' tal by disorders” is further underscored when it the fol- results from a combination of lowing: disability may mental factors. Patterson’s solely depression, solely result from or "First, specify the Plan does not whether a headaches, or from a combination two. disability by is to be classified as ‘mental’ look- ambiguity Since this must also be resolved in ing disability to the cause of the or to its favor, Patterson's he is not within the limita- symptoms. ambiguity Since the is to be re- disability tion for mental disorders if his is favor, disability solved in Patterson’s his is not any by part сaused in headaches.” Id. at 950 subject two-year a mental disorder to the limi- (citations omitted). payments by tation on if it is either manifested though by depression, headaches caused or 7. Patterson filed his claim for benefits under the caused by depres- plan headaches but manifested ERISA disability at issue in that case “for sion. benefits due to headaches.” Id. at 949.

985 any “Monthly Disability for dispute as to vides: Benefits Total genuine no there is due to mental or nervous disorders will not moving party is fact and that the material beyond twenty-four payable be months matter of judgment as a law.” entitled to Catrett, Hospital the insured is in a or 56(c); unless Institu Corp. v. Celotex Fed.R.Civ.P. twenty-four 2548, tion аt the end of the month 91 L.Ed.2d 265 477 U.S. period.” There no (1986). evidence under the Viewing and inferences the evidence provision part limitations reasonably may be drawn therefrom policy power that Reliance has the to exer non-moving light most favorable to the make cise discretion to determinations there are party, must determine whether we a total is due to whether mental fact and any genuine issues of material to which the nervous disorders courts must correctly applied whether the district court Furthermore, pay simply deference. there is County, Harper v. Harris the relevant law. support importing no for the deferential or Chide, Texas, 600; King v. 21 F.3d at arbitrary capricious standard into Cir.1992). ERISA on a wholesale basis. Firestone Tire an A of benefits under ERISA denial 109-114, 109 Rubber & 489 U.S. S.Ct. de novo “unless the benefit must be reviewed Accordingly, at 953-56. Reliance’s denial of fiduciary plan gives the administrator or dis- challenged by Lynd is to be re authority eligibility cretionary to determine viewed under de novo standard. the terms of the for benefits or to construe group long The term insurance Rubber plan.” Firestone Tire & Co. policy (non-participating) that covers

Bruch, 101, 115, 109 956- S.Ct. plan” “employee welfare benefit as de- (1989). Group Long The 103 L.Ed.2d 80 ERISA, fined rather than state contract Disability policy issued Term Insurance Therefore, governs law. federal law Ford, Bacon and Davis does not Relianсe claim.1 Todd v. 47 F.3d AIG Life any language conferring discretion- contain (5th Cir.1995). Congress, adopting authority upon to determine ary Reliance ERISA, expected that “a common federal eligibility or to construe the for benefits rights obligations law of under ERISA- insuring plan. clause terms of the develop.” regulated plans would Pilot Life pay Monthly Benefit if an states: “We will a Dedeaux, 41, 56, v. 481 U.S. 107 Ins. Co. (1) Totally the insured: ‍​‌​​​​​​‌​​​‌​​‌‌​​‌​​‌‌‌‌​‌‌‌‌‌‌​​​‌​‌​​‌​‌‌​​​‍is Disabled as result (1987); 1549, 1557-58, L.Ed.2d 39 95 S.Ct. Injury covered this Poli- of Sickness Tire & Rubber v. see also Firestone Co. (2) Physi- cy: regular care of a is under the Bruch, 101, 110, 109 489 U.S. S.Ct. cian; completed the Elimination Peri- (1989). ascertaining In 103 L.Ed.2d 80 od; satisfactory proof of submits law, applicable common this court has federаl most, all, Disability to us.” At if at this Total may guidance from anal- explained we “draw provision vests Reliance some discretion ogous law.” Todd v. AIG Ins. Co. state Life “proof determining whether the of the Total (5th Cir.1995) 1448, (quoting) 47 F.3d 1451 Disability” “satisfactory.” But the fact (6th Parrott, 310, 913 F.2d 311 McMillan v. totally been con- is disabled has omitted)). Cir.1990) (citation purposes for of the mo- ceded defendants summary judgment. only ques- tion for in this Circuit and It is well settled that, in con- placed majority has been at issue is whether of federal courts tion that plans, struing language are of ERISA federal the benefits to which entitled proferen- rule of contra due to the cause of his total dis- law must follow the restricted tem, that when tеrms ability pro- clause which which directs under a limitation noted, however, paid policy] under for [the ditions as benefits are It should be if illnesses, diagnoses, payable or accidents.” Id. claim had been for benefits for “services all other 664.A.(1); § v. Louisiana Health or nervous at see rendered for the treatment of mental Rudloff benefits, Indemnity Company, 385 So.2d 767 Services & disorders” rather than for law, viz., 22:669, (La. 1979); Hayden Ins. Co. have been v. Guardian state La.R.S. Life of America, (La.Ct.App.1986); Har applicable required payment 500 So.2d 831 of such Co., groder Ins. 559 So.2d 1367 “under the same circumstances and con- v. Protective Life 986 Co., (5th 1448, ambiguous applying ordinary Cir.1995); after

remain Ins. 47 F.3d 1451 Co., 645, interpretation, Thomason v. Aetna Ins. princiрles of contract courts 9 F.3d Life (7th Cir.1993); Heasley 647 see also v. strictly Bel are to construe them in favor of the 1249, Corp., den 2 & Blake F.3d 1257 n. Co., 8 insured. Todd v. AIG 47 Ins. F.3d Life (3rd Jamail, Cir.1993); Carpenters Inc. v. 1451-52; Ramsey at v. Colonial Ins. Co. Life District Council Houston Pension & Wel (5th America, 472, Cir.1994); 12 F.3d 479 of of Trusts, (5th Cir.1992). 299, 954 F.2d 304 Co., Hansen v. Continental fare Ins. 940 F.2d exceptions, exemptions, Because the rule that (5th 971, Cir.1991); Heasley 982 v. Belden & exclusions, provisions and limitations affect (3d 1249, Corp., 2 Blake F.3d 1257-58 Cir. ing coverage strictly against are construed 1993); McNeilly v. Bankers United As Life the insurer within inherent the rule of Co., 1199, (7th 999 F.2d surance 1201 Cir. proferentem contra and consistent with con 1993); Co., Delk v. Durham Ins. 959 Life concerns, ‍​‌​​​​​​‌​​​‌​​‌‌​​‌​​‌‌‌‌​‌‌‌‌‌‌​​​‌​‌​​‌​‌‌​​​‍gressional policy it should rec be (8th 104, Cir.1992); 106 Kunin v. Bene оgnized part as of the federal common law of 534, Trust 910 F.2d 539-40 fit Life rights obligations regulat under ERISA (9th Cir.) denied, 1013, cert. 111 plans. ed 581, (1990); 112 S.Ct. L.Ed.2d 587 v. Glocker ambiguity? ambiguity What is an An ex- (4th 540, W.R. Grace & 974 F.2d 544 if persons ists reasonable can find different Cir.1992); also, see Couch on Insurance document, meanings in a statute or Laskaris (3d ed.), § citing 7:12 at 7-23 n. 78 the above Dells, Inc., City v. Wisconsin 131 Wis.2d of authorities, including and additional v. Lee 525, 67, (App.1986); 389 N.W.2d 70 when Shield, (11th Blue 10 F.3d 1547 Cross/Blue good arguments can be made for either of Cir.1994). contrary positions meaning two as to a of a fact, according every In to the law of state document, Ready-Mix term Atlas Columbia, ambiguities and the District of in Minot, Inc., Properties, Inc. v. White 306 insurance contracts must be construеd 212, (N.D.1981); applica- N.W.2d 220 when against the insurer. Kunin v. Trust Benefit pertinent interpretation tion of rules to an Ins., (9th Cir.1990). 910 F.2d 534 “The Life words, instrument as a whole fails to make certain ‘the contract is to be construed meanings which one two or more is con- against comprise the insurer’ the most famil- veyed by employed by parties. the words expression reports iar of insurance Hatcher, 238, Wood v. 199 Kan. 428 P.2d 2 § cases.” Couch on 22:14 22- Insurance (Kan.1967). City 803 See also Sioux Falls (3d ed.). 31 Co., Inc., Henry v. Carlson 258 N.W.2d Although (S.D.1977); provisos, exceptions, exemp- Leasing Corp. Tastee-Freez tions, Milwid, and words of limitation in Ind.App. the nature of 365 N.E.2d (1977); exception, may freely Dictionary be contracted for Black’s Law 1990). insurer, circuit, 79-80 ed. In virtually we have state courts are unani- law, held that “[u]nder Texas a contract is holding strictly mous in that such terms are if, ambiguous applying after established rules against they construed the insurer where are interpretation, the written instrument ‘re- import reasonably of uncertain susceptible or reasonably susceptible mains to more than construction, of a negate coverage double ” meaning.’ Clardy one Manu. Co. v. Ma- provided policy. elsewhere in 2 See Loans, Inc., 347, rine Midland Bus. 88 F.3d § Couch on Insurance at 22- 22:31 22-66 & (5th Cir.1996) (quoting Enterpris- 352 R P& (3d ed.), 67 and voluminous citations there LaGuarta, Kirk, es v. Gavrel & 596 S.W.2d may collected. We use state common law as (Tex.1980)). 517, 519 a basis for federal common law to the extent that state law not inconsistent with con- The term “total due to mental or gressional policy group long-term concerns. Todd v. AIG nervous disorders” Life (La. 1990); Johnson, (1985); Compare Hospital McKenzie & 15 Louisiana 728 Children’s v. Whit comb, Civil Law (5th Cir.1985) (ERISA Treatise — Insurance Law and Practice 778 F.2d 239 (Supp.1995). § regulating 291 State laws insur preempts plans R.S. 22:669 under uninsured but preempted by ance are not the federal ERISA plans ‍​‌​​​​​​‌​​​‌​​‌‌​​‌​​‌‌‌‌​‌‌‌‌‌‌​​​‌​‌​​‌​‌‌​​​‍by [such not under insured as that insured Metropolitan statute. v. Ins. Co. Massachu Life case].). present Reliance in the 724, 2380,

setts. 85 L.Ed.2d

987 illness; symptoms of an illnesses whose ambiguous because it is disability policy is symptoms depression, are mood primary inter number of reasonable susceptible to a commonly swings and unusual behavior are limitation on Clearly, a pretations. regardless as mental illnesses characterized or disorder is to mental illness due Regardless of of their cause.... the cause reasonably open to the construction disorder, abundantly it is clear that he of his purely have been caused must total laypersons would consid suffered from what with no demon by disturbance a behavioral ”). illness’ Several caveats er be ‘mental See Phil organic physical basis. strable case, regarding the Brewer must be added 978 F.2d Nat Ins. Co. lips v. Lincoln Life It is one of the few ERISA cases howevеr. Cir.1992) (“mental (7th limitation illness” 302 rejected the contra in which a court has applied to ambiguous as plan was of ERISA rule; consequently, Brewer proferentem congenital suffering ence participant strictly the limitation court did not construe illness; organic “men phalopathy caused any against the insurer or consider only refer with reason tal illness” layperson viewpoint than that of an ill read causes such as non-physical illnesses with having expert no advice about the medical in child to abuse suffered those traceable Also, question. particular patient without as experiences such hood or other traumatic refinement, the Brewer definition of further being or to a state divorce or bereavement to, alia, apply inter an mental illness would reality when out of contact with psychotic or abnormal accident victim who exhibits behav organic basis for the accepted no there is injury, of a traumatic head ior as the result condition.); v. Trust Ins. Kunin Benefit Life person suffering from brain cancer who de denied, (9th Cir.), Co., cert. 498 F.2d 534 910 behavior, elderly person an velops unusual 581, 112 587 111 L.Ed.2d S.Ct. U.S. Disease, Alzheimer’s who has contracted finding was not a (upheld that autism suffering high person from a fever a delirious an ERISA because illness under mental Phillips v. staph infection. See caused disturbance tо a behavioral the term refers 978 F.2d 306 Lincoln Nat. Ins. Life organic or no demonstrable with Moreover, Eight n. Circuit subse basis.); Reserve Malerbi Central Life from Brewer quently partially retrenched Neb. 407 America Ins. 225 North proferentem in the ERISA applying contra (Neb.1987) finding (affirming N.W.2d 157 ambiguity an cannot be re context when apply limitation did not that a mental illness language as would by interpreting the solved by organ caused to behavioral abnormalities Delk v. Dur average plan participant. defect); Arkansas Blue Cross & ic brain 104, 105-106 Co., 959 F.2d ham Life Shield, Doe, Ark.App. 733 Inc. v. Blue Cir.1992). (1987) (because the cause of man S.W.2d interpreta- Another somewhat reasonable organic, it was not disease was ic-depressive psychiatric as mental or tion of such terms illness subject policy’s mental to insurance cause nor focuses on neither the disorder limitation). condition, psychiatric but symptoms of a however, believe, persons Other reasonable See the treatment involved. the nature of insur illness or mental disorder that mental Blue Shield v. Blue Cross & Simons apply to abnormal condi ance limitations York, 28, 536 144 A.D.2d New Greater symptoms that an itself tion that manifests (hospital- (N.Y.App.Div.1989) N.Y.S.2d of medi layperson without benefit untutored malnutrition due to treatment of ization for diagnosis would call mental cal advice or subject to not nervosa was anorexia v. Lincoln illness. Brewer disorder or See in-hospi- coverage applicable to limitation of (8th 154 disorders; Nat. Ins. regard- psychiatric tal care for Life denied, Cir.1990), cert. was a anorexia nervosa less of whether 2872, 115 (applying disorder, L.Ed.2d 1038 psychiatric S.Ct. illness or mental poli limitation in an ERISA hospitalization a mental illness was to treat purpose of benefits, despite expert hypo- cy deny aspects evidence malnutrition and physical of tension, naso-gastric feeding and including mood participant suffered from affective hospitalizations were biologically, genetically or medication —thus disorder caused carе). treatment, psychiatric medical “laypersons are inclined to focus on because viz., manifestation/symptom Both the and the that “total due to or mental approaches, nature of treatment reflected in nervous disorders” means a behavioral dis- Simons, organic as Brewer and turbance with no demonstrable or cases such been physical basis. criticized commentators as flawed meth- analyzing particular ods of whether a mental Consequently, summary judgment is not subject illness should be to insurance cover- appropriate because the record discloses that age develop- limits or exclusions. Before the fact, genuine there is a issue as to material research, reasonably intelligent ment of brain i.e., Lynd whether suffers from a total dis- persons could reach a broad consensus on ability due to a behavioral disturbance with physical what was a mental or disorder. Ste- basis, organic physical no demonstrable or ” Garmisa, ven P. “Mental Illness Limitation moving party and that the is not entitled to a Policies, Chicago Daily in Health Insurance judgment opposition as a matter of law. In Bulletin, However, Law Nov. 1990 at 2. summary judgment Reliance’s motion for findings of ill- because medical that serious own, support Lynd and in of his filed the mental, purely nesses once considered suсh deposition treating psychiatrist of his who schizophrenia, disorder, bipolar as affective Lynd totally testified that disabled due depressive physical illness are brain dis- major depression physiologic to a that has a eases, persons disagree reasonable can every diabetes, hyper- basis bit as much as sharply meaning on the of “mental or ner- tension, cardiomyopathy or other diseases average layperson’s vous disorder.” The un- dysfunction and is caused of the neu- derstanding constantly changing should be Deposition rotransmitters in brain. See with advances medical research. As the Dumont, III, M.D., of Arthur pages public learns more аbout the actual causes (attached 40, 43, 49, 42, 52, 56, 57 to the illness, and treatments for mental it follows summary judgment motions for filed average layperson’s understanding Reliance). Clearly, the doctor’s “psy- terms such as “mental illness” and testimony provides the basis for a reasonable change chiatric treatment” will as well. Bri- trier of fact to find or infer that Shannon, Sick, an D. The Brain Gets Too— totally major depression disabled due to a Equal Coverage The Case For Insurance For having organic physiologic basis and Illness, Mary’s Serious Mental 24 St. L.J. not due to a behavioral disturbance with no (1993). 365, 370-382 organic demonstrable basis. In conducting summary judgment review a Nevertheless, regardless any arguments keep summary court judg- must mind that merits, over their there are at least three granted genuine ment should be when no interpretations reasonable of insurance cov issue of material fact exists and when the erage upon payable limitations be moving party judgment is entitled to as a cause of or treatment due to mental closely matter of law. This standard resem- disease, particular, disorder or In illness. verdict, entry bles used for of a directed present the limitation at issue case where the district court must direct a verdict upon Disability benefits for “Total due to only if there can be one reasonable decision mental or susceptible nervous disorders” is governing made under the law. London v. to each interpreta of the three reasonable America, Corp. MAC 44 F.3d 316 tions. The term is not defined in the — Cir.), denied, U.S. -, cert. and it ambiguous applying remains after or (1995); Boeing Ship 133 L.Ed.2d 53 dinary principles interpretation. of contract (5th Cir.1969). man, 411 F.2d 365 Therefore, applying profer- the rule of contra entem in pre actually accordance with this Circuit’s The District Court did not reach Co., supra; cedents of Todd v. AIG the issues discussed here because failed to Life America, Ramsey appreciate v. Colonial Ins. Co. that a de novo review of Reli- Life supra; required by Hansen v. Continental Ins. ance’s denial of benefits is Fire- supra, strictly the term policy should be construed stone under the and limitation clause against the insurer and in by apply- the reasonable at issue. That court fell ‍​‌​​​​​​‌​​​‌​​‌‌​​‌​​‌‌‌‌​‌‌‌‌‌‌​​​‌​‌​​‌​‌‌​​​‍into error insured, sense ing reviewing that is most favorable to the deference Reliance’s denial concluding that the insurer of benefits arbitrarily capriciously.

had not acted however, court stat-

Significantly, a different might it have reached

ed that standard, applied the de novo had it

result grant might have refused to

indicating that had it summary judgment for Reliance policy and of the plenary

made á review coverage provision.

limitation majority fallen

My colleagues in the result affirming the trial court’s

into error perform a de they failed to

because likewise its limitation of the

novo review they to follow and because failed

provision require this Circuit which precedents preferen- rule of contra application lapsed in re- they had not these

tem. If recognized they surely would have

spects ambiguous, clause is con-

that the limitation insurer, strictly against the realized

strued it interpretation that the reasonable

that under genuine there is

is most favorable Reli-

dispute as to a material fact judgment as a matter entitled to

ance law, the sum- and would have reversed

mary judgment and remanded the case for proceedings.

trial or further America,

UNITED STATES

Plaintiff-Appellee, GUERRA, Rolando

Robert

Defendant-Appellant.

No. 95-50678. Appeals, Court of

United States

Fifth Circuit.

Sept. 1996. Sept.

As Corrected

Case Details

Case Name: Lynd v. Reliance Standard Life Insurance

Court Name: Court of Appeals for the Fifth Circuit

Date Published: Sep 3, 1996

Citation: 94 F.3d 979

Docket Number: 95-30588

Court Abbreviation: 5th Cir.