Friday, March 28, 2008

Split Noted: Can a Cause, as Opposed to a Symptom, of an Illness Create Ambiguity in an ERISA Plan?

Per Fitts v. Unum Life Ins. Co., No. 07-7097, *4 (D.C. Cir., March 28, 2008)

A lawyer for Fannie May, Jane Fitts was forced to stop working by her bipolar disorder. She applied for long-term disability benefits, but Unum (the administrator of the benefits plan) informed her that she would only receive benefits for two years because the plan limited benefits for those disabled by a mental illness.

Fitts filed suit under ERISA seeking benefits due under the plan, and the parties disputed whether bipolar disorder was a physical or mental illness. The district court original reviewed Unum's classification for abuse of discretion. The D.C. Circuit reversed and remanded, holding that Unum’s classification was subject to de novo review. After discovery, the district court granted summary judgment to Fitts on the issue of whether bipolar disease was a physical or mental illness. It held that bipolar disorder is a physical illness as a matter of law because it is characterized by an assortment of physical, psychological, and social factors.

In the course of reviewing this ruling, the D.C. Circuit notes that the circuits are split over whether the cause of an illness can create an ambiguity in an ERISA plan. The CAs 5,8 hold that it is the symptoms, not the causes, that determine whether an illness is physical or mental. The CAs 7,9,11 permit cause-based interpretations. The panel does not decide the issue in this case, however, because there were issues of material fact concerning whether physical factors can cause bipolar disorder and if they did so in this case. It thus reverses the grant of summary judgment and remands for further proceedings.

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