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November 30, 2010
What to Do When Doctors Disagree?

A Rhode Island credit union manager complained to her doctors about work-related stress, which was overwhelming her. Her psychiatrist diagnosed her with major depressive disorder, with which she had been troubled 12 years earlier. He classified her as having “marked limitations,” and she applied for long-term disability benefits under the credit union’s plan. But the plan had limitations, too.

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What happened. “Gantry” was working as vice president of operations for the Westerly Community Credit Union when she was again diagnosed with disabling depression, aggravated by workplace stress. When the credit union’s insurer, CUNA Mutual, agreed to send her benefits, it was careful to remind her that the plan placed a 2-year limit on payments because of a mental illness. When the 2 years were coming to an end, however, Gantry launched a barrage of appeals, arguing that her disability was actually rooted in Lyme disease.

The first appeal was in mid-2002, when she first raised the issue that was the basis of her case: About a year after her disability benefits began, she had been bitten by a tick and thereby infected with Lyme disease. After that, she said, her mental illness was caused by the physical disease and should therefore not be subject to the 2-year limitation. Another psychiatrist told CUNA he did not believe that Lyme disease had caused her condition, but Gantry appealed the insurer’s decision five more times before March 2006. As a consequence, the number of physicians asked to review her case by both Gantry and CUNA grew much larger.

They reached, as the opinion in this case put it, “divergent opinions, with some opining that [Gantry] was disabled by Lyme disease and others that [she], if disabled, was disabled by a depressive disorder.” Still without benefits, Gantry sued CUNA for violation of the Employee Retirement Income Security Act (ERISA), which covered the disability plan. A judge in federal district court ruled in CUNA’s favor, and Gantry appealed to the 1st Circuit, which covers Maine, Massachusetts, New Hampshire, and Rhode Island.

What the court said. Gantry argued that it should have been CUNA’s burden to prove she is disabled by mental illness, not hers to prove the Lyme disease theory. But judges found that “CUNA’s evidence is stronger,” so Gantry lost her case again. Gent v. CUNA Mutual Insurance, U.S. Court of Appeals for the 1st Circuit, No. 09-1703 (2010).

Point to remember: When an insurer serves as both administrator and claims payer, as CUNA did, courts can see that as a conflict of interest. But judges did not find that a problem in this case.

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