ERISA: Katsanis v. Blue Cross and Blue Shield Association

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U.S. District Court, Western District of New York

ERISA

Disability Benefits — Mental Health Exclusions

Katsanis v. Blue Cross and Blue Shield Association
07-CV-696
Judge Curtin

Background: This is an action, brought pursuant to the Employee Retirement Income Security Act in which the plaintiff seeks benefits under the long-term disability plan of his former employer, Excellus Health Plan, a nonprofit independent licensee of defendant Blue Cross and Blue Shield Association, the plan sponsor and administrator. The plan provides that a participant who is disabled primarily because of mental illness shall be limited to 24 months of LTD benefits. The plaintiff states that the defendant improperly limited his benefits to a 24-month period after determining that he was disabled as a result of a mental condition. The defendant has moved for summary judgment.
The plaintiff was employed by Excellus as a project manager from April 1992 until Jan. 3, 2003. On Nov. 15, 2002, the plaintiff applied for LTD benefits under the BCBS employee welfare benefit plan. The plan provides that a participant in the plan is entitled to benefits only “if he is found, on the basis of medical evidence satisfactory to the committee, to be disabled.” The plan further provides that “a participant who is disabled primarily because of mental illness shall not receive a disability benefit for a period in excess of 24 months.” 
The plaintiff’s application for LTD benefits was based on “chronic fatigue and insomnia, depression, persistent pain, confusion and difficulty thinking and reasoning and remembering.” He also disclosed that he was being treated for a herniated disc, gastroesophageal reflux disease, and post-thoracotomy pain. The administrator halted benefits after the 24-month mental health limitation period thereby prompting this litigation.

Ruling: The court observes that the plaintiff submitted no evidence that he was disabled by a physical illness or condition, and reasons that ample evidence that his cognitive functioning was a result of psychiatric illness. “In the face of medical opinions that the plaintiff’s cognitive issues were either caused by psychiatric disease, including depression and BPD, or alternatively by an undiagnosed and unnamed physical condition, it was not unreasonable for the administrator to conclude that the cause of the plaintiff’s disability was mental, not physical,” the court concluded. The defendant’s motion for summary judgment is granted, and the complaint is dismissed.

Christen Archer Pierrot of Chiacchia & Fleming LLP for the plaintiff; Dennis K. Schaeffer of Jaeckle Fleischmann & Mugel LLP for the defendant