Opinion ID: 77442
Heading Depth: 2
Heading Rank: 1

Heading: Mental Illness Limitation

Text: 14 UNUM argues that the policy's mental illness limitation, defining a mental illness as mental, nervous or emotional diseases or disorders of any type, is not ambiguous because it is not susceptible to more than one reasonable interpretation. Specifically, UNUM contends that the district court's interpretation is unreasonable because it writes the provision out of the policy by preventing it from applying to OCD, a mental disorder, regardless of its cause. UNUM further contends that the district court's interpretation is unreasonable in light of ERISA's tenets for contract interpretation, which require that words be given their plain meaning. UNUM argues that if the plain meaning is applied to the term mental illness in the policy, it unambiguously encompasses all illnesses that manifest through mental symptoms, regardless of the ultimate cause of the illness. 15 UNUM's argument is based on the opinions of the Eighth and Fifth Circuits, which hold that applying the plain meaning to a mental illness limitation resolves any ambiguity regarding the classification of an illness as mental under the policy. See Brewer v. Lincoln Nat'l Life Ins. Co., 921 F.2d 150, 153-54 (8th Cir.1990) (applying the plain and ordinary meaning as understood by a layperson to the limitation, and thus holding the policy classified illnesses as mental based on their symptoms because [t]he cause of a disease is a judgment for experts); Delk v. Durham Life Ins. Co., 959 F.2d 104, 105 (8th Cir. 1992) (clarifying that the court in Brewer held that the limitation ceased to be ambiguous when it was accorded its ordinary, and not specialized, meaning); Lynd v. Reliance Standard Life Ins. Co., 94 F.3d 979, 983-84 (5th Cir.1996) (adopting the Eighth Circuit's reasoning in Brewer ). Reasoning that laymen know and understand symptoms, these circuits have held that applying the plain meaning to a mental illness limitation eliminates any ambiguity by focusing on the symptoms of the illness to determine whether it falls within the mental illness limitation. Brewer, 921 F.2d at 154; Lynd, 94 F.3d at 983. 16 Billings, on the other hand, argues that the mental illness limitation is ambiguous because the policy is silent as to whether an illness is classified as mental under the policy based on its origin or symptoms. Billings argues that a reasonable interpretation of the policy is that an illness is classified as mental based on its origin rather than its symptoms. Because the policy does not provide how it classifies an illness as mental, Billings asserts that each party presented reasonable interpretations of the limitation, and thus the policy is ambiguous. Applying the state doctrine of contra proferentem, and thereby construing the limitation against UNUM, Billings contends that OCD does not fall within the limitation because it is undisputedly an organically, or physically, based illness. 17 Billings's argument is consistent with the Seventh and Ninth Circuits' reasoning that a mental illness limitation that fails to contain any language suggesting whether the cause or the manifestation [of an illness] determines whether an illness is covered is ambiguous. Phillips v. Lincoln Nat'l Life Ins. Co., 978 F.2d 302, 311 (7th Cir.1992); Patterson v. Hughes Aircraft Co., 11 F.3d 948, 950 (9th Cir.1993). Construing the ambiguity against the drafter under the applicable state law doctrine of contra proferentem, these circuits have held that the limitation does not include organically based illnesses. Phillips, 978 F.2d at 311; Patterson, 11 F.3d at 950. 18 This court has held that [a]n insurance contract is ambiguous if it is susceptible to two or more reasonable interpretations that can fairly be made. When one of these interpretations results in coverage and another results in exclusion, ambiguity exists in the insurance policy. Dahl-Eimers v. Mut. of Omaha Life Ins. Co., 986 F.2d 1379, 1381 (11th Cir.1993) (citations omitted). The district court reasoned that because mental illnesses are categorized according to either their origins or symptoms, each party presented reasonable interpretations of the mental illness limitation where the policy was silent as to the proper classification. Accordingly, the district court held that the limitation is ambiguous, and applying the applicable state law doctrine of contra proferentem by construing the limitation against the drafter, it held that organically based illnesses do not fall within the limitation. 19 As set out above, our sister circuits have reached differing conclusions regarding the ambiguity of a mental illness limitation that fails to provide whether an illness is classified as mental based on its origin or symptoms. Compare Patterson v. Hughes Aircraft Co., 11 F.3d 948, 950 (9th Cir. 1993) (holding that a mental illness limitation containing the exact language at issue in this case is ambiguous because it does not specify whether a disability is to be classified as `mental' by looking to the cause of the disability or to its symptoms, and thus construed in favor of the insured, does not encompass organically based illnesses), and Phillips v. Lincoln Nat'l Life Ins. Co., 978 F.2d 302, 304, 310-11 (7th Cir.1992) (holding that a mental illness limitation limiting the maximum payment for care of mental illness or care of nervous conditions of any type or cause is ambiguous because the plan contains no definition or explanation of the term `mental illness,' and thus, construed against the insurance company does not include physically based illnesses), with Brewer v. Lincoln Nat'l Life Ins. Co., 921 F.2d 150, 153-54 (8th Cir.1990) (applying the plain and ordinary meaning to resolve the ambiguity), and Delk v. Durham Life Ins. Co., 959 F.2d 104, 105 (8th Cir.1992) (acknowledging that the court in Brewer resolved the ambiguity by applying the plain meaning), and Lynd v. Reliance Standard Life Ins. Co., 94 F.3d 979, 983-84 (5th Cir.1996) (adopting the Eighth Circuit's reasoning in Brewer ). 7 We, however, agree with the reasoning of the Seventh and Ninth Circuits. We therefore hold that because [t]he policy contains no definition or explanation of the term `mental [disorder],' and offers no illustration of the conditions that are included or excluded, and fails to contain any language suggesting whether the cause or the manifestation determines whether an illness falls within the limitation, it is ambiguous as applied to Billings. Kunin v. Benefit Trust Life Ins. Co., 910 F.2d 534, 541 (9th Cir.1990); see Phillips, 978 F.2d at 310-11. 20 Furthermore, we are not persuaded by the Eighth and Fifth Circuits' reasoning that the ambiguity can be resolved by applying the plain meaning. See Brewer, 921 F.2d at 154; Delk, 959 F.2d at 105-06; Lynd, 94 F.3d at 983-84. Applying the plain meaning to the limitation does not resolve the ambiguity; doing so merely adopts one reasonable interpretation over the other. It is well-established in this circuit, and among our sister circuits, that once we conclude an ERISA-governed plan is ambiguous, we apply the doctrine of contra proferentem to resolve the ambiguities in the insurance contract. E.g., Lee v. Blue Cross/Blue Shield of Ala., 10 F.3d 1547, 1551 (11th Cir.1994). Application of this rule requires us to construe ambiguities against the drafter . . . . Id. In doing so, we must conclude that Billings's organically based OCD does not fall within the policy's mental illness limitation. See Mongeluzo v. Baxter Travenol Long Term Disability Benefit Plan, 46 F.3d 938, 943 (9th Cir.1995) (explaining that [b]ecause of the rule that ambiguities are to be resolved in favor of the insured, if either a cause or a symptom of the disease were physical and caused the disability in whole or in part, then the disease does not fall within the mental illness limitation); Phillips, 978 F.2d at 310-11, 314 (holding that upon applying the doctrine of contra proferentem, the insured's organically based illness does not fall within the mental illness limitation as a matter of law). 21 Accordingly, we affirm the district court's order granting summary judgment as to Count I.