## Facts

- Eric S. Ringwald, a former casino employee, participated in an employer-sponsored long-term disability (LTD) plan insured and administered by Prudential Insurance Company of America.
- Ringwald stopped working in April 2004, reporting HIV, fatigue, and significant psychiatric conditions (including depression and later bipolar disorder).
- The plan paid LTD benefits for up to 24 months when a participant could not perform the material duties of the regular occupation; continued benefits after 24 months required inability to perform any gainful occupation.
- The plan limited benefits to 24 months (lifetime) for disability “due in whole or in part to mental illness,” broadly defined to include psychiatric or psychological conditions such as depression and bipolar disorder.
- Prudential paid Ringwald benefits for 24 months and then terminated benefits based on the mental-illness limitation.
- During administrative appeals, Ringwald submitted medical records and a letter from a long-time treating physician stating Ringwald was continuously disabled due to HIV, HIV-medication complications, and depression with physical symptoms, and could not work.
- Prudential upheld its termination decision on internal appeal; Ringwald also received Social Security disability benefits, but the record did not clearly show the basis for that award.
- Ringwald sued under ERISA § 502(a)(1)(B) seeking continued LTD benefits; after an appellate remand, the district court reconsidered the denial under de novo review.

## Issues

1. Whether Ringwald’s disability after 24 months was “due in whole or in part to mental illness” under the plan, such that the 24-month limitation barred additional LTD benefits.
2. Whether, on de novo review of the administrative record, Ringwald proved disability under the plan’s post-24-month “any gainful occupation” standard based on HIV and related physical impairments independent of mental illness.
3. How the court should weigh the treating physician’s opinion and the Social Security disability award when determining entitlement to benefits under the plan.

## Decision

- The court applied de novo review because discretionary authority was not granted in the plan document itself.
- The court held the mental-illness limitation applied because the record showed Ringwald’s inability to work was caused, at least in significant part, by depression and/or bipolar disorder within the plan’s definition of mental illness.
- The court concluded Ringwald was not entitled to LTD benefits beyond the 24 months already paid because the limitation capped benefits when mental illness contributed to disability.
- The court treated the Social Security disability award as relevant but not controlling, particularly where its stated basis was unclear.
- Judgment was entered for Prudential, upholding the benefits termination after 24 months.

## Legal Principles

- In an ERISA benefits action, de novo review applies unless the plan document (not merely a summary plan description) grants the administrator discretionary authority.
- A plan limitation for disability “due in whole or in part to mental illness” can apply to mixed mental-and-physical conditions when mental illness is a contributing cause of disability.
- Treating-physician opinions are probative but not automatically controlling; on de novo review, courts weigh them against the full administrative record.
- A Social Security disability determination may be considered but does not bind a court interpreting and applying an ERISA plan’s terms.

## Conclusion

The court held, on de novo review, that the plan’s 24-month mental-illness limitation barred further LTD benefits because Ringwald’s disability was caused at least in part by covered psychiatric conditions, and the record did not establish entitlement to continued benefits beyond the capped period.


Ringwald v. Prudential Ins. Co. of Am., 754 F. Supp. 2d 1047 (E.D. Mo. 2010)