An hour before sunrise one day last spring, Krysten Laib parked her olive green Subaru Legacy on North Fifth Street near the U.S. Mint. She had just dropped off her last Uber passenger, who later told police Laib seemed "nervous but not upset."
Driving for Uber, typically overnight, brought in some money while Laib coped with major depression. Just getting out of bed was a challenge at times.
"Patient is severely depressed, and simple tasks are difficult," her psychiatrist wrote in January 2017. "Poor daily functioning."
Laib, 45, had taken leave from her job as a nursing assistant at an area hospital to deal with her condition and hoped to weather her recovery with long-term disability insurance. However, the insurer, Sun Life Assurance of Canada, rejected her claim.
"The medical and psychiatric treatment documentation does not provide satisfactory proof of Ms. Laib's inability to perform" as a nursing assistant, Sun Life wrote on March 16, 2017.
Twenty-five days later, after sitting in her car on Fifth Street from 5:33 to 6 a.m., she got out and walked in darkness toward the Benjamin Franklin Bridge.
Parking tickets led police to her abandoned car and a suicide note. They found Laib's body in the Delaware River on April 26.
"I wasn't there to catch her," Laib's mother, Kathleen Kelly, said nearly a year after her daughter's death. "I couldn't catch her."
There is no evidence that the insurer's rejection directly caused Laib's suicide. It was one of many crises, large and small, that piled up in the months before she died. But interviews with family and friends, and comments she made before her death, show the struggle for coverage weighed on her.
Mental illness is the fourth most common condition cited in disability claims, but the people suffering from it can have a particularly difficult time getting the benefit. Her case illustrates a central tension in the American health-care system, said lawyers, mental-health advocates, and insurance industry experts: Prove that you are too mentally ill to work — without losing everything.
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"These policies are designed to say no," said Michael Brody, president of the Mental Health Association of Southeastern Pennsylvania. "The hoops that people have to jump through in order to qualify for total disability, especially as it relates to a behavioral health condition, are enormous."
Laib began treatment for depression a month before taking leave from work at Chestnut Hill Hospital, which made her eligible to apply for long-term disability benefits, up to 60 percent of her pay if injury or sickness made it impossible for her to do her job. She was among the one-third of private-industry workers who have access to long-term disability insurance. On average, about two out of three claims are approved quickly. Rejection, though, can mean a prolonged fight.
Sun Life declined to comment on the details of Laib's case, citing confidentiality, but its correspondence with Laib's attorneys cited a lack of documentation in her file, something that can be toxic for a disability claim.
"While a physician's diagnosis is a critical part of the process, it is not the only component that is assessed when looking at a disability claim," said Cathryn Donaldson, a spokeswoman for America's Health Insurance Plans, an industry advocacy group. "Just a diagnosis from a physician does not necessarily equate to a disability."
Laib's lawyers, though, say they answered Sun Life's questions, only to be met with demands for still more information and further rejection.
In a letter from Sun Life written after Laib's death, the insurer added one more reason for denial: Because Laib was driving for Uber before she died — something her lawyers say her policy should have allowed — she was well enough
"The facts are the facts," her lawyer Graham Baird said. "She was so depressed that she killed herself, but at the same time, she had to work or she would be homeless."
Laib picked up her last passenger at 4:22 a.m. April 11, 2017, at Thomas Jefferson University Hospital on South 10th Street. She dropped off the person 21 minutes later at Axe Factory Road in Northeast Philadelphia, said Abington Police Lt. Steve Fink, who handled the case because Laib was reported missing in her hometown.
Laib then drove to Old City and ended her life.
"She was everything I wished I could be," her mother, Kelly, said.
Laib's family and friends described a woman of uncommon poise, a natural dancer. Laib was generous even in childhood, they said. A close friend, Jessica Whitford, recalled the teenage Laib as passionate for singing, dancing, and Pat Benatar's music. She was quiet but had an easy way with strangers and deep compassion for people in need.
"She always gave people grace," Whitford, now of Los Angeles, said. "She was never angry."
Later, while studying nursing, Laib excelled in working with patients.
"Krysten had this unwavering ability to encourage others and help them see their value," Sue Murphy, an instructor at Montgomery County Community College, said at Laib's funeral.
Laib graduated from Temple University in 1994 and had hoped to become a lawyer before a mid-career shift from paralegal work to health care. She began taking nursing classes at MCCC in 2008.
Despite her talents, Laib struggled to find her place, friends said. "She couldn't reach herself," said Rosemarie Timoney, who taught Laib at the Timoney School of Irish Dance in Glenside.
Laib did not seek mental-health treatment until after an episode in August 2015, her mother said, when she broke down over homework, crying that "she couldn't think."
A hiatus from school followed. She was diagnosed with depression in December 2015, records show, and a month later took medical leave from Chestnut Hill Hospital, where she had worked for more than a year and a half.
Laib returned to nursing school, records show, but failed a critical exam in August 2016 and was dropped from the program. The same month, Sun Life rejected her claim for long-term disability. Her leave from work expired a month later, costing her her employer-based health insurance. She spent most of two weeks in bed around that time, Kelly said, and her Facebook posts were so alarming a friend called police out of concern Laib might hurt herself. Later the same year, a romantic relationship ended abruptly.
Her financial situation deteriorated, too. Laib liquidated a $25,000 IRA, much of her retirement money, to pay for health insurance and the mortgage on her home, where her mother also lived. Eventually her older brother began paying the mortgage. She started driving for Uber in fall 2016.
"She felt like such a burden to her mother," said Mary LeMieux-Fillery, an attorney who helped Laib with her claim. "I could definitely see the progressive decline in her."
Laib never applied for Social Security disability benefits (SSDI) — a source of help for people with physical or mental health disabilities, her mother said. Kelly said Laib was discouraged by her experience with Sun Life, but in general, SSDI benefits aren't accessible until a person has been out of work for at least five months.
Sun Life's records chronicled a year of illness as Laib struggled to regain her footing.
Jan. 19, 2016: "…anxiety related to starting nursing school. Struggling with depression was reported."
April 12, 2016: "Ms. Laib continued to report feelings of hopelessness, depression, hypersomnia, fatigue, irritability, anhedonia, decreased focus, and distractibility."
May 19, 2016: "She was not leaving the house except to go to school."
Nov. 1, 2016: "Ms. Laib reported her disability claim was turned down. She was upset by this."
Jan. 20, 2017, four months before her death: "Depressed mood, no interest, no motivation, poor concentration, poor focus, worthlessness, and guilt."
After initially being denied for long-term disability, Laib appealed but was rejected in March 2017. More than 60 percent of appeals are denied, according to a 2017 report from the American Council of Life Insurers. Less than 1 percent of those denials lead to lawsuits, the vast majority of which are unsuccessful. Federal law makes it difficult for a judge to overturn an insurer's denial in most states. Seventeen states have passed rules or laws to balance the field between an insurer and a person claiming disability, but Pennsylvania isn't one of them.
Sun Life assigned three experts to review Laib's appeal. They wrote that her claim lacked documentation on how she was examined or specifics on how her condition limited her ability to work.
"Disability is not paid on a diagnosis," said Carol Harnett, president of the nonprofit Council for Disability Awareness. "It's paid on the impact a condition has on your ability to perform."
Sun Life conducts an evaluation of a claimant's records and activities when it receives a long-term disability claim, a spokesman said.
"Our sincerest condolences are with her family," said Devon Portney Fernald, a Sun Life spokesman. "When someone files a claim for total disability, we seek to obtain and consider all relevant information, including whether the person was working or conducting activities related to their occupation."
Insurers' rigor protects against fraudulent claims and ensures financial stability, industry experts said. Sun Life's claim review also noted it tried to contact Laib's providers for more details but did not hear back.
The concern about documentation is legitimate and complicated, said Joe Dvoskin, an Arizona-based psychologist and national consultant on mental-health issues, but added, "It doesn't seem right to punish her because the doctors don't respond."
Federal regulators have said, though, that insurers' approach can penalize ill and injured people in need.
"Insurers and plans looking to contain disability benefit costs may be motivated to aggressively dispute disability claims," stated a recently enacted Department of Labor rule to protect people making disability claims.
The Department of Labor noted 64 percent of all lawsuits filed over benefits involved long-term disability claims.
"If it's a close case, they'll deny the claim," said Mike Salmanson, a Philadelphia disability attorney of 30 years with no connection to Laib's case. "Maybe the person will drop out of the appeal. Maybe they won't file a lawsuit. At the end of the day, [the insurer] will just have to pay what they should have paid to begin with."
Insufficient information caused 18.5 percent of all long-term disability claim denials in 2016, the single most common reason cited, according to the ACLI report. Claims denied due to fraud were too infrequent to register as a percentage.
The path to disability benefits is even more fraught when mental illness is involved. The effectiveness of mental-health treatments varies by person, making it difficult to predict the results of a treatment regimen, and there is no X-ray or blood test that can clearly quantify the illness' severity.
"I think that the mental illness part of this comes in, even where you have someone who is treated, even someone like Krysten who was taking anti-depressants and anti-anxiety medication," said Baird, who took over Laib's case when LeMieux-Fillery changed jobs. "It's still hard to ultimately show that that person is disabled from all work."
Information is not made public that reveals how insurers' long-term disability rejection rate for people with mental illness compares with the overall rate. As a result, defining the depth of the problem facing the mentally ill is difficult.
Before Laib died, Kelly thought her daughter was recovering. There was a job interview ahead, and she had been accepted to Bucks County Community College's nursing program.
People treating Laib wrote in several evaluations that she was not a suicide risk.
Anticipating suicide can be complicated, said Catherine Moutier, chief medical officer for the American Foundation for Suicide Prevention. Probing questions are needed to uncover suicidal thoughts, she said. And suicide can be spontaneous, with months or years of ideation culminating in a decision acted upon within minutes, experts said.
Laib ran out of medication treating her depression — Zoloft, an antidepressant, and Seroquel, an antipsychotic — a few days before her death. She planned to refill the prescription but never did.
Moutier said that suddenly stopping treatment can be dangerous.
"They're being utilized to treat a medical illness of the brain," Moutier said. "Because the brain is a physical organ and arguably the most complex organ in the body, there are potentially real ramifications when you abruptly discontinue."
In her final note, Laib typed: "I am tired of struggling and being a constant disappointment to everyone, including myself."
She added, in handwriting: "I'm sorry, mom."
It is unknowable whether more financial stability would have helped Laib weather her depression. Her mother is furious, though, that it took suicide to prove the depth of Laib's illness.
Today, Kelly takes solace in faith and memories. A young Krysten asking a mall Santa to bring gifts for poorer children. Her habit of brushing her hand against her mom's back. There's guilt, though, and the awful question: Could she have done more? And there's grief that can't be salved.