The U.S. District Court for the Northern District of California recently clarified what a claimant must demonstrate to meet the standard of “disabled” under the Employment Retirement Income Security Act (ERISA). Specifically, the court found that a claimant is not required to demonstrate absolute incapacitation but must show an inability to perform the substantial duties of her occupation

In Linda Przybyla v. The Prudential Insurance Company of America, 2025 WL 28446 (N.D. Cal. Jan. 3, 2025), the court addressed a dispute involving the denial of long-term disability (LTD) benefits. The plaintiff, Linda Przybyla, filed suit under 29 U.S.C. section 1132(a)(1)(B) after Prudential denied her LTD claim. The court’s analysis focused on Prudential’s denial process, the sufficiency of medical evidence, and the proper interpretation of “disability” under the plan.

Przybyla was employed as an “Engineering Coordinator” and participated in a group LTD plan sponsored by her employer and insured by Prudential. Under the plan, disability benefits were available if a claimant could demonstrate an inability to perform the substantial and material acts of her occupation with reasonable continuity. The plan required proof of disability, including medical documentation, treatment records, and verification of functional limitations.

The plaintiff ceased working and submitted her LTD application in November 2022 due to significant health issues, including chronic pain, dizziness, and vestibular migraines. Her treating physician, Dr. Cameron Oba, diagnosed her with fibromyalgia, ataxia, and fatigue and supported her claim. Despite this, Prudential denied the claim, citing a lack of sufficient evidence demonstrating an inability to perform her occupational duties.

Prudential’s denial relied heavily on the opinions of its medical reviewers, including Dr. Amy Cao, Prudential’s VP and Medical Director. Dr. Cao concluded that while Przybyla had mild cervical stenosis and cervicogenic headaches, the findings did not explain her reported fatigue, dizziness, or gait instability. She also emphasized that the plaintiff showed improvement with physical therapy and medication. A vocational review by Steve Lambert similarly concluded that Przybyla’s occupation could be performed at a sedentary level consistent with Dr. Cao’s findings.

Przybyla appealed the denial and submitted additional medical opinions from multiple treating physicians, including Drs. Oba and Hovsepian, who detailed persistent functional limitations and ongoing symptoms. Dr. Oba emphasized that Przybyla’s “gait difficulties/ataxia requiring a cane for ambulation” and severe fatigue were supported by his direct clinical observations, not merely subjective complaints. Despite this supplemental evidence, Prudential upheld its denial following further review by external consultants, who asserted a lack of objective findings correlating with Przybyla’s reported limitations.

The court applied a de novo standard of review and evaluated the administrative record without deference to Prudential’s conclusions. The court found that Przybyla had met her burden of proving disability under the plan, emphasizing that her medical history, consistent treatment, and the extensive documentation provided by multiple treating physicians established a significant functional impairment. The court criticized Prudential’s reliance on “selective evidence” and failure to adequately consider the consistent clinical findings supporting Przybyla’s disability. The court noted that Plaintiff’s consistent reports of pain and her efforts to obtain pain relief via physical therapy and follow-up visits with her primary care physician, neurologist, rheumatologist, and ENT support the credibility of her complaints of disabling symptoms. The court cited Sangha v. Cigna Life Ins. Co. of New York, 314 F. Supp. 3d 1027, 1036 (N.D. Cal. 2018) (“[T]he consistency and severity of Plaintiff’s complaints and her pursuit of medical treatment over time support her claim of disability”). The court further noted that Przybyla’s treating physicians’ personal and emphatic corroboration of the severity of her symptoms is further support and that given the evidence, Przybyla easily met her burden.

The court cited Muniz v. Amec Construction Management, Inc., 623 F.3d 1290 (9th Cir. 2010) and reiterated that a claimant is not required to demonstrate absolute incapacitation but must show an inability to perform the substantial duties of her occupation. The court also noted, “where the opinions of treating physicians are consistent, well-documented, and supported by the claimant’s medical history, those opinions should not be discounted in favor of non-examining reviewers.”

The court also noted that Prudential’s physicians’ opinions did not persuade it otherwise because their opinions rely entirely on the purported absence from Plaintiff’s medical records of the objective findings they believed would support her reported symptoms. However, the Ninth Circuit has repeatedly stated that objective evidence for chronic pain conditions should not be required under a disability policy. The court cited Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 678 (9th Cir. 2011) for the statement that “Many medical conditions depend for their diagnosis on patient reports of pain or other symptoms, and some cannot be objectively established until autopsy. In neither case can a disability insurer condition coverage on proof by objective indicators such as blood tests where the condition is recognized yet no such proof is possible.” It also cited Cruz-Baca v. Edison Int’l Long Term Disability Plan, 708 F. App’x 313, 315 (9th Cir. 2017) (“Pain is an inherently subjective condition.”).

Ultimately, the court ruled in favor of Przybyla, granting her motion for summary judgment and ordering Prudential to pay LTD benefits. This case underscores the importance of comprehensive medical documentation and highlights the judicial scrutiny applied to insurer denials under ERISA, emphasizing the necessity for insurers to engage in a thorough and unbiased review of all evidence presented.