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The case of Mundrati v. Unum Life Insurance Company of America, __ F. Supp. 3d __, 2025 WL 896594 (W.D. Pa. Mar. 24, 2025), serves as a significant illustration of how courts will apply the abuse of discretion standard of review in disability claims under the Employee Retirement Income Security Act (ERISA). The decision rendered by the United States District Court for the Western District of Pennsylvania on March 24, 2025, reveals the dynamic of long-term disability (LTD) claims and the responsibilities of insurance companies to properly classify the claimant’s occupation and the evidence of disability a claimant provides.
Brief Factual Background
Dr. Pooja Mundrati, a Physical Medicine and Rehabilitation Physician with interventional spine and sports fellowship training, was employed by Summit Orthopedics, Ltd. (Summit), as an Interventional Spine Physician (ISP). Her duties included evaluating patients, performing examinations, administering treatments, and conducting fitness physical examinations. Unum issued a group LTD plan and administered benefits under Group Policy No. 421054001 to Summit, Dr. Mundrati’s former employer (Policy) On February 27, 2018, Dr. Mundrati was involved in a motor vehicle accident that resulted in a traumatic brain injury (TBI). Despite her initial recovery and return to work, she experienced a major setback in January 2019 due to increased workload. Her condition worsened over time, leading to her termination by Summit on January 15, 2021.
Procedural History
Dr. Mundrati filed a claim for LTD benefits with Unum Life Insurance Company of America (Unum) on March 26, 2021, citing her TBI as her disabling condition. Unum denied her claim, leading to her filing a lawsuit on October 27, 2023, under ERISA. The parties filed cross-motions for summary judgment, which were fully briefed and argued on January 22, 2025.
Key Issues in the Case
Misclassification of Occupation: Unum classified Dr. Mundrati’s regular occupation as a physician, a light-duty position, rather than recognizing her specific role as an Interventional Spine Physician, a medium-duty position. This distinction is crucial because it directly impacts the definition of disability under the policy. Dr. Mundrati argued that her actual job duties required significant physical demands that were overlooked.
Evidence of Disability: The court scrutinized Unum’s assessment of Dr. Mundrati’s ongoing health issues, particularly its reliance on the opinions of external paper reviewers, a family medicine physician and an ophthalmologist, over those of her treating physicians. Unum’s denial was based on these reviews and a review of medical records, which the court found to be selective and lacking the necessary depth to accurately reflect Dr. Mundrati’s condition.
Time Relevance of Evidence: Unum denied the relevance of certain medical evaluations conducted after the elimination period, arguing they did not pertain to Dr. Mundrati’s condition during the period in question. The court found that this rationale was unfounded, as there were no substantial changes to her condition that would justify disregarding later evaluations.
Court’s Analysis and Holding
The court concluded that Unum’s decision to deny benefits to Dr. Mundrati was arbitrary and capricious and therefore granted summary judgment in her favor. The court found Unum’s characterization of her position as a physician with light duty activities significant. Under the terms of the plan, while there was language in the Policy that Unum was required to look at Dr. Mundrati’s medical specialty as it is normally performed. It was clear to the court that Unum did not do so and that this failure was an abuse of discretion. Indeed, even if the Policy had a provision that allowed it to look at how her occupation was performed in the “national economy,” Unum was required to also consider how she performed her occupation. The court stated:
Thus, although Unum was not required to look at Dr. Mundrati’s occupation as specifically performed at Summit, and certainly not exclusively so, it was required to consider her specialty in the practice of medicine. Unum has not explained why it chose to categorize Dr. Mundrati as a “physician,” a light-duty occupation, rather than as an ISP or physiatrist which, according to the DOT, is considered a medium-duty occupation “as performed in the national economy.” Its briefs do not discuss Lasser, Weiss or any other case on the issue of “regular occupation.” Indeed, Unum does not dispute Dr. Mundrati’s supplemental statement about her job duties, nor does it contend that they are inconsistent with how the position is performed in the national economy.
Id., 2025 WL 896594, at *15 (Emphasis added).
The court also concurred with Dr. Mundrati that Unum abused its discretion by rejecting crucial pieces of evidence as “not time relevant” even though they related back to her original injury without any evidence of an intervening event1. To the court, Unum could not justify its decision to exclude the vocational report and the Functional Capacity Evaluation (FCE) as not time-relevant. Nor could the court disagree with Dr. Mundrati that it was problematic Unum’s reviewing doctor ignored critical evidence, including the opinions of her treating physicians. While Unum was not required to accept the opinions of the treating physicians, the court found Unum’s “decision to rely on [its own doctor’s] unreasonable and selective paper review over [Dr. Mundrati’s] treating physicians is another factor to take into account in determining whether its review was arbitrary and capricious.”
Finally, the court considered Unum’s decision not to order an independent medical exam (IME), and found that coupled with everything else it further supported Dr. Mundrati’s contention that Unum’s denial of her appeal could not withstand even deferential scrutiny. For these reasons, the court granted Dr. Mundrati’s motion for summary judgment and denied Unum’s motion for summary judgment.
Conclusion
The Mundrati case highlights the importance of accurately classifying an insured’s occupation and thoroughly considering all relevant evidence when evaluating disability claims under ERISA. The court’s decision underscores the need for insurance companies to adhere to the terms of their policies and to conduct fair and comprehensive reviews of disability claims. This case serves as a reminder that arbitrary and capricious denials of benefits will not be upheld by the courts.
