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Court Rules in Favor of Retroactive Disability in Dharmasena v. MetLife

Court Rules in Favor of Retroactive Disability in Dharmasena v. MetLife

In the interesting ERISA case of Dharmasena v. Metropolitan Life Insurance Company, 2025 WL 1563970 (C.D. Cal. May 29, 2025), Judge Jesus G. Bernal of the U.S. District Court for the Central District of California ruled in favor of the plaintiff, Hettihewage Dharmasena, reversing MetLife’s denial of long-term disability (LTD) benefits. This case highlights critical issues in ERISA disability litigation, especially surrounding retroactive disability claims and the evidentiary weight of a favorable Social Security Administration (“SSA”) disability determination. It also reinforces that working up to one’s date of termination does not automatically preclude a finding of disability under the terms of a long-term disability policy.

The Plaintiff’s Claim and the Denial

Dharmasena was a long-time electrical engineer for Schneider Electric when he began to suffer from progressive symptoms of facioscapulohumeral muscular dystrophy, a rare genetic neuromuscular condition. Despite significant physical limitations—including atrophied muscles, impaired mobility, and the need for assistive devices—Dharmasena continued working until his termination on February 4, 2022.

When he applied for LTD benefits from MetLife, the insurer denied the claim on procedural grounds, asserting that Dharmasena’s disability began on February 7, 2022—after his employment and coverage had ended. The denial rested on the assumption that a claimant must stop working due to disability before losing coverage. However, the Court held this reasoning was flawed.

Retroactive Disability: The Key Legal Turning Point

A central issue was whether Dharmasena could be considered disabled before his last day of work, despite his continued employment. The Court ruled that a claimant may be retroactively found disabled, even while still employed. “There is no brightline rule that an employee must claim disability before being terminated to receive long-term benefits,” the Court stated, citing Woo v. Deluxe Corp., 144 F.3d 1157, 1162 (8th Cir. 1998) and Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 918 (7th Cir. 2003).

Judge Bernal clarified that “last day worked” is not the same as the “date of disability.” Under the terms of MetLife’s plan, a participant is “disabled” if they are “unable to earn” more than 80% of their predisability earnings due to illness or injury—regardless of whether they were still on payroll. The Court emphasized that a person can “force himself to work despite an illness that everyone agreed was totally disabling.”

Objective Medical Evidence and the Role of the Treating Physician

The Court gave significant weight to the observations of Dharmasena’s treating physician, Dr. Win, who examined the plaintiff on February 8, 2022—just four days after his termination. Dr. Win noted that Dharmasena “was very weak and cannot walk at all,” could not push a wheelchair, and was unable to use a computer due to upper extremity atrophy.
“Even accepting Defendant’s argument that Plaintiff only needed to sit, use a mouse, and input code for a job,” Judge Bernal wrote, “if Plaintiff cannot sit or use his upper extremities, Plaintiff was disabled…within the meaning of the Plan.”

This real-time clinical assessment, combined with Dharmasena’s long treatment history and consistent functional evaluations, provided compelling support for a retroactive disability finding as of February 4, 2022.

The Significance of the SSA Disability Determination

One of the most impactful holdings of the case was the Court’s treatment of the SSA’s disability finding. Dharmasena had been awarded Social Security Disability benefits, with the SSA agreeing that his disability began on February 4, 2022—the very date MetLife sought to disqualify. Judge Bernal called the SSA’s decision “weighty evidence,” noting that: “The requirements for disability under the SSA are stricter than the Plan.”

While MetLife argued that the SSA did not thoroughly investigate the disability onset date, the Court rejected this claim, explaining that the SSA’s determination was consistent with the medical record. As a result, the SSA’s conclusion bolstered the Court’s finding that Dharmasena was indeed disabled before his termination.

De Novo Review and Remand Rejected

Because the Court reviewed the denial de novo, it was empowered to make its own findings without deference to MetLife’s prior decision. Judge Bernal found that remanding the case back to MetLife for further review would only delay justice: “Both sides have had a fair opportunity to argue their views on whether Plaintiff was disabled under the Plan, and the Court sees no reason to delay Plaintiff’s review further.”

Key Takeaways for Claimants and Practitioners

  • Working until termination does not bar a disability claim. Courts recognize that employees may struggle to remain employed even while disabled.
  • Retroactive disability claims are viable if the claimant can show, by a preponderance of the evidence, that they met the Plan’s definition of disability before coverage ended.
  • Treating physician opinions and clinical contemporaneous evaluations carry significant weight under ERISA, especially when based on long-term treatment relationships.
  • SSA disability awards matter. Even though they arise under a different legal standard, federal courts often give considerable weight to SSA findings in ERISA litigation.
  • Procedural denials based solely on last work date can be overturned. A plan administrator cannot equate “last day worked” with “not disabled.”

Conclusion

Dharmasena v. MetLife serves as a strong reminder that ERISA disability determinations must be rooted in substantive evidence—not procedural technicalities. For claimants facing denial because they worked “too long,” the case offers hope and legal precedent. As the Court put it plainly: “The best evidence of the reality of Plaintiff’s condition comes from the physician who actually examined Plaintiff.”

For the year 2025, Feedspot created a list of the Top 35 ERISA Law Blogs, News Websites and Newsletters to Follow in 2025. McKennon Law’s ERISA and Insurance Litigation Blog was selected by the panelists at Feedspot as one of the Top 35 ERISA Law Blogs and was selected the 6th overall Top ERISA Law Blog among thousands on the internet. Feedspot ranked the ERISA Law Blogs on the web using Google reputation and search ranking, influence and popularity on social media, quality and consistency of posts and Feedspot’s own editorial team and expert review. Top 35 ERISA Blogs

Why Life Insurance Claims Are Denied—and What You Can Do About It

Life insurance exists to provide financial protection and peace of mind to beneficiaries after the loss of a loved one. Yet for many grieving families, that promise is shattered when the insurer denies the claim. While insurers often pay out valid claims, denials still occur with alarming frequency—often for reasons that beneficiaries do not expect and sometimes do not understand. At McKennon Law, we specialize in challenging wrongfully denied life insurance claims and holding insurers accountable. In this article, we break down the most common reasons life insurance claims are denied and what you can do if you are facing a denial.

Misrepresentation or False Information on the Application

One of the most common reasons insurers deny life insurance claims is misrepresentation on the original life insurance application. This means the policyholder provided inaccurate or incomplete information that was requested on the policy application.

Common misrepresentations include failing to disclose a pre-existing medical condition, underreporting smoking or alcohol use, omitting details about dangerous hobbies, or not reporting other life insurance policies. Insurers use the application to assess risk. If the applicant did not disclose some significant medical information that was requested on the application and later dies from a related (or even unrelated) cause, the insurer may refuse to pay out the claim. If the misrepresentation is deemed “material,” the insurer may void the policy, even after years of premium payments. However, the law requires that these misstatements must have actually affected the insurer’s decision to issue the policy, and courts closely scrutinize such denials—particularly if the policy has been in force for more than two years.  

Most life insurance policies have a contestability provision that limits the insurer’s ability to “contest” a policy more than two years after the policy is issued.  During this time, the insurer can investigate the accuracy of the application if the policyholder dies. The claim could be denied if the insurer finds that the policyholder misrepresented material information, even unintentionally.

Lapse in Premium Payments

Life insurance is a contract. You pay premiums, and the insurer agrees to pay a benefit when the time comes. But if those premiums stop, so does the coverage. However, California law (and many others) provides strong protections for policyholders, including mandatory grace periods and advance notice requirements before a policy can be terminated.  In California, life insurance policies must follow specific rules that protect policyholders from losing coverage due to missed payments. Under California Insurance Code §10113.71, life insurance companies must provide a 60-day grace period after a missed premium before a policy can lapse and send a written notice at least 30 days before terminating the policy for nonpayment.

Lapses can be largely avoided by setting up automatic payments. If you are struggling financially, contact your insurer immediately to explore options. Some may offer reduced coverage or temporary relief to help keep the policy active.

At McKennon Law, we frequently litigate claims where insurers failed to comply with these statutes. If an insurer did not provide timely and proper notice, the policy may still be in force—despite a missed payment.

Cause of Death Is Excluded

Not all causes of death are covered under every life insurance policy. Some policies specifically exclude specific causes of death. Common exclusions include suicide within the first two years of the policy, death during the commission of a crime, war or terrorism-related deaths, or death from drug or alcohol overdose.  These exclusions must be clearly stated in the policy and interpreted narrowly under the law.  In many cases, McKennon Law has  successfully argued that an exclusion does not apply, or that the insurer misinterpreted the facts surrounding the insured’s death.

Beneficiary Issues or Disputes

One of the most common reasons we see life insurers not pay claims is that there is a dispute about who is the rightful beneficiary of the death insurance proceeds.  A claim may be denied not because of the policy terms but because of problems with the beneficiary designation  or fights about undue influence upon the insured who named a beneficiary.  Some disputes might include no named beneficiary, a deceased beneficiary, a divorce situation, or when legal restrictions apply, such as minor children without a legal guardian. In some cases, community property laws or ERISA law may affect who is entitled to the death benefit. These disputes are legally complex, and McKennon Law  routinely assists clients in resolving them, whether through negotiation or litigation.

Fraud or Suspicious Circumstances

A less common reason for denial exists if the insurer suspects fraud in some manner not including misrepresentations in the application.  Insurers may launch an investigation and put the claim on hold or deny it entirely. Fraud might involve falsified documents, staged deaths, or suspicious beneficiary behavior. Insurance fraud is taken seriously, and even if the claim turns out to be valid, a lengthy investigation can delay the payout.

The Policy Was Never Activated Because There Was No Evidence of Insurability Provided

Another troubling basis for denial of life insurance claims under employer-sponsored ERISA plans arises when the insurer or employer failed to obtain required Evidence of Insurability (EOI)—even though the insured was told they had coverage. At McKennon Law, we have handled numerous disputes involving life insurers and an ERISA plan participant not qualifying for a policy because they are deemed ineligible for coverage because no EOI was provided. In many cases, employees elect supplemental life insurance during open enrollment and begin paying premiums, only for their beneficiaries to learn after the insured’s death that the insurer never received or approved the necessary EOI forms. Despite confirming enrollment, deducting premiums, and even issuing benefit confirmations, insurers may later claim the coverage was never actually effective. This post-claim underwriting like this is unjust and deeply unfair to employees who reasonably believed they were insured.

Courts have increasingly scrutinized this tactic. Under ERISA, when an employer or plan administrator fails to follow proper procedures or misleads the employee into believing coverage is in place, courts may find that coverage is valid under principles of equity or breach of fiduciary duty.  We have successfully litigated numerous cases where insurers attempted to deny claims on the basis of missing EOI—despite years of premium payments and confirmation of coverage. If you are facing a denial on these grounds, it is critical to have experienced ERISA counsel review whether the insurer or employer mishandled the enrollment process.  We can usually get the life insurer and/or the plan participant’s employer to pay all of most of the death benefit and our attorneys’ fees and costs too.

What You Can Do If a Claim Is Denied

If your life insurance claim has been denied, the first and most important step is not to panic—and not to accept the denial at face value. Insurance companies often deny claims for reasons that do not hold up under legal scrutiny, including alleged misrepresentations, lapses in coverage, lack of EOI, or improperly applied exclusions. Make sure to request a written explanation of the denial that explains the full basis for the denial, along with the claim file and the policy documents. Carefully review the reasons given and the timeline of events surrounding the denial. You have the right to fight the denial decision, and doing so promptly is essential.

Next, consult with an experienced life insurance attorney. Life insurance policies—especially those governed by ERISA—are complex and involve strict legal standards and deadlines. At McKennon Law, we have successfully handled many denied life insurance claims, holding both insurers and employers accountable for wrongful denials. Whether the insurer is claiming a lapse for non-payment, a failure to submit Evidence of Insurability, or asserting a policy exclusion, we know how to navigate these disputes. Often, a denial can be reversed through a strong appeal or litigation if necessary.

Finally, be sure to act quickly, as deadlines for contesting a denial can be short, particularly under ERISA plans. The earlier you engage counsel, the better your chances of preserving evidence, building your case, and recovering the benefits you are owed. At McKennon Law, we offer personalized, aggressive representation aimed at achieving full recovery for our clients. If your life insurance claim has been denied, contact us today for a consultation to evaluate your rights and next steps.

Life insurance lapse disputes have become increasingly common in recent years, especially after the California Legislature enacted Insurance Code sections 10113.71 and 10113.72 (Statutes) to prevent policyholders from inadvertently losing coverage. The Statutes impose specific requirements on insurers before terminating a life insurance policy for nonpayment, including mandatory grace periods and advance notice obligations. The Statutes set forth a “single, unified pretermination notice scheme” consisting of “three components” designed to minimize the chance that policy holders would inadvertently default. McHugh v. Protective Life Ins. Co., 12 Cal. 5th 213, 240 (2021). First, the Statutes require insurers to give policy owners a 60-day grace period to pay a missed premium payment (the Grace Period Requirement). Cal. Ins. Code § 10113.71(a). Second, they require insurers to notify policy owners of their right to designate a third party to receive notices regarding overdue premiums or impending terminations of their policy (the Designee Notice Requirement). Id. § 10113.72(a), (b). Third, and finally, the Statutes require insurers to provide notices regarding any unpaid premium, within 30 days of the missed payment, and notices regarding impending termination for nonpayment, at least 30 days before termination (the Pretermination Notice Requirement). Id. §§ 10113.71(b), 10113.72(c).

In Siino v. Foresters Life Insurance and Annuity Co., __ F.4th___ (9th Cir. 2025), the Ninth Circuit Court of Appeals recently issued a published decision clarifying how these statutes operate and what a policyholder must prove to sustain a challenge to a policy lapse. The result was a split decision that both affirmed protections under the law and emphasized the continued importance of showing causation in breach of contract claims.

The facts in Siino are a cautionary tale about the risks of missed notices. In 2010, Pamela Siino purchased a $100,000 term life policy from Foresters Life Insurance and Annuity Company (FLIAC). In 2014, she moved and attempted to update her address with the insurer, but the change was rejected for lack of a signature. As a result, notices sent by FLIAC regarding upcoming premiums and potential lapse were sent to her old address. After failing to pay the premium due in January 2018, her policy was deemed lapsed. Although FLIAC sent a notice on February 26, 2018, advising her that her policy had lapsed and that she could reinstate the policy within 30 days, Siino never received it. She discovered the lapse only in 2019 after her husband contacted their insurance agent. Rather than reinstating her policy, she eventually purchased new coverage and filed suit under California’s lapse statutes. She filed a putative class action suit against FLIAC asserting claims for declaratory relief under state and federal law, breach of contract, and violations of California’s Unfair Competition Law.

Siino’s claim centered on two critical violations of California law. First, she alleged that FLIAC failed to provide a pretermination notice at least 30 days before terminating her policy, as required by Insurance Code § 10113.71(b). Second, she claimed that FLIAC never informed her of her right to designate another person to receive lapse or termination notices, a violation of Section 10113.72. The district court ruled in her favor, granting declaratory relief and concluding that her policy remained in force so long as she paid back the missed premiums. Siino complied, tendering the overdue amounts with interest. FLIAC appealed.

The Ninth Circuit affirmed in part and reversed in part. In a detailed opinion by Judge Milan D. Smith, the court held that the district court correctly found that FLIAC violated both the Pretermination Notice Requirement and the Designee Notice Requirement. The court noted that FLIAC’s letter to Siino in February 2018 came after the policy was already considered lapsed and thus failed the statutory requirement of providing notice before termination. As the court explained: “FLIAC’s notice failed to provide Siino with the pretermination warning she was owed under the Statutes” because it offered reinstatement rather than warning of an impending lapse.

Likewise, FLIAC failed to produce any evidence that it ever advised Siino of her right to designate someone to receive notices. Siino declared she never received such a notice, and the insurer’s representative could neither confirm nor deny that it had been sent. This, the court held, constituted a clear violation of Section 10113.72. She could properly prove this in part because she was getting her mail at the old address until 2015 and the requirement became effective under California law in 2013. “Because Siino affirmatively declared that FLIAC never sent her notice of the right to designate, and FLIAC failed to bring forward opposing evidence… there is no genuine dispute of fact,” the court wrote.

But the court stopped short of awarding Siino full relief. It reversed the portion of the district court’s order declaring that her policy remained valid and enforceable. Citing its recent decision in Small v. Allianz Life Insurance Co. of North America, 122 F.4th 1182 (9th Cir. 2024), the Ninth Circuit emphasized that declaratory relief premised on breach of contract requires a showing of causation under Small. That is, a plaintiff must show the statutory violations caused the lapse. The court concluded that Siino failed to meet that burden. “Because the record makes clear that Siino moved in 2014 and failed to successfully update her address on file,” the court explained, “any additional notices sent by FLIAC would have been directed to an old address where Siino would not have received them.” Thus, FLIAC’s violations were not the legal cause of her injury.

In conclusion, Siino underscores both the power and the limits of California’s lapse statutes. The Ninth Circuit affirmed the importance of strict compliance by insurers, particularly with respect to pretermination and designee notices. At the same time, the ruling serves as a reminder that plaintiffs still bear the burden of proving causation when seeking contract-based remedies. As life insurers face increasing scrutiny under these statutes, Siino clarifies that while procedural violations matter, they do not guarantee reinstatement absent a clear connection to the loss of coverage. For policyholders and insurers alike, diligence in notice and communication remains paramount.

In the world of ERISA litigation, the stakes are often high for families trying to secure essential health benefits, particularly for residential mental health care. The most contested issue in this realm is whether a treatment is “medically necessary” under the plan’s terms. The Ninth Circuit’s recent unpublished decision in Dan C. v. Directors Guild of America – Producer Health Plan, __ F. App’x __, 2025 WL 1419920 (9th Cir. May 16, 2025) (before Circuit Judges Owens, Bennett, and H.A.Thomas) offers important insights into how courts interpret plan language and fiduciary responsibilities under ERISA.

The case arose when Dan C., the father of a nine-year-old boy (“R.C.”), challenged the Plan’s denial of coverage for his son’s residential mental health treatment. The Plan determined the treatment was not “medically necessary,” citing a lack of clinical criteria such as danger to self or others and severe impairment in daily functioning. Dan C. filed suit under two provisions of ERISA: Section 1132(a)(1)(B) to recover plan benefits, and Section 1132(a)(3) for breach of fiduciary duty. The district court ruled in favor of the plaintiff on both claims, and the Plan appealed.

The Ninth Circuit affirmed the district court’s (Fernando Aenlle-Rocha) decision to award benefits, agreeing that de novo review was appropriate. Though the Plan conferred discretion on its Board of Trustees, the court emphasized that this authority was not unambiguously delegated to the Benefits Committee, which had rendered the final decision. It reached this decision because the board “did not unambiguously ‘delegat[e] its discretionary authority’ to the Board’s Benefits Committee, which made the final decision at issue here.” The court stated that although “the Plan delegates the task of ‘determining claims appeals’ to the Committee and provides that the Committee ‘will have discretion to deny or grant the appeal in whole or part,’ this language falls short of the unambiguous delegation contemplated by our precedent.” This was because “[n]one of the Plan’s provisions expressly ‘grant [the Committee] any power to construe the terms of the plan[.]’”As the court explained, “[m]erely using the word ‘determine’ in the policy does not ensure that the denial of benefits will be reviewed for abuse of discretion” (citing Newcomb v. Standard Ins. Co., 187 F.3d 1004, 1006). In the absence of express language granting the Committee authority to construe plan terms or determine eligibility, the Ninth Circuit upheld the district court’s application of a de novo standard.

The court also rejected the Plan’s argument that the district court had misapplied the “medically necessary” standard by relying on “clinical criteria” instead of the Plan’s four-part definition. The Ninth Circuit clarified that the district court simply mirrored the Plan’s own reasoning. The Plan denied benefits on the grounds that R.C. did not meet the clinical criteria for residential treatment—namely, that he was not a danger to himself or others and did not have serious functional impairments. The Ninth Circuit noted that these criteria implicated the Plan’s medical necessity standard, particularly whether the treatment was consistent with generally accepted medical practice and whether it was the most cost-efficient form of care.

Perhaps most compelling was the court’s endorsement of the district court’s factual findings. The record showed that R.C. repeatedly exhibited violent and disturbing behavior: threats to kill peers and staff, detailed fantasies of violence, and serious behavioral problems such as urinating in inappropriate places and pulling out his own hair. According to the Ninth Circuit, these findings “supported the conclusion that R.C. did pose a danger to himself and others and did experience serious problems with functioning that could not have been managed without residential treatment.”

Even if the more deferential abuse of discretion standard applied, the court found that the Plan’s review process fell short of ERISA’s requirement for a “full and fair review.” The Plan failed to clearly inform the plaintiff that it required evidence of attempts at lower levels of care, such as an intensive outpatient program (IOP) or partial hospitalization program (PHP), before approving residential treatment. Instead, its denial letters generically referenced “outpatient services,” which the plaintiff reasonably understood to include therapy that R.C. had already undergone without success. As the court explained, this “inadequate notice deprived Plaintiff of the opportunity to ‘answer[] in time’ the Plan’s questions about lower levels of care, to engage in ‘meaningful dialogue’ on the issue of medical necessity, and to receive a ‘full and fair’ review of the denial of his claim” Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 679–80).

However, the Ninth Circuit reversed the district court’s judgment on the breach of fiduciary duty claim under ERISA Section 1132(a)(3). The court held that because the plaintiff had already obtained adequate relief under Section 1132(a)(1)(B)—namely, the reinstatement of benefits—no separate equitable relief was available under Section 1132(a)(3). Citing its own precedent in Castillo v. Metropolitan Life Ins. Co., 970 F.3d 1224, 1229 (9th Cir. 2020), the court reiterated that Section 1132(a)(3) is a “catchall” provision and does not apply when relief is available under another ERISA section.

In conclusion, Dan C. is a significant case for ERISA practitioners, particularly in mental health benefits litigation. It underscores the importance of clear plan language delegating discretionary authority, the necessity for consistent and comprehensive communication with claimants, and the courts’ willingness to scrutinize administrative processes that fall short. While the plaintiff did not prevail on the fiduciary duty claim, the Ninth Circuit’s affirmation of his right to benefits based on both procedural and substantive grounds is a strong reminder that ERISA protections, when enforced properly, can make a profound difference for families in crisis.

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.

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