District Court Upholds Insurer’s Denial of ERISA Long-Term Disability Benefits, Highlighting Insufficient Evidence to Support Impairment Due to Long-COVID

In Mendoza v. First Unum Life Insurance Company, No. 3:24-CV-00834-H-VET, 2025 WL 1393871 (S.D. Cal. May 5, 2025), on cross-motions for judgment pursuant to FRCP Rule 52, California Southern District Judge Marilyn L. Huff concluded that Plaintiff Mendoza had failed to demonstrate his entitlement to long-term disability (“LTD”) benefits under an ERISA-governed LTD Policy.

Plaintiff, a former senior underwriting consultant at American International Group (AIG), sought LTD benefits following a severe bout with COVID-19 that allegedly left him with ongoing debilitating symptoms. Mendoza’s employment required the ability to evaluate complex insurance applications, a role he claimed he could no longer perform due to symptoms such as brain fog, memory issues, fatigue, and depression, which he attributed to long-COVID.

Mendoza’s claim was initially approved for short-term disability (STD) benefits, but Defendant Unum subsequently denied his claim for LTD benefits, finding that his symptoms, restrictions, and limitations did not preclude him from performing the material and substantial duties of his occupation. Unum upheld the denial on appeal after multiple independent physician reviewers agreed that Mendoza had full-time work capacity. The instant action ensued.

Under de novo review, the court independently assessed whether Mendoza met the LTD policy’s definition of disability, which required him to prove he was unable to perform the material and substantial duties of his occupation due to sickness or injury, resulting in a significant loss of income.

First, the court found that Mendoza’s physical symptoms, including his cardiac issues, had improved significantly in the recovery following his COVID-19 infection. The medical evidence indicated normalized cardiac function, which would not preclude sedentary work. Mendoza himself conceded that his primary impediment was not physical incapacity but rather cognitive and psychiatric symptoms.

While Mendoza had been diagnosed with major depressive and anxiety disorders, the court found insufficient evidence to demonstrate that these conditions rendered him unable to work. His treatment records lacked indications of severe functional impairments, and his mental status exams were largely normal. The court noted the absence of intensive psychiatric treatment, which would typically be expected for impairing conditions. Finally, Mendoza argued that cognitive issues, including brain fog and concentration deficits, were the primary barriers to performing his job. However, the court weighed medical evaluations that showed his cognitive performance was within normal limits or only mildly impaired. Neuropsychological testing and evaluations by speech pathologists did not substantiate claims of significant cognitive dysfunction. The court also expressed skepticism regarding Mendoza’s reported extreme fatigue, which was inconsistent with his ability to engage in international travel and other activities documented in the record.

The court concluded that Mendoza did not meet his burden of proof to show by a preponderance of the evidence that he was disabled under the terms of the LTD plan. The court emphasized that while Mendoza experienced symptoms consistent with long-COVID, he failed to demonstrate that these symptoms precluded him from performing his occupational duties during the elimination period. The court upheld Unum’s decision to deny Mendoza’s claim for LTD benefits.

This decision highlights the critical role of detailed medical documentation and the challenges posed by conditions like long-COVID, which may present with varied and subjective symptoms. If Unum or your disability insurer has denied or otherwise limited your ERISA benefits claim, contact us for assistance.