Massachusetts District Court Awards LTD Benefits to Claimant with Dysautonomia, Finding Insurer Failed to Prove Mental Health Limitation Applied Under But-For Causation Standard

In DeMario-Miko v. United of Omaha Life Insurance Company, No. 1:24-cv-11058-IT, 2026 WL 948948 (D. Mass. Apr. 8, 2026), the United States District Court for the District of Massachusetts granted summary judgment to the Plaintiff on her claim for long-term disability benefits, rejecting United of Omaha’s contention that her disability was the result of a mental disorder subject to the plan’s 24-month limitation.

Plaintiff, a former Governmental Affairs Manager, stopped working full-time in January 2020 following a significant flare-up of rheumatoid arthritis triggered by a miscarriage. She was subsequently diagnosed by a board-certified autonomic disorder specialist with a triad of interrelated physical conditions — hyperadrenergic postural orthostatic tachycardia syndrome (POTS), mast cell activation syndrome (MCAS), and hypermobile Ehlers-Danlos syndrome (hEDS) — supported by objective testing including Holter monitor studies documenting persistent tachycardia and an abnormal EKG. United approved her for long-term disability benefits through May 8, 2023, but then terminated benefits based on a neuropsychological evaluation by Dr. Jonathan DeRight, who diagnosed somatic symptom disorder, and paper reviews by several of United’s retained physicians who questioned whether Plaintiff’s physical diagnoses were supported by the medical evidence.

Conducting de novo review — applicable because the plan excluded discretionary authority — the court first found that Plaintiff established disability under the policy. While her sedentary occupation as a Government Affairs Manager would ordinarily accommodate many physical limitations, the court found that the evidence from her treating providers and a Functional Capacity Evaluation compellingly demonstrated she could not sit for the required 5.5 hours or stand or walk for the required 2.5 hours in an eight-hour workday due to chronic pain and weakness. The court credited Plaintiff as a “consistent and credible reporter of pain” and found unpersuasive United’s challenge to her Functional Capacity Evaluation, where the evaluator himself stated she gave maximum effort and was not a symptom magnifier, and United’s retained rheumatologist offered no substantive elaboration for his criticism of the evaluation’s methodology.

Turning to the mental health limitation, the court placed the burden of proof on United, consistent with prior decisions in the District of Massachusetts holding that an insurer must prove the applicability of a limitation that reduces coverage the insured would otherwise receive. The court further adopted the but-for causation standard recognized by the Fifth, Sixth, Eighth, and Ninth Circuits, holding that a mental health limitation applies only where the claimant’s physical disability, by itself, is insufficient to render her totally disabled. Evidence that mental health conditions “play a role” or “affect” physical symptoms does not satisfy this standard.

United failed to carry that burden. The court found that United’s reliance on Plaintiff’s history of anxiety and depression could not explain the acute onset in 2021 of her numerous objective physical symptoms, including tachycardia, hypertension, and cardiac abnormalities, particularly given that she had experienced anxiety since childhood without corresponding functional limitation. As for the somatic symptom disorder diagnosis, the court found Dr. DeRight’s opinion significantly undermined by the fact that Plaintiff’s treating therapist and treating psychiatrist — who had generated hundreds of pages of treatment notes — never identified somatic symptom disorder as a diagnosis and expressly disagreed with Dr. DeRight’s assessment. The court also noted that Dr. DeRight’s report did not adequately explain the testing methodology underlying his conclusion that Plaintiff was overreporting symptoms. Moreover, while United’s retained paper reviewers questioned whether Plaintiff’s physical diagnoses were fully supported, none of them affirmatively concluded that the cause of her disability was a mental disease — rather, United simply asked the court to draw the inference that because its experts doubted her physical diagnoses, her limitations must be psychiatric in origin. The court declined to do so.

The court also denied United’s counterclaim seeking recoupment of $98,039.71 based on Plaintiff’s failure to apply for Social Security Disability Income. Although United’s own representative had told Plaintiff’s spouse that she was not eligible for SSDI while working part-time — which she was throughout much of the relevant period — and Plaintiff had not yet been found eligible for SSDI, the court found that United had made no showing of any funds actually in Plaintiff’s possession upon which an equitable lien or constructive trust could attach. Accordingly, United had not established entitlement to equitable relief under ERISA section 502(a)(3).