Doe v. First UNUM Life Insurance Company

Background

Guangyu Li, a former McKinsey & Co. employee, sued First Unum under the Employee Retirement Income Security Act of 1974, or ERISA. He alleged that First Unum improperly denied his application for long-term disability benefits under McKinsey’s group policy. The policy provided a maximum monthly benefit of $35,000 and required an insured to show that an injury or sickness prevented performance of each material duty of the insured’s regular occupation. It also required the disability to continue through a 180-day elimination period.

Li reported anxiety and depression, submitted treatment records and statements from Dr. Hongxia Zhang, and later submitted evaluations from other medical professionals. First Unum obtained reviews from medical professionals who questioned whether Li’s treatment records showed functional impairment severe enough to prevent him from working. First Unum denied the claim in July 2022. After Li submitted additional materials and requested further review, First Unum upheld the denial on May 30, 2023.

Li sought a declaration that he was entitled to benefits from June 8, 2022, until age 65, as well as attorneys’ fees. The parties agreed to resolve the case on the paper record rather than through live testimony.

Standard of Review

The court held that the plan gave First Unum discretionary authority to determine benefit eligibility, resolve factual disputes, and interpret and enforce the plan. The court therefore reviewed First Unum’s decision under the arbitrary-and-capricious standard rather than reviewing eligibility anew. Under that standard, the court could overturn the decision only if it was without reason, unsupported by substantial evidence, or legally erroneous.

The court also rejected Li’s argument that First Unum’s failure to follow ERISA claims procedures required de novo review. The court found that First Unum complied with the applicable requirements concerning consultation with health care professionals during the appeal and explanation of the reasons for disagreeing with treating professionals’ views.

Merits Ruling

The court held that First Unum’s denial was supported by substantial evidence. It found that First Unum reasonably relied on the reviews by Dr. Peter Brown and Dr. Malcolm Spica and gave reasoned explanations for discounting or not following the opinions of Dr. Zhang, Dr. Wilfred van Gorp, Dr. Peifen Yao, and Dr. Bahrach Talei.

The court concluded that First Unum reasonably determined that Dr. Zhang’s treatment records did not show a sufficiently severe disability during the elimination period. It also found that First Unum reasonably treated Dr. Talei’s May 2023 report as lacking medical information relevant to Li’s condition during the December 2021-to-June 2022 elimination period. The court rejected Li’s arguments that First Unum improperly limited its reviewers’ assessments, relied on factual errors, or failed to address the risk of self-harm. The court also held that First Unum was not required to give special weight to Li’s treating psychiatrist.

Evidence Outside the Administrative Record

The court denied Li’s request to consider medical records and other materials created after First Unum’s appeal decision. In ERISA benefits cases, judicial review generally is limited to the record before the claims administrator unless the claimant shows good cause for considering additional evidence. The court found that Li had not shown good cause because First Unum had given him ample time to submit materials and had reasonably analyzed the materials he submitted.

Disposition

The court directed the Clerk of Court to enter judgment for First Unum and close the case.