Demario-Miko v. United of Omaha Life Insurance Company

1
UNITED STATES DISTRICT COURT
DISTRICT OF MASSACHUSETTS
DEVIN DEMARIO-MIKO,
Plaintiff,
*
*
*
*
v. 	*
*
Civil Action No. 1:24-cv-11058-IT
UNITED OF OMAHA LIFE INS. CO.,
Defendant.
*
*
*
*
MEMORANDUM & ORDER
April 8, 2026
TALWANI, D.J.
Pending before the court are Plaintiff Devin DeMario-Miko’s and Defendant United of
Omaha Life Insurance Company’s (“United”) cross-motions for summary judgment on
DeMario-Miko’s claim for long-term disability (“LTD”) benefits, under the Employee
Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001 et seq. (“ERISA”). See Def.’s Mot.
for Summ. J. [Doc. No. 34]; Pl.’s Mot. for Summ. J. [Doc. No. 38]. United contends that Plaintiff
has remained out of work for more than two years, is unable to show that her disability, if any, is
due to reasons other than “mental disorders,” and since May 9, 2023, is no longer eligible for
benefits under the limitation on mental health benefits in the employee benefit plan at issue here.
Plaintiff contends that she has established that she is disabled under the plan and that United has
not demonstrated that her disability is caused by any mental disorder. She asserts that she is
therefore entitled to plan benefits and seeks reinstatement of her benefits from May 9, 2023,
forward. United also seeks summary judgment on its Amended Counterclaim to recover for an
alleged overpayment of benefits arising from Plaintiff’s eligibility for Social Security Disability
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 1 of 30

2
Income (“SSDI”) while receiving benefits from United. The parties ask the court to decide the
case on the written record.
For the reasons set forth below, DeMario-Miko’s Motion is GRANTED, and United’s
Motion is DENIED.
I. 	FACTUAL BACKGROUND
A. The Parties
DeMario-Miko worked fulltime as a Governmental Affairs Manager for the U.S.
Association of Fish and Wildlife Agencies (“AFWA”) prior to the events at issue here. DeMario-
Miko had both short-term and long-term disability coverage under an employee welfare benefit
plan sponsored by AFWA. The Plan was funded by a group insurance policy issued to AFWA by
United. United has served as the claim administrator and group insurer of LTD benefits under the
Plan.
B. DeMario-Miko’s Medical History Prior to Her Short-Term Disability
DeMario-Miko has long reported experiencing chronic muscle pain and was diagnosed
with fibromyalgia at some point prior to 2020. Admin. R. 001138. DeMario-Miko has also
reported experiencing anxiety since childhood and has a history of obsessive-compulsive
disorder and post-traumatic stress disorder. Id. at 000348–51.
DeMario-Miko’s physical symptoms significantly increased in 2016 following a bout of
respiratory illness. Id. at 001138. Following her 2016 illness, DeMario-Miko was treated by a
rheumatologist, who diagnosed her with rheumatoid arthritis. Id. She managed her rheumatoid
arthritis symptoms, including joint and muscle pain, fever, and fatigue, but experienced a
significant flare-up of her rheumatoid arthritis symptoms in late 2019, when she miscarried at 9
weeks of pregnancy. Id. at 000335.
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 2 of 30

3
C. DeMario-Miko’s Short-Term Disability
Following the flare-up, DeMario-Miko’s condition worsened significantly, and she
ceased fulltime work at AFWA on January 29, 2020. Id. at 000052; Def.’s SOF ¶ 1 [Doc. No.
37]. She continued to work part-time remotely. Admin. R. 001138.
DeMario-Miko’s short-term disability benefits application reported “rheumatoid arthritis
flare up triggered by miscarriage of pregnancy” as the nature of her illness. Id. at 0000048. Her
application was supported by a report from her treating internist, Dr. Reza Golesorkhi, who
identified the initial date of treatment as October 18, 2017, and her most recent treatment as
February 20, 2020. Id. at 000053. Dr. Golesorkhi reported that DeMario-Miko was unable to lift,
stand, sit, or carry, and that her evaluation was ongoing and treatment still underway. Id. at
000051, 000053.
On May 13, 2020, United approved her short-term disability with a disability date of
January 30, 2020, awarding retroactive benefits starting February 6, 2020. Id. at 015595. United
approved her short-term disability through August 5, 2020. See Pl.’s Resp. to Def.’s Undisputed
Facts ¶ 16 [Doc. No. 49].
D. DeMario-Miko’s Long-Term Partial Disability and her Dysautonomia Diagnosis
After August 6, 2020, United transitioned DeMario-Miko’s claim to long-term disability.
Admin. R. 002037. DeMario-Miko continued working part-time. Id.
In Fall 2020, DeMario-Miko underwent a sleep study which documented her heart rate as
being over 140 beats per minute (“bpm”) during sleep. Id. at 002624; see id. at 002629. A high or
tachycardic heart rate exceeds 100 bpm. Because of the sleep study results, DeMario-Miko’s
doctor referred her to a cardiac specialist for potential dysautonomia. Id. at 002624.1
1 Dysautonomia is a nervous system disorder that disrupts the autonomic nervous system. Due to
the breadth of actions and mechanisms at play, dysfunction of the autonomic nervous system can
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 3 of 30

4
During her January 6, 2021 evaluation with Dr. Hasan Abdallah, board-certified in
autonomic disorders, DeMario-Miko reported “chronic muscle pain; fever; weight gain;
excessive fatigue; vision changes due to positional changes; ringing in ears; sore throat / sinus
problems; chest pain; coughing; [shortness of breath]; abdominal pain; vomiting; heartburn;
muscle and bone aches/pains; dizziness; headaches; numbness; depression, anxiety; excessive
sweating; thyroid issues; enlarged lymph nodes; [and an inability] to exercise.” Admin. R.
000185–91. DeMario-Miko also reported that she “has difficulty breathing on exertion.” Id. at
000188. DeMario-Miko described “painful and rapid breathing . . . [and] shortness of breath on a
daily basis” and that she experienced shortness of breath even by rolling “over in bed[.]” Id. at
000188. Dr. Abdallah assessed that DeMario-Miko’s heart rate increased from 132 bpm in the
supine position to 144 bpm after standing for two minutes, and that she experienced shortness of
breath, burning and fatigue in her lower back down to her legs, body pain, tingling hands, and
starry vision. Id. at 000189. She also had an abnormal EKG. Id.
Dr. Abdallah ordered a Holter monitor study to examine DeMario-Miko’s heartrate. Id. at
000186. During the 24-hour study in January 2021, DeMario-Miko was tachycardic for most of
the day, including during sleep, with a maximum heart rate exceeding 150 bpm between 9:00
p.m. and 11:00 p.m. Id. at 002994.
manifest in a variety of different symptoms, but primarily manifests in cardiovascular,
neurological, gastrointestinal, and sensory-related symptoms. Dysautonomia may also cause
chronic fatigue and sleep disturbances. Because dysautonomia can affect so many bodily systems
and manifest in different symptoms, providers often mistake the condition for others, such as
anxiety disorders, chronic fatigue syndrome, or diabetes-related autonomic neuropathy. An
accurate diagnosis often requires taking a detailed medical history, physical examination, and
objective testing, such as a tilt table test, to assess blood pressure and heart rate responses. See
generally Dysautonomia, C LEVELAND C LINIC ,
https://my.clevelandclinic.org/health/diseases/6004-dysautonomia (last accessed April 3, 2026).
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 4 of 30

5
Dr. Abdallah described in his January 25, 2021 provider’s note that when undergoing a
stress test, DeMario-Miko’s “oxygen consumption is very low at 29.8% of predicted for her age,
sex, and height . . . [and her] severely below predicted maximal oxygen consumption
[is]. . . most likely due to venous pooling that is due to peripheral autonomic neuropathy[.]” Id. at
000209. Dr. Abdallah further noted that, in his opinion, “excessive chronotropic response and
reduced ventricular filling during tachycardia may be a contributing factor” to DeMario-Miko’s
low oxygenation. Id.
By March 19, 2021, Dr. Abdallah had diagnosed DeMario-Miko with three inter-related
autonomic disorders:
• 	hyperadrenergic postural orthostatic tachycardia syndrome (“POTS”)2;
• 	mast cell activation syndrome (“MCAS”)3; and
2 POTS is a type of orthostatic intolerance that causes elevated heart rate or tachycardia when
transitioning from sitting or lying down to standing up. Because of autonomic dysfunction, the
body is unable to regulate heart rate and blood pressure during postural changes. The majority of
people diagnosed with POTS are women aged 15 to 50 years. People are at higher risk of
developing POTS following a traumatic or stressful event, such as significant viral or infectious
illness, pregnancy, or surgery. See Postural Orthostatic Tachycardia Syndrome (POTS),
C LEVELAND C LINIC , https://my.clevelandclinic.org/health/diseases/16560-postural-orthostatic-
tachycardia-syndrome-pots (last visited on April 2, 2026). Hyperadrenergic POTS (“hPOTS”) is
a specific subset that affects 10% of POTS patients, and refers to overactivation of the
sympathetic nervous system. This overactivation causes higher levels of norepinephrine
(adrenaline) in circulation and higher blood pressure upon standing. Symptoms of hPOTS
include anxiety, tremors, orthostatic hypertension, cold hands and feet, fatigue, palpitations,
presyncope, syncope, excessive sweating, nausea/diarrhea/bloating, excessive stomach acid,
increased urine output upon standing. See Admin. R. 009502.
3 Mast cells are seen as “first responders” that deal with pathogens by alerting other immune
cells and coordinating immune responses in the innate and acquired immune systems. When
activated, a mast cell can either selectively or rapidly release compounds or mediators from
storage granules into the local environment. MCAS is an immunological condition in which mast
cells, a type of white blood cell, function improperly and either excessively or needlessly release
histamine, heparin, and other mediators. Symptoms include hypotension, flushing, itchy skin,
hives, nasal congestion, swelling, constipation or diarrhea, abdominal pain, vomiting, shortness
of breath, syncope, fatigue, and anaphylaxis. See Mast Cell Activation Syndrome (MCAS),
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 5 of 30

6
• 	hypermobile Ehlers Danlos syndrome (“EDS”)4
Admin. R. 000215, 000185.
Also in March 2021, DeMario-Miko was evaluated by Dr. Oral Alpan, an allergist and
immunologist. Id. at 000230. Dr. Alpan noted that DeMario-Miko had “[r]ecurrent infections,
Mast cell disorder; [and] Fatigue,” had a “history of CIU [chronic spontaneous urticaria or
recurrent occurrence of hives] and POTS,” and reported a 70-pound weight gain in the last year.
Id. at 008378-80. Dr. Alpan continues to treat DeMario-Miko for MCAS, initially in conjunction
with Dr. Abdallah and now with DeMario-Miko’s general practitioner.
During a second Holter monitor study ordered by Dr. Abdallah in October 2022,
DeMario-Miko was tachycardic for nearly half of the 72-hour study. Id. at 002995, 008356. Dr.
Abdallah also ordered a 24-hour ambulatory blood pressure report in October of 2022 that
confirmed hypertension while sleeping/prone. Id. at 002997.
In November 2021, DeMario-Miko developed acute appendicitis and had an emergency
appendectomy. Id. at 000062, 000099. She has had significant gastro-intestinal issues, including
gastroesophageal reflux disease (“GERD”), colitis, and diverticulosis. Id. at 002601–02,
008167–68.
C LEVELAND C LINIC , https://my.clevelandclinic.org/health/diseases/mast-cell-activation-syndrome
(last visited on April 2, 2026).
4 EDS is a cluster of inherited connective tissue disorders that share a variety of common
features, most notably hyperextensibility of the skin, hypermobility of the joints, and fragility of
the tissue. Hypermobile Ehlers Danlos Syndrome (“hEDS”) affects both large and small joints,
and may lead to frequent joint subluxations (partial dislocations) and dislocations. Symptoms
typically include easily bruised skin and chronic muscle or bone pain. See U.S. NAT’L L IBR . OF
M ED., https://ghr.nlm.nih.gov/condition/ehlers-danlos-syndrome (last visited on April 2, 2026).
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 6 of 30

7
While she had been working roughly 25 hours per week since August 2020, the
worsening of her condition in late 2021 into 2022 led her to resign from the AFWA in May 2022.
Id. at 000062, 0000104, 000909.
DeMario-Miko was treated at the Johns Hopkins University Pain Treatment Program for
one month in July 2022. See Pl.’s SOF ¶ 13 [Doc. No. 40].
Dr. Abdallah treated DeMario-Miko for hyperadrenergic POTS from 2021–2022, after
which care was transitioned over to Demario-Miko’s general practitioner. DeMario-Miko also
sees a primary cardiologist (a non-POTS specialist) every three to five months to assist with
cardiac symptoms secondary to her POTS.
DeMario-Miko’s LTD claim was approved from August 6, 2020, through May 8, 2023,
with partial benefits from August 25, 2020, through May 6, 2022, due to part-time return to
work. Admin. R. 002037. On July 25, 2022, United notified DeMario-Miko that she had been
approved for full LTD benefits, finding that she was unable to fulfill the material functions of
any “Gainful Occupation,” effective August 6, 2022. Id. at 000874.
E. LTD Claim Denial
As discussed further below, the Policy had a limitation of two years for mental health
benefits. While reviewing DeMario-Miko’s claim, United’s internal physician, Jon McAllister, an
internal medicine specialist, opined that she had a “very complicated psychiatric history” and
likely suffered from a “somatization disorder [rather than a physical illness] given the numerous
somatic complaints with minimal physical exam/diagnostic findings.” Admin. R. 000878–81. On
Dr. McAllister’s recommendation, United required DeMario-Miko to undergo
neuropsychological testing and referred her to neuropsychologist Jonathan DeRight, PhD, ABPP-
CN.
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 7 of 30

8
Dr. DeRight evaluated DeMario-Miko on February 7, 2023. Id. at 008183–95. As part of
the evaluation, Dr. DeRight reviewed a significant portion of DeMario-Miko’s medical record,
interviewed her, and administered cognitive testing. Id. Dr. DeRight determined that DeMario-
Miko’s “ability to perform even relatively simply daily tasks is likely to be affected by her high
level of emotional distress (in addition to any physical conditions as opined by her medical
doctors).” Id. at 008194. Dr. DeRight noted “[DeMario-Miko] is able to perform some tasks
without issue but experiences sporadic periods of significant distress that affect her
performance.” Id. Dr. DeRight found that DeMario-Miko was restricted and limited in her ability
to complete interpersonal tasks, make important decisions, learn and recall information, and
adapt to change, but concluded that the disability was due to her “somatic symptoms disorder[,]”
a psychiatric condition. Id. Dr. DeRight also determined that DeMario-Miko’s IQ had declined
since her illness onset, decreasing from an estimated 115 to 102. Id. at 008192.
Following Dr. DeRight’s evaluation, United sought further review from three additional
physicians. On March 7, 2023, United’s Medical Director, Dr. Thomas Reeder (board-certified in
internal medicine), determined that DeMario-Miko had a “somatic symptom disorder with
extreme over reporting of physical and psychological symptoms.” Id. at 007414. Dr. Reeder
denied that any of the diagnoses provided by DeMario-Miko’s treating physicians, including
POTS, MCAS, or Ehlers Danlos Syndrome, were appropriate given DeMario-Miko’s normal test
results. Id. at 007414.
On April 12, 2023, Dr. Richard Lavi (board-certified in allergy/immunology) determined
that “[f]rom the allergy/immunology perspective, functional impairment is not supported during
[January 30, 2020 – April 3, 2023].” Id. at 008243. Dr. Lavi noted that he spoke with Dr. Alpan,
DeMario-Miko’s treating allergist and immunologist, and that “Dr. Alpan confirmed there is no
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 8 of 30

9
specific diagnosis present and clinical proof of functional impairment could not be established.”
Id.
On May 1, 2023, Dr. Kelsey Flint (board-certified in cardiovascular disease) determined
that sufficient evidence in DeMario-Miko’s medical record supported a diagnosis of POTS. Id. at
009539. Dr. Flint determined that DeMario-Miko would “need to be in a job that is mostly
sedentary[]” and that she should restrict walking to less than 30 minutes daily and should not
run, jump, or climb. Id. at 009539–40. Dr. Flint noted, however, that DeMario-Miko’s POTS was
being appropriately managed by treatment with Dr. Abdallah and that DeMario-Miko’s
symptoms were “probably not attributable to POTS,” but rather to “somatic symptom disorder”
diagnosed by Dr. DeRight. Id. at 009540.
On May 8, 2023, United acknowledged that DeMario-Miko was “significantly impaired.”
Id. at 012070. United also acknowledged that, based on Dr. DeRight’s evaluation, DeMario-
Miko suffered “cognitive deficits as compared with [her] baseline abilities.” Id. United
concluded, however, that these impairments resulted from psychiatric conditions, such as
“anxiety, depression and somatic symptom disorder.” Id. United concluded further that while
“these deficits . . . would preclude [her] from performing the material duties of both [her]
occupation and any occupation,” because United determined that the cognitive deficits resulted
from a psychiatric source, DeMario-Miko’s policy did not allow for continued benefits. Id.
Accordingly, United denied DeMario-Miko’s LTD claim, stating that no medical
documentation supported any functional impairment resulting from her MCAS and that, while
“the medical documentation d[id] substantiate [POTS], it is the opinion of Dr. Flint, that
[Demario-Miko] would be limited to seated work.” Id. at 12070–71. Because DeMario-Miko’s
“occupation as a Government Affairs Associate is performed at a sedentary capacity,” United
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 9 of 30

10
found that DeMario-Miko did “not meet the definition of disability from a physical perspective
per [her] policy and no benefits are payable beyond August 5, 2023.” Id.
F. 	The Appeal Process
1. 	DeMario-Miko’s Appeal
Following receipt of the May 8, 2023 initial denial letter, DeMario-Miko appealed the
determination, and submitted additional documentation from her treating physicians, including
but not limited to Dr. Abdallah, Dr. Alpan, Dr. Golesorkhi, Dr. Chandrika Balgobin (treating
psychiatrist), Dr. Asma Khapra (treating gastroenterologist), Dr. Kim Byungki (treating
gastroenterologist), Dr. Kambeez Berenki (treating cardiologist), and LCSW Wilkins-McKee
(treating psychotherapist). Id. at 008276–311. The medical documentation submitted by
DeMario-Miko’s treating physicians and providers reaffirmed her POTS, MCAS, hEDS
diagnoses. Id. None of DeMario-Miko’s treating providers agreed with Dr. DeRight’s assessment
that her symptoms resulted from somatic symptom disorder. Id.
In association with the appeal, DeMario-Miko underwent a Cognitive Functional
Assessment (“CFA”), conducted by Bahareh Talei, Psy.D. Id. at 009467–73. DeMario-Miko also
underwent a Functional Capacity Evaluation, conducted on August 23, 2023, by Dave Sahley,
DPT, OCS, COMT. Id. at 009476–81. LCSW Wilkins-McKee submitted a report in association
with the appeal, stating that she had treated DeMario-Miko from 2020 to 2022, and collaborated
with DeMario-Miko’s medical doctors. Id. at 009483–87. The court discusses these reports
further below. See infra Part III.B.
2. 	United’s Response
In response to DeMario-Miko’s appeal, United requested the reports of three additional
physicians, who reviewed her medical record but did not examine DeMario-Miko or speak with
her providers. On December 26, 2023, Dr. Joseph Guzzo (board-certified cardiologist)
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 10 of 30

11
determined that “from a cardiac standpoint, no functional impairments required cardiac-focused
restrictions or limitations from 5/9/23 and thereafter.” Admin. R. 002366. Dr. Guzzo made this
determination based on his findings that DeMario Miko had “no definitive vital sign suggesting
orthostasis or tachycardia . . . [had] no recurrent syncope or near syncope. Her cardiac function
was normal. Multiple ECGs were normal . . . [she did not have] clinically significant
arrhythmia.” Id.
On December 28, 2023, Dr. Neal Greenstein (board-certified rheumatologist) concluded
that “from the rheumatologic perspective, the reported severity of the constellation of
symptoms/conditions is in excess/disproportionate to the medical evidence (exams, diagnostics,
response to treatments).” Id. at 002276. Accordingly, Dr. Greenstein found that “[n]o
restrictions” to DeMario-Miko’s capacity to work were supported by her medical record. Id. at
002277. Dr. Greenstein opined that insufficient evidence supported a connective tissue disorder
diagnosis. Id. at 002276. Dr. Greenstein did not comment on the sufficiency of the evidence
supporting DeMario-Miko’s rheumatoid arthritis diagnosis but noted that Dr. Zarbalian
(DeMario-Miko’s treating rheumatologist) had not submitted any office notes for Dr.
Greenstein’s review. Id. at 002277. Dr. Greenstein acknowledged that DeMario-Miko had been
diagnosed with fibromyalgia but opined that fibromyalgia itself was not a basis for physical
limitation or restriction. Id. at 002276–77. Dr. Greenstein took general issue with the Functional
Capacity Evaluation conducted by Dave Sahley, DPT, concluding that it had “no validity
measures” and was therefore unreliable. Id. at 002277.
On January 2, 2024, Dr. Michael Blumberg (board-certified in allergy and immunology)
stated that the “criteria for a diagnosis of [MCAS] is a tryptase level > 20 ng/ml and the typical
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 11 of 30

12
symptoms of idiopathic anaphylaxis.” Id. at 002358. Dr. Blumberg concluded that the medical
record lacked sufficient evidence to support a diagnosis of MCAS or chronic uticaria. Id.
On January 18, 2024, United sent the reports of Drs. Guzzo, Greenstein, and Blumberg to
DeMario-Miko and permitted her to reply.
3. 	DeMario-Miko’s Rebuttal
In rebuttal to the new reports, DeMario-Miko submitted letters from Drs. Abdallah and
Alpan. Id. at 002626–27, 002566. Dr. Abdallah referenced DeMario-Miko’s symptoms and the
testing he conducted to arrive at the POTS diagnosis. Id. at 002626–27. Dr. Alpan also pointed to
evidence in the medical record to support the link between DeMario-Miko’s elevated levels of B-
Cell tetherin and her autoimmune conditions. Id. at 002566. DeMario-Miko submitted additional
documentation regarding cardiac dysfunction, including tachycardia, syncope, and abnormal
ECGs. Id. at 006048–51. Finally, DeMario-Miko submitted a letter from her treating
rheumatologist, Dr. Zarbalian, who confirmed her diagnoses of Rheumatoid Arthritis, Raynaud’s
phenomenon, and pericarditis, and her general functional limitations due to her illness, but did
not include treatment notes or records. Id. at 002623–24.
United did not respond in detail to DeMario-Miko’s rebuttal, other than general
statements from Dr. Guzzo and Dr. Greenstein that the additional information did not
meaningfully alter their prior opinions. Dr. Guzzo maintained that DeMario-Miko had “no
functional impairment that required cardiac-focused restrictions or limitations.” Id. at 002369.
Dr. Greenstein maintained that no evidence supported the MCAS diagnosis. Id. at 002381–82.
4. 	Denial of the Appeal
On March 1, 2024, United upheld its denial of DeMario-Miko’s LTD claim, with
coverage termination effective May 9, 2023. Id. at 002034–45. In the final denial letter, United
stated “while we acknowledge Ms. Demario Miko’s reported multiple disabling conditions, the
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 12 of 30

13
medical documentation within the file did not support her inability to complete the Material
Duties of Regular Occupation from May 09, 2023, ongoing.” Id. at 002043.
II. 	PLAINTIFF’S ERISA CLAIM
DeMario-Miko challenges United’s termination of her LTD benefits.
A. Standard of Review
Under ERISA, a participant or beneficiary may bring a civil action “to recover benefits
due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to
clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). A
denial of benefits is reviewed de novo unless the plan grants the “administrator discretionary
authority to determine eligibility or construe plan terms.” Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 115 (1989). Here, the parties agree that the benefit plan excludes discretion to
decide benefits, see Def.’s Mem. 12 [Doc. No. 35]; Pl.’s Mem. 17–18 [Doc. No. 39], and this
court therefore examines Plaintiff’s claim to recover benefits de novo, see Allen v. Adage Inc.,
967 F.2d 695, 697–98 (1st Cir. 1992).
To perform de novo review, the court must “independently weigh the facts and opinions
in the administrative record to determine whether the claimant has met [her] burden” of showing,
by a preponderance of the evidence, coverage of claims under the applicable plan. Richards v.
Hewlett-Packard Corp., 592 F.3d 232, 239 (1st Cir. 2010); see Stephanie v. Blue Cross Blue
Shield of Mass. HMO Blue, Inc., 2016 WL 3636978, at *2 (D. Mass. June 30, 2016). The court
“stand[s] in the shoes of the administrator to determine whether the administrative decision was
correct.” Richards, 592 F.3d at 239 (internal quotation marks and ellipses omitted). “[N]o
deference [is given] to the administrator’s opinions or conclusions.” Gross v. Sun Life Assur. Co.
of Canada, 734 F.3d 1, 17 (1st Cir. 2013) (citing Scibelli v. Prudential Ins. Co. of Am., 666 F.3d
32, 40 (1st Cir. 2012)). In reaching its decision on de novo review, the court “may weigh the
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 13 of 30

14
facts, resolve conflicts in the evidence, and draw reasonable inferences.” Stephanie C. v. Blue
Cross Blue Shield of Mass. HMO Blue, Inc., 852 F.3d 105, 111 (1st Cir. 2017).
Further, the court does not accord special deference to the opinions of treating physicians
based on their status as treating physicians alone. See Black & Decker Disability Plan v. Nord,
538 U.S. 822, 834 (2003). Instead, opinions must “be accorded whatever weight they merit.”
Jebian v. Hewlett-Packard Co. Emp. Benefits Org. Income Prot. Plan, 349 F.3d 1098, 1109 n.8
(9th Cir. 2003) (citing Black & Decker, 538 U.S. at 834). A court may give greater weight to a
treating physician’s opinion where it is evident a particular physician has had a “greater
opportunity to know and observe the patient than a physician retained by the plan administrator”
who conducts a file review. Id.
In an ERISA benefit-denial case, summary judgment operates as “a vehicle for deciding
the issue.” Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 517 (1st Cir. 2005) (citation
omitted). Unlike the usual summary-judgment standard, “the non-moving party is not entitled
to . . . inferences in its favor.” Id. A motion for summary judgment in this context “is simply a
mechanism for” deciding the case on the merits, based on the administrative record. Stephanie
C., 852 F.3d at 110.
B. Policy Terms
DeMario’s group insurance policy (the “Policy”) provided a monthly disability benefit
for both total and partial disability. Admin. R. 000020. The Policy defines “Disability” and
“Disabled” to mean that:
because of Injury or Sickness,[5] a significant change in Your mental or physical
functional capacity has occurred in which:
5 The Policy defines “sickness” as “a disease, disorder or condition, including pregnancy, that
requires treatment by a Physician.” Admin. R. 000039.
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 14 of 30

15
(a) during the Elimination Period,[6] You are prevented from performing at least
one of the Material Duties of Your Regular Occupation on a part-time or
full-time basis; and
(b) after the Elimination Period, You are:
1. 	prevented from performing at least one of the Material Duties of Your
Regular Occupation[7] on a part-time or full-time basis; and
2. 	unable to generate Current Earnings which exceed 99% of Your Basic
Monthly Earnings due to that same Injury or Sickness.
After a Monthly Benefit has been paid for 2 years, Disability and Disabled mean
You are unable to perform all the Material Duties of any Gainful Occupation. [8]
Id. at 000036.
The Plan’s mental health-related limitation that United relies on here states: “If You are
Disabled and your Disability is a result of a Mental Disorder, Your benefits will be limited to a
total of 24 months[.]” Id. at 000028 (emphasis added). The Plan defines Mental Disorder as:
“any condition or disease, regardless of its cause, listed in the most recent edition of the
International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of
Mental Disorders (DSM) as a mental disorder. Not included in this definition are conditions or
diseases related to Alcohol and Drug Abuse and/or Substance Abuse.” Id. at 000037.
No such limitation applies where a claimholder is disabled—that is, unable to work
because of a disease, disorder, or condition requiring physician treatment—and the disability is
not the result of a mental disorder. See id. at 000028; see also Kamerer v. Unum Life Ins. Co. of
6 The Policy defines the “Elimination Period” as “the number of days of Disability which must
be satisfied before You are eligible to receive [LTD] benefits.” Admin. R. 000037.
7 The Policy defines “Regular Occupation” as “the occupation You are routinely performing
when Your Disability begins. Your regular occupation is not limited to Your specific position
held with the Policyholder, but will instead be considered to be a similar position or activity
based on job descriptions” compiled by the U.S. Department of Labor. Admin. R. 000038.
8 The Policy defines “Gainful Occupation” as “an occupation for which You are reasonably fitted
by education, training or experience.” Admin. R. 000037.
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 15 of 30

16
Am., 334 F. Supp. 3d 411, 428 (D. Mass. 2018) (explaining that in ERISA context, mental
disability should be construed as but-for cause for limitation to apply).
C. DeMario-Miko’s Disability9
The court begins first with the question of whether DeMario-Miko is unable to perform
the material duties of her occupation due to a condition treated by a physician. DeMario-Miko
bears the burden of proof as to this issue. See Orndorf, 404 F.3d at 519.
United takes issue with the sufficiency of the medical evidence supporting DeMario-
Miko’s clinical diagnoses of POTS, MCAS, and hEDS, and whether those illnesses render her
unable to work. See Def.’s Mem. 15–16 [Doc. No. 35]. The court agrees that DeMario-Miko’s
diagnoses alone do not establish her disability. See Def.’s Opp’n 6–8 [Doc. No. 45]. Indeed, the
Policy does not base coverage on diagnoses. Instead, United must provide benefits to plan
participants who are unable to work because of injury or sickness, with the Policy defining
sickness as “a disease, disorder, or condition that requires treatment by a Physician.” Admin. R.
000039. Therefore, the court evaluates whether DeMario-Miko’s inability to work is caused by a
condition requiring treatment by a physician.
The court finds that DeMario-Miko met her burden here.
1. 	Inability to Perform Material Functions
The parties agree that DeMario-Miko’s occupation correlates to the Department of
Labor’s definition for a Government Affairs Manager and that the Department’s definition
applies to the court’s inquiry. See Def.’s Opp’n. 2–3 [Doc. No. 45]; Def.’s SOF ¶ 20 [Doc. No.
9 The parties also dispute whether DeMario-Miko is cognitively disabled. See Pl.’s Mem. 31
[Doc. No. 39]; Def.’s Mem. 8 [Doc. No. 45]. Because the court finds that DeMario-Miko’s
physical conditions render her disabled under the terms of the Policy, the court need not consider
the impact of any cognitive disability.
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 16 of 30

17
37]; Pl.’s Mem. 23 [Doc. No. 39]; Pl.’s SOF ¶ 8 [Doc. No. 40].10 Pursuant to an occupational
analysis ordered by United, the “physical demand characteristics of” the Government Affairs
Manager “generally fall within the sedentary exertion level, which is defined as exerting up to 10
lbs. of force occasionally and a negligible amount of force frequently to lift, carry, push or
otherwise move objects.” Admin. R. 000076 (emphasis omitted). A worker must be able to sit for
over 5.5 hours in an 8-hour workday. See id. Additionally, a worker must be able to reach or
handle items between 2.5–5.5 hours in a workday and reach downward, finger, and use a
keyboard between 0–2.5 hours in a workday. See id. Cognitively, a Government Affairs Manager
is required to direct, control, or plan the activities of others, influence people, make judgments
and decisions, deal with people, remember and carry out both short and detailed instructions,
frequently adapt to change, travel, and independently plan. See id.
DeMario-Miko asserts that she is disabled because, in an eight-hour workday, she is
unable to (1) sit for 5.5 hours; (2) stand and/or walk for up to 2.5 hours; and (3) change from sit
to stand posture more than twice. See Pl.’s Mem. 18–19 [Doc. No. 39]. The limitations are
supported by the findings of her treating provider, physician’s assistant Daniel Coleman, and an
evaluator, physical therapist David Sahley, both of whom describe her limitations as arising from
significant pain and weakness. Additionally, Dr. Zarbalian, DeMario-Miko’s treating
rheumatologist and internist, opined that she is unable “to stand for more than 5 minutes on most
days” because of “the disabling nature of her cardiovascular dysfunction,” referencing testing
conducted by Dr. Abdallah. Admin. R. 002624.
10 The court notes that the Policy requires after two years of coverage that DeMario-Miko be
unable to perform all of the material functions of any occupation for which she is reasonably
fitted by education, training or experience. See Admin. R. 000036. Where Defendant does not
rely on the “Gainful Occupation” provision, the court treats any distinction between her Regular
Occupation, and any Gainful Occupation, waived.
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 17 of 30

18
In March 2022, DeMario-Miko’s treating provider Daniel Coleman, a physician’s
assistant at the University of Virginia Medical Center, assessed DeMario-Miko and determined
that, due to “significant pain and weakness,” she was unable to sit for longer than three hours in
an 8-hour workday and that she could not stand or walk for long periods of time. Id. at 000065.
PA Coleman also noted that DeMario-Miko was unable to “quickly and repeatedly change
posture” and that she had “myalgia, arthralgia [and] weakness [that] prevent[ed her] from
executing repetitive movements.” Id. PA Coleman also noted that DeMario-Miko had mild
difficulties with talking consistently at times due to fatigue, pain, and nausea. Id. at 000067.
Dr. Sahley wrote that, during an August 2023 Function Capacity Evaluation (“FCE”),
DeMario-Miko was “restricted with lifting all weights because she was unable to open her hands
to fully grip the weights. When she was able to grip the weights, she was limited by pain in the
back and or pressure on her fingers.” Id. at 009481. Additionally, Dr. Sahley noted that “[d]uring
all resistance activities, she needed to take breaks because of nausea. Her pain fluctuated
throughout 3–8/10. The leg press, stair negotiation and sit to stands were limited by pain. She
was unable to reciprocate up the stairs because of weakness and the fear of the leg giving way.”
Id. Dr. Sahley explained that she was unable to sit for 1–2 hours due to pain. See id. at 009477.
Dr. Sahley stated that DeMario-Miko “gave maximum effort” and was not a “s/xs [symptoms]
magnifier.” Id. at 009477. Dr. Zarbalian opined that he agreed with the FCE results. Id. at
0011870–71.
Accordingly, both treating provider PA Coleman and evaluator Dr. Sahley support
DeMario-Miko’s assertion that she is restricted from sitting for the 5.5+ hours and standing or
walking for the up to 2.5 hours required in a workday for a sedentary occupation due to pain. Dr.
Zarbalian’s opinion notes limitations relating to standing due to cardiac dysfunction. Further, Dr.
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 18 of 30

19
Sahley’s evaluation demonstrates that DeMario-Miko was unable to grip items because she could
not fully extend her hand. These limitations would affect her ability to reach or handle items with
frequency or occasionally use a keyboard.
United does not refute the findings of PA Coleman. See Def.’s Opp’n 2 [Doc. No. 45].
United discounts Dr. Sahley’s evaluation, citing rheumatologist Dr. Greenstein’s opinion that the
evaluation had “poor validity measures” and was based on uncorroborated self-reported
symptoms of pain. Id. at 4. But where Dr. Sahley concluded that DeMario-Miko “gave maximum
effort” and was not a “s/xs [symptoms] magnifier,” Admin. R. 009477, and Dr. Greenstein offers
no further elaboration as to the purported deficiencies of the evaluation, the court finds this
portion of Dr. Greenstein’s opinion unpersuasive, see id. at 002277.
Further, the court disagrees that DeMario-Miko’s reporting of pain is uncorroborated or
unreliable. DeMario-Miko has been a consistent and credible reporter of pain since the outset of
her short-term disability claim. See, e.g., Collins v. Continental Cas. Co., 87 F.App’x 605, 607
(8th Cir. 2004) (explaining that an ERISA plan abused its discretion in denying benefits where it
failed to consider participant-claimant’s “credibility with respect to her self-reported symptoms
of chronic and disabling pain, which limited her abilities to perform the simplest of tasks”). In
January 2021, during her initial evaluation with Dr. Abdallah, DeMario-Miko reported that she
had “always had chronic muscle pain but pushed through.” Admin. R. 000187. Her symptoms
increased following a 2016 illness and, as of 2021, she experienced full-body chronic pain “all
day every day.” Id. at 000188. DeMario-Miko noted that pain “radiates throughout her body
everywhere” and that “muscle weakness” required her to use both hands to “bring[] a mug to her
lips[.]” Id. DeMario-Miko’s providers have credited those reports, prescribing multiple
medications for chronic and muscle pain since at least 2022. See id. at 000276–77. Further, in
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 19 of 30

20
July 2022, DeMario-Miko was admitted to a 30-day program at the Johns Hopkins Pain
Treatment Center. See Pl.’s SOF ¶ 13 [Doc. No. 40]. United takes issue with the lack of evidence
regarding discussion of surgical intervention to resolve DeMario-Miko’s pain. See Def.’s Mem.
14 [Doc. No. 35]; Def.’s Opp’n 4 [Doc. No. 45]. However, the record lacks any support for a
finding that surgery would reduce her pain or allow her to sit for 5.5 hours or stand for 2.5 hours
in an 8-hour workday.
Ultimately, DeMario-Miko has established that it is more likely than not that she is
unable to sit, stand, or handle objects such that she can complete an 8-hour workday in a
sedentary occupation. These restrictions and limitations have been documented by both treating
providers and an evaluator. DeMario-Miko has shown, by a preponderance of the evidence, that
her restrictions and limitations are more likely than not caused by chronic pain for which she has
received significant treatment and medical attention and consistently reported as chronic and
debilitating for many years. See Krizek v. Cigna Group Ins., 345 F.3d 91, 99, 101–02 (2d Cir.
2003) (explaining that a court reviewing administrator’s decision de novo may make credibility
determinations about claimant’s subjective reports of pain). Therefore, the court finds that she is
unable to fulfill the material functions of the Governmental Affairs Manager position.
2. 	Condition Treated by a Physician
United disputes that DeMario-Miko is disabled due to a physical condition and asserts
that the record lacks any “objective medical evidence that [DeMario-Miko’s] conditions rendered
her unable to work at her own sedentary occupation.” Def.’s Mem. 14 [Doc. No. 35]. United
takes issue with the sufficiency of the medical evidence supporting Dr. Abdallah’s dysautonomia-
related diagnoses. See id. DeMario-Miko relies on the opinions of her treating providers who all
affirm her diagnoses. See Pl.’s Mem. 22–23, 25 [Doc. No. 39]. After weighing the facts in the
record, resolving conflicts in the evidence, and drawing reasonable inferences, the court finds
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 20 of 30

21
that DeMario-Miko’s conditions, including POTS, MCAS, hEDS, rheumatoid arthritis,
fibromyalgia, have caused her inability to work. See Stephanie C., 852 F.3d at 111.
Dr. Abdallah, board-certified in autonomic disorders, diagnosed DeMario-Miko with
POTS, MCAS, and hEDS in 2021. Admin. R. 000215. United hired two independent
cardiologists to conduct a record review of DeMario-Miko. One cardiologist, Dr. Flint, affirmed
that DeMario-Miko had POTS due to her orthostatic vital signs measured on January 6, 2021, by
Dr. Abdallah and agreed that DeMario-Miko had several physical restrictions due to POTS. Id. at
009539–40 (including “no changes in position (sitting to standing, etc.), or limited to 1–2 per
day”). The second, Dr. Guzzo, denied that her “vital signs suggested orthostasis [change in blood
pressure] or tachycardia.” Id. at 002366. Dr. Guzzo also noted that DeMario-Miko had no history
of recurrent syncope and that her “cardiac function was normal.” Id. Based on these findings, Dr.
Guzzo opined that “no established cardiac etiology [explained] her multiple symptoms” and that
“no functional impairments required cardiac-focused restrictions or limitations from 5/9/23 and
thereafter.” Id.
The record belies Dr. Guzzo’s findings regarding DeMario-Miko’s vitals and cardiac
function. For example, in response to DeMario-Miko’s rebuttal, Dr. Guzzo later acknowledged
that her vitals were “mildly orthostatic.” Id. at 002369. Additionally, the record demonstrates that
DeMario-Miko has a lengthy history of significant tachycardia, including while sleeping. See id.
at 002995. DeMario-Miko reported pre-syncope regularly and experienced a syncope episode in
2023, for which she was hospitalized. Id. at 002976–80. Finally, DeMario-Miko had multiple
ECGs that presented abnormal findings. Id. at 000185–91, 006048–53. Accordingly, weighed
against the opinions of Drs. Abdallah and Flint, and the evidence of DeMario-Miko’s
tachycardia, orthostasis, and cardiac abnormalities, Dr. Guzzo’s opinion is unpersuasive. The
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 21 of 30

22
court finds that DeMario-Miko had POTS, was treated for POTS by physicians, and that both her
symptoms and noted restrictions are attributable to POTS.
D. Mental Health Limitation
Having found that DeMario-Miko is disabled under the policy, the court now turns to the
applicability of the Policy’s Mental Disorder limitation. United argues that DeMario-Miko’s
inability to work is caused by a mental condition and her coverage is therefore limited after May
8, 2023, by that two-year bar. See Def.’s Mem. 13 [Doc. No. 35].
1. 	Burden of Proof
DeMario-Miko argues that United bears the burden to show that the Policy’s Mental
Health Limitation applies to her. See Pl.’s Mem. 26–27 [Doc. No. 39] (citing Kamerer, 334 F.
Supp. 3d at 428). United asserts that DeMario-Miko bears the burden of proving that she is
disabled by a condition not qualifying as a Mental Disorder, see Def.’s Opp’n 2 [Doc. No. 45],
but does not address Kamerer or offer any caselaw related to the burden of proof on insurance
policy limitations, see id. at 2, 8–10.
Both the court in Kamerer and another session in this district have required insurers to
establish the application of an insurance policy provision that limits coverage. See U.S. Fire Ins.
Co. v. Peterson’s Oil Serv., No. 23-cv-40044-DJC, 2024 WL 3030538, at *7 (D. Mass. June 17,
2024); Kamerer, 334 F. Supp. 3d at 427–28. Both sessions noted that where a limitation reduces
coverage the insured “would otherwise receive,” the burden of proof should be shifted to the
insurer. U.S. Fire Ins. Co., 2024 WL 3030538, at *7 (noting that, in Massachusetts, “the insurer
bears the burden of demonstrating than an exclusion exists that precludes coverage”) (citing AIG
Prop. Cas. Co. v. Cosby, 892 F.3d 25, 27 (1st Cir. 2018)).11 The court agrees with the reasoning
11 The court also notes the discussion of the burden-shifting issue in a third case, Ovist v. Unum
Life Ins. Co., No. 4:17-cv-40113-TSH, 2020 WL 1931755, at *4 (D. Mass. Feb. 21, 2020), report
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 22 of 30

23
of these decisions, and finds it appropriate to shift the burden on United to prove, by a
preponderance of the evidence, the applicability of the mental-health limitation to DeMario-
Miko’s claim for LTD benefits. Cf. Okuno v. Reliance Standard Life Ins. Co., 836 F.3d 600, 609
(6th Cir. 2016) (holding that the insurer “bears the burden to show that the exclusion on which it
based denial of benefits, the Mental and Nervous Disorder Limitation, applies in this case.”).
2. 	But-For Causation
Moreover, as noted in Kamerer, the Fifth, Third, Eighth, and Ninth Circuits have also
considered the applicability of mental-health limitations and determined that the proper inquiry is
whether a mental disability is a “but-for cause” of the plaintiff’s total disability. 334 F. Supp. 3d
at 428. These courts have concluded that an insurer may limit coverage only when the claimant’s
physical disability by itself fails to make individual totally disabled. See McEachin v. Reliance
Standard Life Ins. Co., 121 F.4th 571, 575 (6th Cir. 2024) (citing Okuno, 836 F.3d at 609); Weyer
v. Reliance Standard Life Ins., 109 F.4th 1072, 1077 (8th Cir. 2024); George v. Reliance Standard
Life Ins. Co., 776 F.3d 349, 354–56 & n.9 (5th Cir. 2015); Gunn v. Reliance Standard Life Ins.,
399 F. App’x 147, 153 (9th Cir. 2010); Michaels v. Equitable Life Assurance Soc’y, 305 F. App’x
and recommendation adopted, 2020 WL 1931958 (D. Mass. Mar. 27, 2020). The decision
explained that the burden shifting outlined in Kamerer is not justified where an insured was
informed from the outset of her claim approval that her coverage was time-limited. 2020 WL
1931755, at *2, *4. The First Circuit “acknowledge[d]” the Secretary of Labor’s amicus brief, in
which the Secretary supported “placing the burden on the plan, and not the plan participant, to
prove the applicability of a benefit limitation,” Ovist v. Unum Life Ins. Co., 14 F. 4th 106, 108
n.2 (1st Cir. 2021), but affirmed the decision without deciding that issue because it was non-
dispositive in that appeal, id. at 118 n.10. Where DeMario-Miko was approved for short-term and
then long-term coverage based on a physical disability, and only in United’s initial denial letter
did the insurer allege that DeMario-Miko’s disability was due to the mental health limitation, the
court finds Ovist distinguishable. Admin. R. 12067–73; see Kamerer, 334 F. Supp. 3d at 428
(“[I]t is fitting that [insurer] bear the burden of demonstrating the limitation applies” where
insurer, after determining that insured was physically disabled, “changed course and alleged that
[insured’s] disability was due to psychological conditions.”).
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 23 of 30

24
896, 901, 904 (3d Cir. 2009). Finding these decisions persuasive, the court concludes that
evidence that mental health conditions “play[] a role” or “affect[]” a claimant’s physical
symptoms does not rise to the level of but-for causation. Kamerer, 334 F. Supp. 3d at 429.
Accordingly, the court must determine whether United has met its burden to show whether
DeMario-Miko’s mental-health conditions are but-for causes of her disability. Based on the
record evidence, the court finds that United has failed to do so.
3. 	Medical Analysis
The Policy limits coverage to 24 months where a participant-claimant’s disability is “a
result of a Mental Disorder.” Admin. R. 0000028. The Policy defines “Mental Disorder” as “any
condition or disease” listed in the ICD and the DSM. Id. at 0000037.
United relies on three different sets of evidence for its coverage denial: (1) DeMario-
Miko’s diagnoses of and treatment for generalized anxiety disorder and depression; (2) the
reports of various medical reviewers retained by United who found that DeMario-Miko’s
diagnoses of POTS, MCAS, hEDS were not established by the medical record; and (3) the
Neuropsychological Evaluation of Dr. DeRight, in which he diagnosed DeMario-Miko with
somatic symptom disorder. See Def.’s Mem. 13–16 [Doc. No. 35].
Regarding DeMario-Miko’s psychiatric history, United fails to explain how DeMario-
Miko’s anxiety and depression caused the acute onset of her symptoms (including tachycardia,
hypertension, dizziness, vision changes, ringing in ears, night sweats, gastro-intestinal distress,
constant fatigue, muscle weakness, shortness of breath, and chronic pain) in 2021. See id. at 13–
14. The record lacks any support for a causal connection, particularly where DeMario-Miko
reported experiencing anxiety since childhood but only debilitating symptoms in 2021. See
Admin. R. 000348–51.
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 24 of 30

25
United also relied on the reports of several physicians who conducted a paper review of
her medical records. Dr. Guzzo found that the POTS diagnosis was not supported. Admin. R.
002366. Dr. Greenstein found that “the reported severity of the constellation of
symptoms/conditions is in excess/disproportionate to the medical evidence” and that the
evidence supporting her hEDS diagnosis was “insufficient.” Id. at 002276. Dr. Blumberg wrote
“[t]here is not enough data presented to support a diagnosis of mast cell activation syndrome or
chronic urticaria.” Id. at 002358. While this evidence undermines the support for DeMario-
Miko’s diagnoses of specific physical illnesses, none of United’s physician experts support that
the cause of her disability is a mental disease. Instead, United asks the court to draw the
inference that, because its experts opine that DeMario-Miko does not have POTS, MCAS, or
hEDS, her disabling limitations can only be attributable to a psychological condition. See Def.’s
Mem. 15–16 [Doc. No. 35].
United’s denial of benefits thus rests on Dr. DeRight’s opinion. Dr. DeRight found that
DeMario-Miko’s responses to tests conducted during his evaluation “were strongly indicative of
overreporting of symptoms [and that his] evaluation [of her was] strongly indicative of a somatic
symptoms disorder, and the ramifications of these symptoms are likely to play a large part in the
claimant’s ability to function.” Admin. R. 008193. In addition to emotional distress, Dr. DeRight
observed DeMario-Miko “noticeably sweating and frequently check[ing] her heart rate [and
using] an ice pack” during the evaluation and “vomiting in the parking lot” after the evaluation.
Id. at 008190–91. The report does not explain the tests Dr. DeRight used to determine that
DeMario-Miko “produced extremely high scores on scales of overreporting of somatic . . . and
cognitive . . . symptoms[.]” Id. at 008191. Dr. DeRight noted “it unlikely that she is malingering
neurocognitive dysfunction.” Id. at 008193. He ultimately found her disabled due to his
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 25 of 30

26
diagnosis of somatic symptom disorder and the high levels of emotion distress he witnessed her
undergo throughout the evaluation. Id. at 008194.
Dr. DeRight’s opinion, that DeMario-Miko severely overreported her symptoms based on
testing inscrutable to this court, is insufficient to carry United’s burden to show that DeMario-
Miko is disabled because of a somatic symptom disorder. See Kamerer, 334 F. Supp. 3d at 428.
The court must weigh Dr. DeRight’s evaluation against the report and treatment notes of
DeMario-Miko’s treating therapist, LSCW Wilkins-McKee, who denied any basis for Dr.
DeRight’s diagnosis. LSCW Wilkins-McKee noted that, in discussing DeMario-Miko’s care with
her other treating providers, including two psychiatrists, Wilkins had “not been part of a
conversation where anyone has claimed that Ms. DeMario-Miko’s challenges [with
functionality] are rooted in a ‘complicated psychiatric history.’” Admin. R. 009487. LCSW
Wilkins-McKee opined that the “list of other [non-psychological] medical diagnoses is
inconsistent with a primary somatic disorder.” Id. (emphasis omitted).
In addition to LCSW Wilkins-McKee’s opinion, it is notable that, across hundreds of
pages of treatment notes from treating psychiatrist Dr. Chandrika Balgobin, the diagnosis of
somatic symptom disorder never came up. Id. at 000058 (Dr. Balgobin’s Attending Physician
Statement reflecting diagnoses of major depressive disorder, generalized anxiety disorder, and
psychophysiological insomnia). Given the conflict between Dr. DeRight’s diagnosis and the
opinions of DeMario-Miko’s treating providers, the court finds that the persuasive force of Dr.
DeRight’s evaluation is minimally neutralized, if not undercut. See Jebian, 349 F.3d at 1109 n.8.
Evaluating the record as a whole, United has not carried its burden to prove that somatic
symptom disorder, generalized anxiety, and/or depression are but-for causes of DeMario-Miko’s
disability and that the mental-health limitation bars coverage. See Kamerer, 334 F. Supp. 3d at
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 26 of 30

27
428 (explaining that while claimant’s “psychological struggles may be playing a role in her
physical well-being, . . . [the fact t]hat her depression is influencing her fibromyalgia, . . . does
not rise to the level of but-for causation.”).
Accordingly, here the record is fully developed, contains no significant factual disputes,
and establishes that the claimant is entitled to benefits, the appropriate remedy is an award of
benefits. See Cook v. Liberty Life Assurance Co. of Boston, 320 F.3d 11, 24 (1st Cir. 2003)
(remand unnecessary where the record compels a finding in claimant’s favor).
III. 	UNITED’S COUNTERCLAIM
In its Amended Counterclaim [Doc. No. 30], United alleged that DeMario-Miko had a
duty to apply for other benefits for which she was eligible and that she had failed to apply for
Social Security Disability Income (“SSDI”) benefits. United alleged that “[b]ecause [DeMario-
Miko] claimed to be disabled under the terms of the Plan, she was also eligible to receive” SSDI
benefits and that her “eligibility to receive SSDI benefits resulted in an overpayment of STD and
LTD benefits[.]” Am. Answer 7–8 [Doc. No. 30]
United now moves for summary judgment on its counterclaim, asserting that United is
owed $98,039.71 based on DeMario-Miko’s failure to apply for SSDI benefits while she
received both STD and LTD benefits from United. See Def.’s Mem. 17 [Doc. No. 35].
Under section 502(a)(3) of ERISA, a fiduciary may bring a civil action “to obtain other
appropriate equitable relief . . . to enforce any provisions of this subchapter or the terms of the
plan.” 29 U.S.C. § 1132(a)(3). This provision authorizes only “those categories of relief that
were typically available in equity.” Sereboff v. Mid Atl. Med. Servs., Inc., 547 U.S. 356, 361
(2006) (quoting Mertens v. Hewitt Assocs., 508 U.S. 248, 256 (1993)). Such authorized relief
includes constructive trusts or equitable liens on “particular funds or property in the defendant’s
possession.” Id. at 362 (quoting Great-West Life & Annuity Ins. Co. v. Knudson, 534 U.S. 204,
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 27 of 30

28
213 (2002)). But it does not include legal relief, such as “compensatory damages,” id. at 361
(quoting Mertens, 508 U.S. at 255), or “the imposition of personal liability,” id. at 362 (quoting
Knudson, 534 U.S. at 214). As the summary judgment movant, United bears the burden to
establish that DeMario-Miko was eligible to receive SSDI benefits and that United is entitled to
equitable relief to recoup any overpaid funds. See Celotex Corp. v. Catrett, 477 U.S. 317, 323
(1986).
United uses a form Group Disability Benefits Reimbursement Agreement with two
options. Option 1 provides that United “will estimate the amount of Other Income Sources” for
which the participant is eligible “and reduce the benefit” paid to the participant “by such
estimated amount.” Admin. R. 001572. Option 2 provides that United will pay a participant
“any . . . benefit payable . . . with no reduction based on the estimated amount” of other potential
income sources. Id. If a participant selects Option 2, the Agreement obligates the participant to
“apply for Other Income sources for which [the participant is] or may become eligible.” Id.
Additionally, the Policy language itself requires a claimant to “apply for Other Income Sources
for which You are or may become eligible, including but not limited to Social Security disability
and/or dependent benefits, and do what is needed to obtain them” and permits United to reduce
the benefits it pays to a claimant by those “Other Income Sources.” Id. at 000021–22.
On April 15, 2021, DeMario-Miko signed the Group Disability Benefits Reimbursement
Agreement and selected Option 2, acknowledging that United was permitted to reduce her LTD
benefits by other income sources, including SSDI benefits which DeMario-Miko either received
or was eligible to receive. Id. at 001572–73.12 Accordingly, by the plain language of the Group
12 On March 25, 2021, DeMario-Miko selected Option 1 on the Agreement. Admin. R. 001586–
87. However, a few weeks later, on April 15, 2021, she selected Option 2, thereby superseding
the earlier selection. Id. at 001572–73; Pl.’s Resp. to Def.’s SoF ¶ 30 [Doc. No. 49].
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 28 of 30

29
Disability Benefits Reimbursement Agreement and the Policy, DeMario-Miko was obligated to
apply for SSDI if she was eligible. United asserts that because United determined that DeMario-
Miko was eligible for STD and LTD benefits from 2020–2023, she must have been eligible for
SSDI benefits as well.
DeMario-Miko asserts that she was not eligible for SSDI because she worked part-time
sporadically throughout 2021–2022. Pl.’s Opp’n 23 [Doc. No. 48]. On May 6, 2022, a United
representative spoke with DeMario-Miko’s spouse regarding her resignation from AFWA. Id.;
Admin. R. 007453. The United representative informed DeMario-Miko’s spouse that DeMario-
Miko was not eligible for SSDI while she was working part-time. Admin. R. 007453. On this
record, United has failed to show that DeMario-Miko was eligible for SSDI benefits when she
was working part-time.
The United representative also told DeMario-Miko’s spouse that following her
resignation, she would be required to apply for SSDI and United would require proof of filing.
Id. The record is undisputed that DeMario-Miko has not applied for SSDI benefits. See Def.’s
Mem. 16 [Doc. No. 35]; Pl.’s Opp’n 22 [Doc. No. 48]. Accordingly, if requested, United would
be entitled to an order directing DeMario-Miko to apply for SSDI benefits for the period starting
May 6, 2022. And if such benefits are awarded, United may be entitled to a reduction in benefits
corresponding with the benefits obtained and recoupment of some of the disability benefits paid.
But where DeMario-Miko has not yet been found eligible for SSDI benefits, United has
made no showing that DeMario-Miko has received funds in her possession for which the court
could construct an equitable remedy. See Jette v. United of Omaha Life Ins. Co., 387 F. Supp. 3d
149 (D. Mass. 2019), vacated on other grounds, 18 F.4th 18 (1st Cir. 2021).
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 29 of 30

30
Therefore, United has failed to carry its burden on summary judgment that it may recoup
$98,039.71 from DeMario-Miko pursuant to 29 U.S.C. § 1132(a)(3) and its Motion with respect
to its counterclaim is DENIED.
IV. 	CONCLUSION
Where DeMario-Miko is unable to perform the material requirements of her occupation
due to physician-treated conditions and United has failed to establish that DeMario-Miko’s
disability is caused by a mental condition, the court GRANTS DeMario-Miko’s Motion for
Summary Judgment [Doc. No. 38] and DENIES United’s Motion for Summary Judgment [Doc.
No. 34] as to DeMario-Miko’s ERISA claim. The court also DENIES United’s Motion for
Summary Judgment [Doc. No. 34] as to its counterclaim because United has not shown that it is
entitled to recoupment of an overpayment of benefits.
IT IS SO ORDERED.
April 8, 2026 	/s/ Indira Talwani
United States District Judge
Case 1:24-cv-11058-IT Document 52 Filed 04/08/26 Page 30 of 30