In Kaviani v. Reliance Std. Life Ins. Co., 2020 U.S. App. LEXIS 3006 (11th Cir. Jan. 31, 2020), the Eleventh Circuit held that an insurer had failed to give sufficient credence to a claimant's self-reports of pain and unreasonably disregarded corroborative evidence while evaluating an ERISA-governed LTD claim.

The case serves as a cautionary tale to insurers denying claims based on self-reported complaints of pain. In Kaviani, a dentist insured under a group disability plan ("Kaviani") sought benefits based on neck and back pain three years after a car accident. Between the accident and filing the claim, Kaviani continued working as a dentist, although he asserted the pain was exacerbated by his continued dental work and that it caused him to practice dentistry unsafely. Kaviani underwent significant treatment for several months immediately following the accident, but then sought no pain-related medical care for approximately a year and a half. At that point, Kaviani underwent additional testing which caused his treating physician to opine that Kaviani should change professions. Kaviani submitted his resignation and then worked for an additional 30 days before filing his LTD claim.

In support of his claim, Kaviani submitted medical records documenting various treatments for pain, as well as a functional capacity exam ("FCE") and a report by an independent medical examiner ("IME"). He also submitted statements from numerous physicians and colleagues attesting to his infirmities. During the claim review process, Reliance had two physicians examine Kaviani's file, both of whom determined that Kaviani's self-reports of pain were not supported by the medical evidence.

Reliance denied the claim, finding that Kaviani had failed to demonstrate he was unable to perform the material duties of his regular occupation, dentistry. Reliance concluded that Kaviani's reports of pain were not credible because (1) Kaviani did not file for LTD benefits until three years after the accident, (2) following his initial treatments after the accident he did not receive additional treatments for a year anda half, and (3) he continued to work for 30 days after giving notice of his resignation. Kaviani exhausted his administrative remedies, and then filed suit in a Florida district court.

Applying a discretionary standard of review, the district court granted Kaviani's motion for summary judgment, finding that Reliance had "cherry-picked" evidence by which to deny the claim and ignored "unfavorable findings of disability." The Eleventh Circuit affirmed.

In so holding, the court noted that while Reliance was not required to defer to the FCE and IME reports, it could not reject them without a reasoned basis. "Although a plan administrator has substantial discretion in adjudicating disability claims, it cannot ignore uncontradicted record evidence of disability. We agree with the district court that Reliance did just that when it rejected Kaviani's claim for LTD benefits."