Our client, Ms. J, formerly worked as a Senior Manager of a treatment facility. In October 2016 a number of medical issues, including fibromyalgia, chronic pain syndrome, chronic fatigue and depression forced Ms. J to stop working and submit her claim for disability benefits, first under her employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. The STD coverage was administered and funded by Mutual of Omaha. Ms. J’s occupation as Senior Manager was quite intellectually complex, detail oriented and physically demanding. Under her employer’s STD policy, she would be considered totally disabled if he was unable to perform all of the material duties of her own “regular occupation.”
After filing her claim under the STD policy, Mutual of Omaha denied STD benefits on the basis that Ms. J allegedly no longer met the policy definition of disability. Specifically, Mutual of Omaha determined that “the medical records received do not support a functional or mental impairment that prevented [her] from performing the material duties of [her] regular job after October 11, 2016.” After receiving the denial, Ms. J contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Mutual of Omaha’s investigation of her claim and its physician consultant’s medical review, and agreed to prepare and submit Ms. J’s ERISA appeal with the assistance of his appeal team. In addition, Attorney Symonds recommended that Ms. J initiate an LTD claim simultaneous with the STD appeal.
The STD appeal addressed all of Mutual of Omaha’s short-comings and reasons for denial, with a special focus on the purported medical review conducted by Mutual of Omaha’s in-house nurse consultant and Mutual of Omaha’s assessment of the material duties of Ms. J’s regular occupation. In particular, the appeal identified several mischaracterizations and misinterpretations of Ms. J’s medical records by Mutual of Omaha’s in-house medical staff. In addition, the appeal established that Mutual of Omaha failed to consider the requirements of Ms. J’s actual regular job – as required by the STD Policy – in reaching its determination that she allegedly did not qualify for benefits.
Approximately 1 month after submitting her appeal and hundreds of pages of supporting exhibits and medical records, Mutual of Omaha overturned its decision to terminate the claim and paid Ms. J’s full short-term disability benefits through the maximum benefit period. Shortly thereafter, Ms. J’s LTD benefit claim was approved and she began receiving payments avoiding an unnecessary delay or gap in coverage and, more importantly, monthly income.