Dell & Schaefer Successfully Appeals Denial of Benefits to Quality Control Inspector
Author: Attorney Victor Peña
Before going on disability, Mr. M was working as a quality control inspector for Tam International. In 2009, after years of service, Mr. M sustained an injury while at work and he was forced to file a claim for disability with his employer sponsored disability plan. His claim was based on low back pain, osteoarthritis, neuralgia, radiculitis, neck pain, shoulder pain, muscle spasms, headaches, and generalized anxiety disorder.
Ms. M’s Disability and his claim for disability benefits
Mutual Omaha, the claims administrator for Mr. M’s employer sponsored disability policy, approved Mr. M’s claim and paid him disability benefits. After two years of benefits, Mutual of Omaha began a review of Mr. M’s claim to determine if he was disabled from any occupation. Due to the nature of Mr. M’s various conditions, his condition had only worsened over the years and his pain and inability to work had progressed. As a result, Mutual of Omaha approved Mr. M’s continued claim and continued paying him benefits until February 27, 2014.
In February 2014, Mr. M received an 8-page letter from Mutual of Omaha stating that based on a review of Mr. M’s claim for ongoing LTD benefits Mutual of Omaha had determined that Mr. M retained the ability to return to work in his pre-disability occupation as a quality control inspector and that no further benefits were payable on the claim beyond the date of the letter.
At the time, Mr. M had been receiving benefits for over 5 years and there had been no improvement in his condition. Over the years, Mutual of Omaha had periodically reviewed Mr. M’s ongoing claim and had consistently found that Mr. M. was disabled and unable to work in any gainful occupation. Having relied on his monthly benefits for the last 5 years, Mr. M. was put in a difficult position and did not know what to do. Mr. M was given 180 days to appeal the claim decision if he disagreed with their decision.
Mr. M contacts Attorneys Dell & Schaefer for help with his appeal
Mr. M immediately contacted our law firm and spoke with Attorney Victor Peña.
Attorney Peña reviewed Mr. M’s denial letter and after discussing his case with Mr. M. it became apparent that Mutual of Omaha had failed to understand the significance of Mr. M’s disabling conditions. Mr. M retained Attorneys Dell & Schaefer to handle his appeal of his LTD denial and Attorney Peña immediately requested a copy of the claim file from Mutual of Omaha and thoroughly picked through the file. During his review, Mr. Peña uncovered major flaws in Mutual of Omaha’s review, which he focused on in drafting the appeal. Of particular significance was the fact that Mutual of Omaha had relied on a Transferable Skills Analysis (“TSA”) dated September 7, 2012 finding that there is no gainful occupation which Mr. M. can perform and, based on that TSA, had affirmed and reaffirmed Mr. M.’s eligibility for benefits. Although Mutual of Omaha had appropriately relied on the September 2012 TSA during its periodic reviews over the years, Mutual of Omaha had completely ignored the TSA report in terminating Mr. M.’s benefits.
A review of the TSA report and the notes in the claim file revealed that the TSA was based on the results of an IME report dated June 19, 2012, which Mutual of Omaha had conveniently left out of the claim file sent to Mr. Peña. The report relied on the following statement from the IME physician:
“I do not think he can go back and do his former job, but he can do a full time sedentary job with no appreciable lifting/carrying of more than 20 pounds occasionally, 10 lbs. frequent. He needs a sit/stand option. I do find that he would be able to drive. He should avoid overhead lifting of more than 10 pounds.”
There was nothing in the claim file suggesting that there had been an improvement in Mr. M’s condition since the June 19, 2012 IME. More importantly, there remains to be no “gainful occupation” of which Mr. M. is able to perform all of the material duties. A review of the claim file revealed that Mutual of Omaha had repeatedly found that there are no occupations that Mr. M qualifies for which meet the gainful earnings threshold required in the policy. Despite the fact that Mr. M’s qualifications have not changed and his condition has not improved Mutual of Omaha wrongly terminated Mr. M’s claim despite knowing that Mr. M continues to be eligible for benefits.
Mutual of Omaha overturns denial on appeal
The appeal submitted to Mutual of Omaha pointed out the flaws in their review and included updated medical records from all of Mr. M’s treating physicians. Additionally, Mr. M underwent a three-hour Functional Capacity Evaluation (“FCE”), which was requested by his attorney, and the results of the FCE were included in the appeal. The FCE report detailed Mr. M’s current limitations. Notwithstanding the results of the FCE, Mutual of Omaha insisted on retaining a doctor of their choice to evaluate Mr. M. once again. Rather than trusting Mutual of Omaha to provide the relevant medical records to its hired physician prior the “Independent” Medical Evaluation (“IME”), Mr. M’s attorney sent the most relevant records to the IME physician for a thorough review.
Although Mutual of Omaha declined to provide a copy of the IME report to Mr. M or his attorney, a letter addressed to Attorney Peña was received days after the evaluation notifying Attorney Peña and Mr. M that Mutual of Omaha had overturned its decision and a check representing all back benefits owed would be sent under separate cover.
Attorneys Dell & Schaefer continues to manage Mr. M’s claim with Mutual of Omaha to ensure he has the best chances of remaining on claim as long as he remains disabled.