United of Omaha overturns decision to deny benefits to disabled Quality Assurance Manager after Appeal discredits its medical review and vocational assessment

In 2016, Cathy, a Quality Assurance Manager for a medical device company, sought surgery for a tear in her right rotator cuff. Cathy fully expected to heal, recover and return to work. However, disappointingly, things did not turn out quite like she expected. After continuing to experience pain, discomfort and restriction in her right shoulder range of motion, she discovered that her shoulder did not heal properly following her surgery. Five months after her original surgery, Cathy had her second right shoulder surgery. Unfortunately the second surgery did not resolve her issues and she further developed adhesive capsulitis, also known as frozen shoulder.

During this time Cathy had remained out of work on medical leave and had filed disability claims under her employer provided long term disability insurance through United of Omaha Life Insurance Company a/k/a Mutual of Omaha. United reviewed and approved her disability claims, first paying her short-term disability benefits, and then approving her claim for long-term disability.

In early 2017 Mutual of Omaha decided to conduct a medical review of Cathy’s claim and requested updated medical records from her surgeon and other treating physicians. Mutual of Omaha then sent the records and file to its nurse consultant and its vocational consultant for review.

After completing their reviews, both the nurse consultant and vocational consultant concluded that Cathy had some restrictions, however, that they believed that her physical functional abilities exceeded what she claimed her restrictions and limitations to be, and that she could perform her occupational duties as a Quality Assurance Manager. Upon receiving the reports from its nurse and vocational consultants Mutual of Omaha notified Cathy that it was terminating her long-term disability claim. It further informed her that she could appeal the decision in writing within 180 days.

Cathy spent the next three months contemplating what to do next. With three months remaining in her appeal period she contacted Dell Disability Lawyers and hired Attorney Cesar Gavidia to represent her. With limited time to submit a proper and exhaustive appeal, Attorney Gavidia and his team immediately got to work by requesting Cathy’s complete claim file which contained all of the records, notes and documentation that Mutual of Omaha used to arrive at its decision. Also, all of Cathy’s medical records were obtained from her medical providers and a medical review was conducted.

In his review of the case, Attorney Gavidia discovered that the nurse consultant’s medical review was flawed and failed to support a reasonable basis for Mutual of Omaha to terminate Cathy’s claim. On Appeal, Attorney Gavidia argued that Cathy’s range of motion, as reported by her doctors and the medical evidence, was significantly more restricted than the nurse consultant’s review depicted, and thus the nurse consultant misrepresented the extent of Cathy’s physical limitations. In addition, Attorney Gavidia argued that the nurse consultant’s opinions were invalid on account of the fact she failed to hold any specialization or credentialing in the areas of orthopedic medicine, neurology or physical medicine. The obvious question being, how could a nurse, with no medical specialization in these areas, possibly supersede the opinions of board certified physicians specialized in the appropriate areas of medicine.

It was also discovered that the occupational analysis conducted by the vocational consultant was invalid since it failed to consider any of the duties pertaining to Cathy’s occupation and simply arbitrarily reduced her occupation as a Quality Assurance Manager to a simple physical “light level” demand category.

Despite having only three months to compile all of the relevant records and evidence necessary to submit with Cathy’s Appeal, Attorney Gavidia and his Appeal Team at Dell Disability Lawyers were able to make a timely submission.

Approximately two months after the Appeal was submitted Mutual of Omaha notified that it was exercising its right under ERISA to an extension of additional time to review the Appeal. Approximately two months later Mutual of Omaha communicated that it was overturning its decision, paying all back benefits owed and reinstating Cathy’s long-term disability claim.

Cathy has once again begun receiving long-term disability benefits and Attorney Gavidia and his team continue to represent Cathy and assist in her submission of monthly proof of loss to Mutual of Omaha.


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Mutual of Omaha

I do not understand how a “medical review team” who has never laid eyes on my wife can say she is able to return to work when her doctors who see her on a regular basis have documented that she can't

Reviewed by Dwight on November 14th 2017   Verified Policyholder
My wife fell three years ago and broke her back. She has been found permanently disabled and receives Social Security Disability Benefits. She has also been receiving Bene... read more >
Reply
Sent on November 14th 2017 by Attorney Stephen Jessup

Dwight, please feel free to contact our office to discuss the denial of your wife’s claim. It is unfortunately all too common that an insurance company denies benefit... read more >

Mutual of Omaha

THEY SCAMMED ME AND DID NOT CARE

Reviewed by Debbie on January 31st 2017   Verified Policyholder
We have had life insurance with Mutual of Omaha since 1998 with a chronic illness rider that we decided to use in 2016. Our policy was for 500k, they approved us for 66,95... read more >
Mutual of Omaha

This company is awful

Reviewed by Mike on December 17th 2015   Verified Policyholder
I think there should be laws put in to place to cover the average Joe. This company is awful. They say so much they don’t even know what lies they have told. My husband ... read more >
Mutual of Omaha

I would encourage anyone who has problems with Mutual of Omaha or United of Omaha to immediately contact an attorney.

Reviewed by Robbie Winder on July 24th 2015   Verified Policyholder
I would encourage anyone who has problems with Mutual of Omaha or United of Omaha to immediately contact an attorney. I want to talk about a specific situation in which I ... read more >
Mutual of Omaha

MOO attempted to strong arms me with collection tactics. Now, they're stalling

Reviewed by Jeff on February 11th 2015   Verified Policyholder
I was disabled in 2009 with a multitude of medical problems. I started a process with Mutual Of Omaha Disability. After months of jumping through hoops they finally decide... read more >
Mutual of Omaha

MOO stopped my husband's benefits before telling him. They handled his claim terribly

Reviewed by Jerry on January 30th 2015   Verified Policyholder
My husband has been on claim for disability insurance since July, 2008. He was found to be able to do sedentary work but had no transferrable skills in 8/2009 and benefits... read more >
Reply
Sent on January 30th 2015 by Attorney Gregory Dell

Jerry, you and your husband are certainly not alone in your dealings with Mutual of Omaha. Please feel free to contact our office to discuss how we may be able to assi... read more >

Mutual of Omaha

This company is very corrupt, Be aware

Reviewed by M. Girmes on January 28th 2014   Verified Policyholder
Please hesitate & educate yourself when deciding on short term or long term disability insurance via Mutual Of Omaha. The company is very corrupt. They speak to you like y... read more >
Mutual of Omaha

Mutual of Omaha is a rip off.

Reviewed by Genita Hill on November 13th 2013   Verified Policyholder
Mutual of Omaha is a rip off. When my husband died in 2011, they refused to pay his death benefit because they said he was disabled when I insured him. He retired from his... read more >
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Answered on May 10th 2017 by Attorney Stephen Jessup
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Answered on March 20th 2017 by Attorney Jay Symonds
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