Kentucky Woman Wins Lawsuit Against Mutual Of Omaha Insurance

Claiming that her long term disability benefits were denied improperly under the Employment Retirement Income Security Act of 1974 (ERISA) and 29 U.S.C.§ 1001, et. seq., Nancy C. and her Kentucky disability lawyer filed a disability lawsuit against her employer and disability insurer alleging that the denial of her long-term disability benefits by the insurer was “arbitrary and capricious” and constituted a “breach of fiduciary duty and/or bad faith” on the part of the defendants.

History of the Claim

Employed as a Kentucky Home Care Case Manager/Consumer Directed Options Support Broker for the Paducah Area Development District, Nancy C. made a Mutual of Omaha application for disability benefits due to her inability to work as the result of “severe abdominal pain, fatigue, malaise.” She reported that these symptoms first appeared in December of 2004, but she continued working. However, by October 22, 2009, she could no longer function in her job and resigned her position.

Mutual of Omaha Disregards Claimant’s Dependence upon Medications to Work

Upon the collection of Nancy C.’s medical records, the insurer learned that was diagnosed with abdominal pain, portal vein thrombosis and degenerative joint disease of the knees and that she had been treated with anti-coagulation therapy as well as receiving intermittent treatment of venipuncture blood draws. In addition, as a result of her thrombosis, Nancy C. was found to have “hepatocellular disease with diffuse fatty infiltration in the liver, esophageal varices (dilated veins), splenomegaly (enlarged spleen), and ileus,” according to a CT scan performed on January 21, 2010. Prior to her resignation in October, 2009, Nancy C. paid numerous visits to her physician noting a plethora of symptoms that included shortness of breath, swelling of lower extremities, abdominal pain, fever, chills, pain, nausea, and visual disturbances. With an increase in her medications, Nancy C. continued to work, though her doctor reported that her prognosis for improvement was not optimistic. Her return to work, according to her treating physician was “comprised solely of medicine management” and would require her to cease driving as long as she continued to take her prescribed narcotics.

On March 10, 2010 Carpenter’s long term disability claim was denied by Mutual of Omaha, who stated that the medical documentation available on Nancy C.”does not appear to support restrictions and limitations to preclude sitting 6 hours out of an 8-hour day with ability to occasionally make position changes or occasionally lift up to 10 pounds.” Thus, the insurer determined that Nancy C. could perform the material duties of her regular occupation and thus, did not qualify for long term disability benefits. As expected, Nancy C. appealed the decision, supplemented her medical records to the insurer, and got another opinion which determined that Nancy C.”would benefit from further expertise.”

Mutual of Omaha upheld its denial of Nancy C.’s benefits stating that she “has had the abdominal distention and portal vein thrombosis conditions for some time and that they are established problems, noted to be ‘stable and improved.'”  Using the standard dictated by ERISA that the Court must look at a claim of contested benefits in light of the “information actually considered by the administrator” of a claim. Quoting case law to justify its consideration, the Court applied the “arbitrary and capricious standard of review” to Nancy C.’s issue. In their complaint and brief, Nancy C. and her attorney alleged that the insurer denied Nancy C.’s claim without giving proper consideration to her medical records or her receipt of Social Security Disability Benefits.

Court Determines that Mutual of Omaha Had a Conflict of Interest in this Case

According to the Court’s memorandum on this case, even though neither party brought up the topic of the insurer having a conflict of interest, the Court felt that it should point out that this was a consideration as the insurer is both the payor and the reviewer of Nancy C.’s claim and that that should be considered in the review of her case. The Court found that the insurer did indeed act arbitrarily and capriciously in one respect in that Nancy C. was required to drive to eight different counties in Western Kentucky to fulfill the material functions of her job when her physician clearly stated that she should not be driving.

The Court determined that the insurer’s “minimal analysis focused on the symptoms [Nancy C.] does not exhibit, such as abnormal bleeding or poorly controlled blood pressure, instead of focusing on the symptoms she does exhibit and then analyzing how these symptoms would not prevent her from performing the material duties of her occupation” was a factor here. In addition, the Court noted that the insurer disregarded the opinion of her treating physician and his determination of Nancy C.’s “limitations and restrictions but did not expressly explain why it did so.” The Court also found fault with the insurer’s reliance upon the opinion of nurse reviewers, the performance of a file-only review, and the fact that more weight was given to the review of her file than to her treating physician’s medical evaluation of his patient

Quoting several cases which pointed to the insurer’s lack of basing its evaluation of Nancy C.’s claim in a reasonable fashion, the Court ruled that Mutual of Omaha did act arbitrarily and capriciously when it decided to deny her claim for long term disability benefits. The Court further opined that it was “troubled” by the insurer’s “determination that the available medical documentation did not support [Nancy C.’s] reported restrictions when it never had a physician examine her or provide a full analysis of her claim.” And, the Court further admonished the insurer that it believed that the denial of Nancy C.’s claim “was not the result of a deliberate principled reasoning process and was not supported by substantial evidence. However, the Court did state that it didn’t believe that the record associated with this case automatically entitles Nancy C. to receive long term disability benefits and thus, remanded the claim back to the defendant to conduct a full and fair review of her case.


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Mutual of Omaha Reviews
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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 March 20th 2017 by Attorney Jay Symonds
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