Mutual of Omaha Reinstates Benefits of Business Development Manager after Appealing the Termination of Her LTD Benefits
Author: Attorney Rachel Alters
Our Client, a successful Business Development Manager began experiencing severe physical limitations resulting from fibromyalgia, low back pain, L4-5 spondylolisthesis, L4-5 degenerative disc disease and chronic fatigue. As a result she was unable to perform with reasonable continuity at least one of the material duties of her regular occupation on a part-time or full-time basis.
Denial Based Solely on Nurse Consultant Review
Mutual of Omaha’s decision to deny her claim for LTD benefits was based on the review of medical records performed by Mutual of Omaha’s in-house nurse consultant, who after merely reviewing the medical records, concluded that fulltime and full duty working activities are not contraindicated with a diagnosis of Fibromyalgia. In her opinion, “this condition and the symptoms associated with Fibromyalgia are typically treated with increased activity, regular exercise program, and regular working activities.”
It was the opinion of this nurse reviewer that it was reasonable to expect the claimant to be able to walk or stand for 6 hours out of an 8-hour day. Lift no more than 20 pounds on an occasional basis and up to 10 pounds on a frequent basis. She further opined that the claimant presented with self-reported symptoms with no acute physical findings. The severity of symptoms documented was inconsistent to provide a clear explanation that she would have any restrictions and limitations.
Claimant Physicians Disagree with Nurse Reviewer Opinions
Mutual of Omaha’s nurse was incorrect in her opinions regarding the claimant’s functional capacity and Mutual of Omaha acted with bias and in conflict of interest when it relied solely on their in-house nurse’s opinion in reaching its decision to deny the claim for long term disability benefits without retaining a physician in the proper specialty to perform a peer review of the claim. The nurse consultant was clearly not qualified to render a medical opinion with regard to the claimant’s functional capacity to perform work duties, nor was she qualified to provide an opinion as to what might be the best medical treatment for her medical conditions.
All of the claimant’s treating physicians concluded, based on their physical examinations and treatment over an extended period of time, the claimant did not have the functional capacity to perform even sedentary work due to severe pain all over her body, fatigue and cognitive deficits.
In her peer review report, the nurse failed to explain on what evidence she based her conclusion that the claimant could walk or stand for 6 hours out of an 8-hour day and could lift no more than 20 pounds occasionally and up to 10 pounds frequently. Further, she failed to explain how the claimant would be able to perform both the physical and cognitive demands of her regular occupation in light of her complaints of severe, disabling pain and fatigue. Her occupation required more than just standing, walking and lifting 10 to 20 pounds. Her occupation as a Business Development Manager required long hours, the ability to multi-task, to think on her feet and ability to focus. The nurse reviewer failed to give consideration to the fact that the claimant suffers flares of her symptoms which prevent her from performing the material duties of her occupation with reasonable continuity, 8 hours per day, 5 days per week, on a continuing basis. During periods when the claimant experienced a flare up of her symptoms, she is completely disabled and barely able to care for herself.
Mutual of Omaha’s Determines It’s Decision Was Wrong
After Attorney Alters submits a length appeal accompanied several physicians’ opinions and medical records all supporting the claimant’s inability to work, Mutual of Omaha overturned its denial and reinstated the claimant’s LTD benefits. She is still unable to work and remains on claim. Attorney Alters will continue to manage the claim the help ensure that her benefits are paid until she is able to return to work.