Mutual of Omaha Disability Denial Upheld by Appellate Court

In Giovanna Reichard v. United of Omaha Life Insurance Company (Mutual of Omaha or Omaha), Plaintiff, a nurse employed by a hospital, suffered from headaches, arthritis, Crohn’s disease, and fibromyalgia. She eventually had to quit work because of her illnesses and applied for long-term disability (LTD) benefits through her employer’s group-disability plan administered by Mutual of Omaha.

Omaha granted her request for LTDs for two years during which time the plan considered a person disabled if they were unable to work in their own occupation. Omaha informed Plaintiff that in two years, the definition of disability would change, and she would have to prove she was unable to work in any occupation for which she was “‘reasonably fitted by training, education, or experience’ that would pay at least 60% of her pre-disability earnings within a year of going back to work.”

After two years, Omaha re-evaluated Plaintiff’s claim under the narrow definition of the policy. The company had her medical records reviewed by four professionals: a nurse, a vocational rehabilitation consultant, a physician, and a board-certified rheumatologist, who conducted an independent medical exam (IME). He also reviewed the reports of Omaha’s other medical record reviewers.

After reviewing the four reports, Omaha denied Plaintiff’s claim, and she appealed. On the administrative appeal, Plaintiff objected on the grounds that Omaha:

Omaha responded by having Plaintiff’s medical records reviewed by Dr. Thomas Reeder, its in-house appeal reviewer who also happens to be board-certified in internal medicine. Dr. Reeder is also a senior vice-president for Omaha and its medical director.

Dr. Reeder concluded that there was only one of Plaintiff’s four treating physicians who believed Reeder could not work in any occupation. Dr. Reeder noted that the doctor’s opinion conflicted with notes the doctor had made in the medical file.

Dr. Reeder sent letters to Plaintiff’s four treating physicians informing them of his opinion and inviting them to contact him if they had any objections. Only a neurologist contacted Dr. Reeder and that doctor said he had no objections.

Based on Dr. Reeder’s report, Omaha denied Plaintiff’s appeal, and she filed an ERISA lawsuit in the U.S. District Court for the Eastern District of Pennsylvania. When the District Court ruled in favor of Omaha, Plaintiff appealed to the U.S. Court of Appeals for the Third Circuit.

The Court of Appeals upheld the ruling of the District Court, which held there was substantial evidence to support the Plan Administrator’s decision, so “the insurer’s denial of benefits was not arbitrary and capricious.”

There Was Substantial Evidence to Support Omaha’s Decision to Deny Benefits

The Appellate Court found Omaha’s decision to deny LTD benefits was based on substantial evidence and therefore not arbitrary and capricious when:

Procedural Irregularities do not Make the Denial of LTD Benefits Arbitrary and Capricious

Plaintiff argued that procedural errors occurred, so she was denied a fair hearing. The appellate court disagreed pointing out the flaws in Plaintiff’s argument. The Court listed Plaintiff’s arguments and why it ruled against them.

She argued Omaha did not tell her what they needed from her to support her claim. The court said there really was little doubt about what was required. She corresponded “at length” with Omaha and submitted extra documentation. In her appeal, she did not state what she would have provided Omaha if she had been asked.

One doctor had several typos in his report which, the Court agreed looked sloppy and did not “inspire confidence,” but the mistakes were not substantive, but only typographical. The Court concluded that the typos “are immaterial.”

She alleged that Dr. Reeder’s employment with Omaha created a conflict of interest. The Court agreed that factor weighed against Omaha but was not enough to overcome the finding that the denial of benefits was based on substantial evidence.

Cumulative effect of the errors was insignificant and did not render Omaha’s decision arbitrary and capricious.

In finding in favor of Omaha, the Appellate Court held that:

“We do not doubt that [Plaintiff] suffers serious illnesses and side effects. But the issue here is whether she can work at any job that pays 60% of her previous salary. United of Omaha found that she could, and our review of its decision must be deferential. It assessed her functional limitations and listed five specific sedentary jobs she could do. Its decision to deny continued benefits rested on evidence from many doctors, and it reasonably disagreed with the one outlier. So, while its procedures might have been imperfect, its ultimate decision was not unreasonable.”

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This case was not handled by our office, but we feel it may be instructive to those who are having similar problems with their insurance company. If you have any questions about this case, or about any issue concerning your disability claim, feel free to contact one of our disability attorneys at Dell & Schaefer for a free consultation.

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Dawn P.

I had to quit working after 8 years of dealing with chronic pain from 2 bulging and torn discs from an injury and failey back surgery. I was approved for Long term disability through my employer benefits, with Unum. They covered me with payments for one year, and suddenly sent a letter that their doctors disagreed with my surgeon and pain management doctors, and they felt I could go back to work full time. I hired a local attorney, trying to save some money, but I don’t think he had much experience dealing with big LTD companies such as Unum. He filed terrible appeals on my behalf with little to no effort on his part of building a good case for me. After a year of dealing with his condescending attitude and loosing my final appeal, I decided to call up Dell & Schaefer. I had contacted them a year prior when searching for an attorney. Cesar was willing to take my case and felt I had a good one. But I didn’t want to pay the percentage he was asking for if we won back then. The old saying, “you get what you pay for”, proved to be true in this case and I regretted not hiring him from the beginning!

Once I did hire him, and thank goodness he was still willing to take my case even though he was dealing with defending poor appeals by my previous lawyer, things got moving along for me. Because of his years of experience dealing with Unum, and his record of wins against them, within 6 months we had a settlement I could live with! The stress I suffered before Cesar and weight on my shoulders was gone! Cesar is a kind, caring, attorney who will fight for your rights! His assistant Michal always talked to me when I called in with questions or to check up on my case and never made me feel bad for calling. It was nothing like the previous relationship I had with my other attorney and his staff, who avoided me. Cesar explains the process well and keeps you updated on your options throughout the process. He was worth every penny!

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