United of Omaha criticized for relying on in-house medical review and failing to obtain independent examinations
- Court Criticizes Mutual Of Omaha & Rules on the Side of Policy Holder
Author: Attorney Victor Peña
This case was decided by a district court in Illinois and involved United of Omaha Life Insurance Company. An ERISA action was filed by the Plaintiff, Gina Tassone, after her LTD benefits were terminated. She had been paid two-years of regular-occupation benefits for her inability to work as a Finance Manager and like many group disability policies, her insurance policy’s definition of disability changed after two-years of benefits.
During its two-year review, United of Omaha relied on the opinions of two in-house clinical experts who reviewed the medical records, neither of whom ever examined Ms. Tassone. First, an in-house nurse opined that “it would be reasonable to expect Ms. Tassone to be able to sit for 6 hours out of an 8 hour day, lifting no more than 10 pounds occasionally with possible frequent lifting of small objects.”
Next, Dr. Reeder, United of Omaha’s medical director, provided a long list of reasons as to why Ms. Tassone’s medical records were deficient. Interestingly, Ms. Tassone’s file consisted of over 5,400 pages of medical records.
Following his review, Dr. Reeder sent letters to a number of Ms. Tassone’s treating doctors, asking them to respond to his conclusions, including a clarification regarding their treatment and restrictions and limitations. Each of Dr. Reeder’s letters indicated that if he did not get a response within 10 days, he would assume that the recipient was in agreement with his conclusions that Ms. Tassone was able to perform at the sedentary level.
None of the plaintiff’s treating doctors responded to the medical director’s challenge.
United of Omaha argued that by failing to disagree, those treating doctors tacitly agreed. The court disagreed pointing out that the letters were obviously written in a manner designed to lure the recipient into either agreeing with the medical director’s limited and biased review of the records or enter into a war of diagnoses with him. There is no upside for any doctor to engage in a dispute with an in-house physician so the court placed no significance on the doctor’ silence to such a biased letter.
The court placed little weight on the in-house nurse and doctor’s opinions, finding them undoubtedly biased given that both work for the defendant.
The court also pointed out that in-house medical director had been criticized in a similar case for ignoring conditions that cause pain despite the fact that it is the plaintiff’s extreme pain that supports her claim for LTD benefits.
Ms. Tassone was given a fee award and an award of prejudgment interest following the court’s finding that Ms. Tassone was unable to work full time at a sedentary position.