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United of Omaha Overturns Decision to Deny Benefits to Disabled Quality Assurance Manager After Appeal Discredits Its Medical Review and Vocational Assessment

Attorney Cesar GavidiaAuthor: Attorney Cesar Gavidia

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 Attorneys Dell & Schaefer 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 & Schaefer 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.