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Court Finds Mutual Of Omaha Claim Determination To Lack Any Reasonable Grounds

A Federal Judge in Alabama has taken Mutual of Omaha to task for its denial of a long-term disability insurance claim governed under ERISA (Employee Retirement Income Security Act).

Following a thorough consideration of the record (noted by the Judge to be 1545 pages), factual background, medical evidence, and applying the 11th Circuit framework to its decision, the Judge evaluated Mutual of Omaha’s conduct, consideration (and lack thereof) of the medical and other evidence, and considered Mutual of Omaha’s inherent conflict of interest, arising out of its role from paying and deciding claims.

Following this considered evaluation, the Court determined that Mutual of Omaha’s determination to deny long-term disability insurance benefits to the claimant was without reasonable grounds to support the decision. The Court determined that Mutual of Omaha’s vocational consideration, determining that the claimant’s position as a Senior Business Systems Analyst was simply a “sedentary” occupation. This required sitting most of the time, with brief standing or walking. Mutual of Omaha’s medical consultant – who never met, treat, examined or evaluated the claimant, coincidentally had determined that the claimant maintained functionality to sit for up to six hours in an eight-hour workday and stand and walk to allow for sedentary capacity.

The Court noted that the claimant’s medical issues had limited his ability to perform his regular occupation, due to an inability to maintain attention and concentration required to perform repetitive analytical tasks on a sustained basis, an essential function of his position.

The Court noted that the claimant’s medical records contradicted these Mutual of Omaha opinions from the non-examining, paper reviewing physician. In reaching this conclusion, the Court considered the persuasiveness of the claimant’s medical support, noting that his condition caused paresthesia, pain, fatigue and weakness, and which was objectively verified through testing (EMG, EEG and MRI). In addition, the claimant suffered co-morbidly from fibromyalgia, radiculopathy, neuropathy and other orthopedic and neurological conditions. As a result of this array of conditions, the claimant’s doctors restricted him substantially, rendering him unable to work.

Defendant had argued that claimant’s medical providers had failed to respond to letters addressing the Mutual of Omaha medical review. The Court was not pleased (on behalf of the claimant) that the doctors had not responded, the Court ascribed little weight to the failure to respond, in the face of the strong medical evidence. The Court stated that “the failure of treating physicians to respond to a follow-up request for additional information is no reason to disregard medical diagnoses that have been well documented by extensive records of physical examinations, supporting tests, and actual treatments conducted over a period of years.”

In chastising Mutual of Omaha’s actions, the Court stated emphatically, “Ignoring the breadth and depth of such objective evidence allows insurance companies to subvert meritorious claims by simply increasing the paperwork burden on a claimant’s physicians.”

The Court thus reversed the decision from Mutual of Omaha. Wiley v. Mutual of Omaha

There are numerous tips for claimants from this case. First, it is often crucial to have your treating doctors involved, engaged and able to address negative reports that might be issued by the insurance company, like here. Fortunately here, the power of the medical evidence overcome the doctors’ lack of help.

Staying vigilant with your doctors is critical – or having an advocate to engage with your doctors to develop the powerful medical support.

There is no substitute for objective evidence where it exists. Many conditions are not able to develop objective evidence. But where one can, that evidence is often more powerful to a Judge than any other evidence.

The Court was unpersuaded by the utilization of a paper reviewing physician. Often however, Courts will utilize such support as sufficient “substantial evidence” or “reasonable grounds” to support a claim determination, particularly if the abuse of discretion standard of review applies.



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Super Lawyers | Justin 10.0Justin Corey Frankel
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