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FEDERAL JUDGE UPHOLDS DECISION BY MAGISTRATE JUDGE AGAINST MUTUAL OF OMAHA

Wednesday, July 27th, 2016

A Federal Judge has determined that the report and recommendation of the assigned Magistrate Judge should be affirmed, and granted further long term disability insurance benefits to a claimant who had been paid for about six years under her coverage with Mutual of Omaha. She was disabled due to symptoms relating to Meniere’s Disease and other co-morbid medical problems.

Mutual of Omaha sought to develop an inconsistency between the claimant’s doctor’s support statement and the office records. It also sought to cherry pick portions of the medical records which could be favorably considered to support the termination, while failing to credit other evidence supportive of continued impairment.

Then, based upon an in-house medical review, Mutual of Omaha determined that restrictions and limitations were no longer supported. In considering her appeal of the terminated claim, Mutual of Omaha arranged for a Functional Capacity Evaluation, which reached the determination that the claimant had part-time functionality only. After Mutual of Omaha sought “clarification” as to full-time work capacity, the FCE provider indicated no to full-time work status, but affirmed the part-time functionality, and indicated that she might be able to build up from that. Despite this, Mutual of Omaha reached the determination that the claimant could perform full-time sedentary work.

In reviewing Mutual of Omaha’s decision and claim handling, the Court indicated that the conflict of interest of Mutual of Omaha, as claim payor and claim administrator, influenced its claim handling, including its misrepresentation of the FCE results, as well as factual information provided to the FCE examiner about her functionality.

The Court determined that Mutual of Omaha’s claim decision was “illogical, implausible, and without support” concerning the inferences that it drew from the record. The Court was also troubled by its finding that Mutual of Omaha’s claim personnel took an advocacy position when engaging with the claimant’s treating doctor, rather than as a neutral. The Court also took issue with the failure to afford consideration to the approval of the claimant’s Social Security disability claim.

Accordingly, the Court ordered reinstatement of benefits, with interest.

No one v. United of Omaha

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