Case Story: Our Client v. United of Omaha Life Insurance Company
After a year of increasing back pain, our client had to leave their job as a legal assistant. United of Omaha paid our client short term disability benefits for the maximum amount of time but denied their claim for long term benefits. Id. To qualify for short term benefits, a claimant had to be unable to perform their “Regular Job”, the occupation the claimant was routinely performing when they became disabled. Id. However, to qualify for long term benefits, the claimant had to show that they could not perform their “Regular Occupation”. “Regular Occupation” meant a similar position based on job description and requirements but not the exact job the claimant had before disability. Id. our client’s employer required them to lift files that weighed up to twenty-five pounds. Id. at 743. Because our client could lift no more than twenty pounds, they were unable to perform their Regular Job and thus qualified for short term benefits. Id. This did not, however, automatically qualify our client for long term benefits, since Omaha enforced stricter requirements for long term benefits.
After our client first applied for long term benefits, Omaha sent their file to Nurse Rosenstock for review. Id. Rosenstock reported that the restrictions and limitations imposed by our client’s treating physicians were unsupported and that our client could perform the duties of their occupation. Based on this report, Omaha denied our client’s claim. Id. After our client appealed, Omaha sent our client’s file to another case management nurse for review. Id. at 744. This reviewer, Beumer-Anderson, found that our client had only been disabled for a limited time period while our client was recovering from back period. Omaha then denied our client’s appeal, claiming that their complaints of severe back pain were “inconsistent with the physical examinations and the medical evidence.” Id.
We then filed suit for the court to consider whether our client was entitled to long term benefits. Since the plan gave Omaha discretion to interpret the plan requirements, the court reviewed Omaha’s actions under the arbitrary and capricious standard of review. Id. at 744-45 (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Perez v. Aetna Life Ins. Co., 150 F.3d 555 (6th Cir. 1998)). However, since Omaha both determines eligibility and pays benefits, it has a conflict of interest such that its decision must be viewed “with some skepticism.” Id. at 745-46. (citing Helfman v. GE Grp. Life Assurance Co., 573 F.3d 383, 392 (6th Cir. 2009); Black & Decker Disability Plan v. Nord, 538 U.S. 822, 832 (2003); Moon v. Unum Provident Corp., 405 F.3d 373, 382 (6th Cir. 2005)).
The court held that Omaha’s reliance on file reviewers who did not physically exam our client was arbitrary and capricious under the circumstances. Id. at 746-49. Although there is nothing inherently improper about using file reviewing experts to evaluate claims, sole reliance on file reviews with no physical examinations can “raise questions about the thoroughness and accuracy of the benefits determination.” Id. at 747 (quoting Calvert v. Firstar Fin., Inc., 409 F.3d 2866, 295-96 (6th Cir. 2005); citing Helfman, 573 F.3d at 393)). Here, the plan gave Omaha the right to conduct a physical examination, but Omaha did not do so. Id. The court held that Omaha’s reliance on the file reviews alone was questionable considering Omaha’s conflict of interest. Id.
Reliance on these file reviews was additionally questionable given the content of the reviews. Id. Dr. Kalen’s report included only conclusory remarks not supported by evidence. Id. For instance, Dr. Kalen, who had performed a file review for Omaha’s consideration of our client’s claim for short term benefits, declared that our client “did not have any physical or functional impairments that would have prevented” them from performing their occupation but provided no evidence or explanation of this conclusion. Id. Similarly, Rosenstock asserted that there was insufficient evidence to support our client’s restrictions and limitations but did not describe their reasoning for this conclusion or reconcile their report with the contradicting evidence from our client’s treating physicians. Id. at 748. Beumer-Anderson reported that our client’s pain was “inconsistent with physical examinations” but in the same report acknowledged that neither they nor any of Omaha’s file reviewers had conducted physical examinations. Id. The court held that reliance on these reports demonstrates that Omaha had not conducted a “deliberative and principled reasoning process”. Id.
Finally, the court remanded our client’s claim to Omaha to conduct a proper evaluation of its merits. Id. at 749 (citing Elliot v. Metro. Life. Ins. Co., 473 F. 3d 613, 622 (6th Cir. 2006)(When “the problem is with the integrity of [the plan’s] decision-making process…the appropriate remedy generally is remand to the plan administrator.”)).
