Sixth Circuit remands United of Omaha Life to engage in a meaningful review process in evaluating long term disability benefits for claimant with chronic back pain.
In Koning v. United Omaha Life Insurance Company, the Sixth Circuited remanded to a Michigan district court with instructions for the Plan to properly consider Koning’s medical condition as presented by her treating physicians. The court found at least four errors made by the Plan in determining claimant’s chronic back pain did not prevent her from performing all the duties of her job as a Human Resource Manager.
Specifically, the court held that, “The Plan ignored favorable evidence submitted by her treating physician(s), selectively reviewed the evidence it did consider from the treating physicians, failed to conduct its own physical examination, and relied on non-treating nurses and other non-treating physicians.”
Ignoring Favorable Evidence from Koning’s Treating Physicians
Relying on precedent, the court noted that although Plan administrators are not required to accord any “special deference to the opinions of treating physicians,” they must “give reasons for adopting an alternative opinion.” In rejecting Koning’s claim, the Plan simply issued a conclusory statement, based on a reviewing nurse’s analysis, that the medical record did not justify long term disability benefits to Koning who, the reviewing nurse concluded, could perform the material duties of her regular occupation as a human resource manager.
United Omaha Life Insurance Company totally ignored the treating physician’s medical opinion that her chronic and severe back pain made it impossible for her to “sit, stand and/or bend for any significant period of time.” In addition to ignoring this opinion, the Plan cited no conflicting medical evidence in conflict with the doctor’s opinion and gave no reason for “adopting an alternative opinion” as required.
Selectively Reviewing Treating Physician’s Evidence
The Plan’s reviewers concluded that Koning was not disabled without any adequate medical evidence to support that finding. The reviewers specifically discounted her pain and the opinions of the treating physicians that she had a restricted range of motion, had undergone several surgeries and that an MRI documented degenerative disc disease. Relying on precedent, the court found this selective review was “arbitrary and capricious.”
Failing to Conduct its Own Physical Evaluation
Although a Plan may rely on a file review without conducting its own physical evaluation, the court noted that the failure to do so raises “questions about the thoroughness and accuracy of the benefits determination.” In this case, where the Plan reviewers “second-guessed” the treating physicians, and the reviewer claimed the Functional Capacity Exam (FCE) did not support her disability claim when the treating physicians relied on the FCE in determining she was disabled from doing her job, the lack of an independent review was an indication of a lack of a thorough review.
The Sixth Circuit noted that “the Plan should have explained the basis for refusing to credit Dr. Fizgerald’s medical opinion.” The court concluded that its “review of the Plan’s decision making process indicates that the Plan’s denial of Koning’s LTD benefits was in error.”
Significant Changes in Physical Functional Capacity
The Sixth Circuit held the District Court erred in concluding that Koning did not prove she had “suffered a significant change in her physical functioning capacity” as required by the Plan. The court referenced the evidence in the record that supported her claim and remanded based on its conclusion that “Koning may be able to meet this burden.”
Remand as the Proper Remedy
The Sixth Circuit held that this was a case where “the problem is with the integrity of the plan’s decision-making process, rather than that a claimant was denied benefits to which he was clearly entitled.” Therefore, it remanded the case to the district court with instructions to remand the case to the Plan administrator “for a full and fair review consistent with this Court’s opinion.”
This case was not handled by our office, but it may provide claimants guidance in their pursuit of long term disability benefits. If you need assistance in pursing a claim for either short or long term disability benefits, please contact any of our lawyers for a free consultation.