Mutual of Omaha denied long-term disability benefits to this 40 year old woman who could still work part-time. Injuries from a car accident prevented her from working full time.
We won her appeal for her. She was a high wage earner, so the claim was more difficult.
Before her May, 2020 accident, our client was a high-functioning individual at her dream job at a major international organization. But then, after her accident and concussion, her symptoms worsened. Following the accident, she had constant headaches every day for months, in addition to back pain and tingling in her arms and leg. On top of that, she now has exhaustion, and cognitive issues. Around five months after the accident, she returned to work on a limited basis against the advice of her treating doctor. Initially, she returned to work at 3.5 hours a day, 3 days a week. Over time, however, she has been able to increase to 8 hours, 3 days a week.
Currently, she is only able to work those 24 hours per week but only under extreme difficulty. Now, her pace has slowed, and she has too push herself to the limit, expending all of her energy just to stay afloat. It takes all of her energy just to focus on those hours of work and her writing, of which a huge part of her job relies, has become scattered. She is constantly anxious that she’s not doing enough. And, due to her disability, she fears that she might lose her job or that she might not be able to keep up.
Her personal life has flipped upside down too. She no longer keeps up with any personal emails or phone calls, she no longer replies to texts. She always feels exhausted and feels like she can barely keep her head above the water. She used to be problem-solver, energetic, and bubbly. But now she struggles to do the bare minimum. She no longer can live independently and has to live with her parents until she recovers. She cannot even do basic things like drive or grocery shop. Far from the independent and fulfilling lifestyle and career she enjoyed before the accident, her accident and disability has profoundly affected her life for the worse.
The long-term disability policy said this:
Disability and Disabled mean that because of an Injury or Sickness, a significant change in Your mental or physical functional capacity has occurred, as a result of which:
a) during the Elimination Period, You are prevented from performing at least one of the Material Duties of Your Regular Job (on a part-time or full-time basis); and
b) after the Elimination Period, You are:
1. prevented from performing at least one of the Material Duties of Your Regular Job (on a part-time or fulltime basis); and
2. unable to generate Current Earnings which exceed 99% of Your Basic Weekly Earnings1 due to that same Injury or Sickness.
Disability is determined relative to Your ability or inability to work. It is not determined by the availability of a suitable position with the Policyholder.
Material Duties means the essential tasks, functions, and operations relating to Your Regular Job that cannot be reasonably omitted or modified.
We argued, in part:
Here, evidence satisfied her initial burden to prove that she was unable to perform the duties of her own occupation. MOO’s denial letter, on the other hand, lacked support for its conclusions. To justify the denial, MOO relied on a peer review report by a single physician while completely dismissing or ignoring the opinions of the treating physicians. Other than the sole opinion of one doctor who has never before seen the claimanti in person or talked to any physician who has, MOO provides no other reasons for terminating long-term disability benefits. Moreover, MOO agreed that the claimant was unable to work from the date she became disabled until May 28, 2020, but MOO offered no explanation as to why it chose May 28, 2020 as the day she was no longer disabled as opposed to any other day.