District Court Affirms ERISA Insurer’s Denial of Short-Term and Long-Term Disability Benefits Due to Lack of Supporting Documentation

In Gray v. United of Omaha Life Insurance Company, No. 223CV00630MCSPLA, 2024 WL 324899 (C.D. Cal. Jan. 29, 2024), California Central District Judge Mark C. Scarsi awarded judgment for United of Omaha on Plaintiff’s ERISA Complaint seeking recovery of short-term and long-term disability benefits, finding that Plaintiff failed to satisfy her burden of proving disability.

Plaintiff was a participant in an ERISA-governed long-term disability (“LTD”) plan insured and administered by United of Omaha. Plaintiff submitted a claim for short-term disability (“STD”) benefits claiming to be disabled from her occupation as a supervisor and mental health therapist as of August 9, 2021, due to “back pains, sharp pains in arms/hands.” An Attending Physician Statement (“APS”) listed a diagnosis of lumbar radiculopathy with symptoms of “severe pain & spasms.” However, the doctor did not order diagnostic testing. United of Omaha approved STD benefits through September 12, 2021, but advised that for benefits to continue, Plaintiff would need to submit the results of diagnostic testing. Plaintiff submitted additional progress notes from her physicians, which indicated a positive “ortho exam” but no testing. United of Omaha then submitted the file for an orthopedic peer review. The reviewing physician disagreed with Plaintiff’s treating providers, and noted no diagnostic imaging studies to document any pathology of the lumbar spine that would support impairment. Based on the conclusion of the peer reviewer, United of Omaha terminated STD benefits.

Plaintiff retained counsel who appealed the STD termination and also initiated Plaintiff’s claim for LTD benefits. During a phone interview with United of Omaha, Plaintiff reported that she had not seen her certifying physician since August 2021, was seeing only her primary care provider every two months and was taking over-the-counter Motrin 3-4 times per week for her pain. She claimed that her primary disabling condition was back pain, and that she could not work because sitting 10–12 hours per day and typing on the computer hurt. Plaintiff said she had to change her position often, lie down, and take several breaks. However, Plaintiff reported she was able to do housework, care for her child, drive, and independently complete her activities of daily living. Plaintiff further advised that her primary care physician stated she could return to work in June of 2022, but that she had doubts about returning to her job due to COVID-19.

United of Omaha referred her file for review by a clinical nurse consultant, who found an overall paucity of documentation to suggest any functional impairment. In response, Plaintiff submitted a letter from her treating provider concluding that she was unable to work, but again offering no testing or objective evidence of lumbar radiculopathy. United of Omaha upheld the STD termination by letter dated June 10, 2022.

On the LTD claim, United of Omaha referred the file for review by another clinical nurse consultant, who similarly concluded the medical documentation did not support Plaintiff’s claimed diagnosis of lumbar radiculopathy and there were no functional impairments identified. On July 26, 2022, United of Omaha denied the LTD claim. On subsequent appeal, United of Omaha obtained an orthopedic peer review, which again concluded there was no evidence of radiculopathy, no physical exam findings or testing, and no correlating functional impairment. United of Omaha upheld the LTD denial on appeal and the instant action ensued.

On de novo review, the Court concurred with United of Omaha’s decision to deny STD and LTD benefits based on the lack of medical documentation supporting a finding of disability. The Court stated that in briefing, Plaintiff offered only one sentence of argument toward her burden to prove she is disabled: “Every doctor that saw Plaintiff concluded that Plaintiff could not return to work.” The Court found, however, that the treating provider opinions were not entitled to significant weight, noting: (1) the treatment history was sparse; (2) neither doctor appeared to have a specialty relevant to the diagnosis of lumbar radiculopathy, such as an orthopedic specialization; (3) the detail contained in the physicians’ notes and records was thin, and the doctors failed to connect their findings to their opinions on Plaintiff’s functional limitations; and (5) virtually all the information provided in the doctors’ notes that supports the claimed disability rests on subjective reports by Plaintiff, and the opinions are too sparse and too dependent on subjective reporting to be accorded much significance.

The Court found significantly more persuasive the opinions of the independent reviewing physicians and nurses, particularly those of the two orthopedic surgeons. Based on its review of the administrative record, the Court found that Plaintiff had not proven by a preponderance of the evidence that she was disabled within the meaning of the Plans after September 12, 2021.

If United of Omaha or your insurance company has denied or terminated your disability claim, contact us for assistance.