Ms. Williams suffered from fibromyalgia and rheumatoid arthritis. She had been found disabled and placed on claim for several years. However, after the employer decided to switch long term disability carriers, United of Omaha decided to terminate Ms. Williams’ claim. It did so principally using its own in house medical director, Dr. Thomas Reeder.
Of course, with fibromyalgia, the only objective evidence that can be ascertained generally is the tender point test as defined by the American College of Rheumatology. Ms. Williams had been diagnosed with treating physician’s examining her and noting the criteria necessary to meet this test. All of the treating doctors agreed that there is objective support for fibromyalgia except for United of Omaha’s in house doctor, Dr. Reeder. An independent medical evaluation in 2007 (with a doctor selected by United of Omaha) in fact confirmed that Ms. Williams had fibromyalgia with severe pain. All of the evidence until 2011 was sufficient to pay benefits for this claim.
However, in 2011, United of Omaha reversed course and decided to terminate the claim ignoring all prior evidence. The court noted the consistency of the medical records for the Plaintiff and the opinions of the various doctors and in fact that all of the doctors as well as the Social Security Administration had confirmed the Plaintiff was disabled. United of Omaha in fact found that the Plaintiff was disabled for several years before reversing its position after it no longer had the employer’s business. There was no change or improvement in the Plaintiff’s condition sufficient to where she could return to work and so this was very puzzling to the court. In the end, Judge Bowdre noted “United of Omaha’s actions do not pass the smell test”.
This case underscores the importance of having experienced ERISA counsel handle your claim. It is important clearly articulate all restrictions and limitations. It is vital to point out problems with the insurance company’s position and present all evidence necessary to show that the insurance company’s position is wrong and unreasonable. This must all be done before suit is filed and so an aggressive approach is required as occurred here. To wait and hire an attorney when it is time to file a lawsuit, is usually too late. Sometimes something can be done, but more times than not, the claim has not been completely presented. It will then be much more difficult to show that the insurance company did not pass the smell test.