Receiving a letter informing you that Mutual of Omaha has denied your claim for long term disability benefits can be a major blow during an already stressful time. At Dell & Schaefer, our nationwide team of disability insurance attorneys has handled hundreds of Mutual of Omaha claims and can provide you with the depth of experience you’ll need to submit a strong appeal. Learn more about some of our tips to win an appeal of Mutual of Omaha’s denial of your claim for long term disability benefits.

GREG DELL: Hi, I’m Greg Dell with attorneys Dell and Schaefer, here with attorney Alex Palamara. And we are going to discuss Mutual of Omaha and some tips about how to file a successful long-term disability appeal. Now Mutual of Omaha also does some short-term, but whether it’s short-term or long-term, it’s pretty much the same type thing.

But the bulk of what we do is the long-term disability appeal, and you can take the tips that we’re going to suggest to help you with the short-term disability appeal. So, Alex, we’ve helped hundreds of people to submit their appeal, and I want to get into what do you think is the most important thing when submitting appeal in order to give yourself the best chance to get approved?

In Order to Submit a Successful Appeal The Mutual of Omaha Claim File Must Be Reviewed

ALEX PALAMARA: Well, first and foremost, you know why they’re denying your claim. And, of course they’re going to send you a denial letter that might be three to 10 pages long, that gives you kind of a description of why they’re denying your claim. But if you look at the denial letter, you’ll see that they’re relying upon either independent physician reviews. Maybe they sent you to an independent medical examination or maybe their own medical directors performed a review of the claim.

So the first thing you have to do once you get that denial letter, besides contact us, is to order a copy of the administrative record, the claim file, from Mutual of Omaha. Because the claim file is going to have all the records they’ve compiled on your case, all the records you’ve submitted, your doctor submitted, all the records they’ve drafted, made up on their own, all the reviews they’ve relied upon, the IME, results of the IME they’re relying upon. And you need to review those reviews in order to figure out why they’re denying your claim in order to poke holes in their reviews

GREG DELL: And the challenge with those, Alex, is that that can be from 200 pages to we’ve had them to be over 10,000 pages, depending upon how long a person’s been on claim. So you really have to go through that claim file with a fine-tooth comb to figure out what’s important and what’s not important. Because we find all kinds of stuff in there. And the idea is, we’re trying to show what did they miss and how did they act unreasonably.

ALEX PALAMARA: I mean, if you’re disabled and they’re denying your claim, they’ve missed something or they’re doing something improper. And we have to find it.

Medical Records are Essential: Mutual of Omaha Claims Are Only as Good as They Look on Paper

GREG DELL: So, Alex, it’s super important. You get that claim file, you break it out. Now you got to put a strategy in place for medical support. And that is a tremendous feat. Why is that so challenging, and yet, so important?

ALEX PALAMARA: Well, when you are filing an administrative appeal or filing a claim for disability insurance benefits, the most important thing you can possibly do is file proof. It’s your responsibility to prove your claim. The policy will call it, proof of loss. And as the claimant, it’s your responsibility to prove your claim. And you do it with proof, and proof is typically in the form of medical documentation.

So once you get the copy the claim file from the insurance company, next thing you need to do is get updated records from all of your treating providers. You need to go through those records with a fine-tooth comb, because you’ve got to figure out what the records say, what they’re not saying. Only you know what you’re feeling. Maybe your doctors are just willy nilly putting records together.

I think you have to also consider is that your records written by your doctors are not written to prove to an insurance company that you’re disabled. They’re written to treat you. So sometimes you have to ask your doctors to expand upon their records to prove to the insurance company that you actually are disabled. So you have to get a copy the claim, and then get a copy of your records. Figure out what the weaknesses are in your records, and you have to obviously fix those weaknesses.

GREG DELL: What’s your strategy when representing a claimant to get good medical support? What tools do you use?

ALEX PALAMARA: Well, you can reach out to the treating providers and ask them what can be done to further strengthen my client’s medical records, what can be done to fix certain things in the records. Is there any other testing that we can get done? Depending what the client’s suffering from, there’s other testing that you could use in certain scenarios to further prove or further give objective evidence of the claim.

GREG DELL: And do you guide the client to get that information? How do you how do you know what would be helpful based upon the facts and circumstances of your client’s claim?

ALEX PALAMARA: I mean, our experience. We’ve handled, whether it be a back condition, fibromyalgia, mental health disorder, we’ve pretty much handled it all. I can’t think of any medical condition that we’ve not handled. We’ve spoken to many different types of doctors, many specialists, to figure out what is the best way to prove our client’s claim.

GREG DELL: Once you’ve obtained the medical support and now you’re going to move on with the claim, the next element you have to prove is basically the occupational duties.

ALEX PALAMARA: Right.

GREG DELL: And how do you reconcile proving the occupational duties with the definition of disability in the policy?

Vocational Experts Document Occupational Duties and the Skills Required for the Job

ALEX PALAMARA: Well, as you’re well aware, the definition of disability under most disability insurance policies with Mutual of Omaha can be twofold. For the first time period, typically the first 24 months, in order to be considered disabled, you have to be unable to perform the duties of your own occupation. And then after two years or 24 months, the definition of disability changes. At that point you have to be unable to perform the duties of any occupation, which takes into account your training, education and experience.

Now, the insurance companies love to deny claims, especially at the any occupation stage, but they’ll deny your claim as well during the own occupation stage. And they’ll probably just go to the Dictionary of Occupational Titles and find an occupation that’s similar to your own occupation. And more often than not, your own occupation’s a little bit more, could be a little bit different, it’ll have different requirements. So just by them going to the Dictionary of Occupational Titles, that’s just a kind of a fallback they use to say, hey, you can do this sedentary job. We don’t find you disabled after we reviewed your medical records.

Sometimes we like to use the opinion of a vocational expert to actually review the requirements of your job and give their own opinion regarding the duties, the material essential duties of your occupations. So sometimes you actually have to reach out to a vocational expert to get their opinion. And we will utilize that report in our appeal.

GREG DELL: And why is it so important to write a very detailed and great appeal?

ALEX PALAMARA: The appeal is the most important thing you can possibly do for your claim. The appeal, it kind of satisfies two prongs. One, it gives you a chance of getting back on claim. So you want to do the best job you possibly can to prove to the insurance company that they should be paying your benefits. Because if not, if they deny your appeal, you’re going to be another six months, maybe a year before you get any recovery.

Now the reason why, especially under the ERISA laws, any policy is governed by the ERISA laws, the reason why you have to file a strong appeal, this is your last chance at strengthening your file for a potential lawsuit. What most people don’t realize, is that once the insurance company denies your appeal, the claim file is closed. So you cannot get any more documentation into your file.

So let’s just say they deny, you file a quick appeal. Say you guys are wrong, please take a look at these old medical documents, please review the medical documents and approve my claim. But you don’t send any other, maybe there’s a certain doctor you failed to send in their medical records and or you just assumed your doctor sent records, when actuality, Mutual of Omaha never actually received it. But once the denial letter comes, once they deny that quick appeal that you filed, the claim file is closed.

Then when you file your lawsuit, you can never submit any more documentation to prove your claim. The judge is restricted to review only the claim file as it was in front of the insurance company on the day that they issued the final denial letter. So if you get more documentation showing that you get hit by a bus and went to the ER to get treated, but you never submitted it with your appeal, too bad, so sad. That documentation will never be received by the judge.

GREG DELL: Now for someone who’s writing an appeal, is there a certain page length it has to be? Or what’s a traditional standard appeal that you submit? How long are they often/

ALEX PALAMARA: I mean, there’s no requirements, but I mean, we’re typically filing appeals that are anywhere from at the very minimum, a bare minimum case, at least 10 pages, upwards of 50 plus pages. We’re giving arguments, pages upon pages of arguments of where the insurance company messed up, what they overlooked, what the medical documentation says.

Then sometimes we summarize the medical documentation. So we put it right in the appeal, so they can’t ignore it. It’s in multiple written forms. It’s in our appeal arguments. It’s in our appeal medical record summary. And we’ve give them the medical records as well. So it’s three different areas where the insurance company cannot overlook the strength of our file.

What is the “Chinese Wall” in the Mutual of Omaha Appeal Process?

GREG DELL: Can you touch on this quasi Chinese wall that goes on from the denial to the appeal in terms of what that means and why that kind of, I think, gives someone a better chance to win an appeal as opposed to going back to the same person?

ALEX PALAMARA: I believe what you’re referring to, is the fact that the person that works at the insurance company at Mutual of Omaha that has denied your claim, they should have no responsibilities, no ability to see your appeal. They should be separate and apart of your appeal. The person who made the original decision to deny your claim should have no influence and no effect, and not be involved one iota with the review and the decision on your appeal.

We hope that to be true. We have no reason to think that it’s not true. We have no reason to, or no way to check to see if it’s actually true or not. I mean, I have seen denial letters with the same person’s name on them before, and it’s kind of like a, we got you moment, you know? But for the.

GREG DELL: Yeah. Because that’s a no-brainer violation. You’re going to win that appeal, just for them failing to comply with the ERISA regulations.

ALEX PALAMARA: Correct. So, but the ERISA regulations require that they have basically a different set of eyes, a different person at the insurance company in charge of the appeal, and different people rendering the ultimate decision on the appeal.

GREG DELL: What about the initial doctor or nurse who reviewed the claim? Can they look at it again on the second level?

ALEX PALAMARA: They can. I have seen that on a regular basis actually. Where they go back to the same doctor, which just blows my mind that they’ll do that. They typically don’t do that, but in certain scenarios, they will.

GREG DELL: From a first appeal?

ALEX PALAMARA: I have seen that before. Most insurance companies are smart enough not to do that.

GREG DELL: Is that legal if they do that?

ALEX PALAMARA: You know, it’s questionable. I mean, I would think common sense would dictate that you would not do that. You want another set of eyes, just so you have more support for your claims. Instead of one doctor saying no in the beginning and no on the appeal, you have multiple doctors saying no to strengthen their decision to deny your claim.

GREG DELL: Right. I know many times we’ve argued, and there’s case law to support the position that they can’t go back to the same treating physician, or really anybody who was involved with the claim. And we can kind of see in their internal notes if they’re being candid about what they’re doing, as to who touched the claim. But literally, the person who denied the claim is supposed to take it, send it to the appeal division, and never look at it again, unless it gets reversed. Which we win the appeals all the time, and then it goes back to the initial person, which is a little awkward, because they were proved wrong.

But I don’t think they harbor any bad, ill, or feelings towards the claimant, because you know that these claim people, especially at Mutual of Omaha, they just rubber stamp what their nurse consultant or medical doctor tells them. And they go, well, we don’t find any restrictions or limitations. But the claimants don’t, the claim person at Mutual of Omaha doesn’t establish restrictions and limitations. They just gather information. They often choose to ignore the treating doctors and go with the company doctors.

ALEX PALAMARA: For sure.

GREG DELL: So if you have a Mutual of Omaha claim, what we suggest you do, is get us a copy of the denial letter, whether it’s Alex, myself or any of our disability lawyers, we’re going to immediately provide you with a free consultation to review the denial letter, review a copy of your policy, if you send it to us, so that we can tell you if we think that you have a chance to win the appeal, and how we would go about helping you.

All of our clients are located all over the country. We make the process very simple for you. where everything’s handled telephonically. You’re not going to have to go to court or do anything like that. So it’s going to be a very smooth process for you. We never charge any fees or costs, unless we make a recovery for you. So from that standpoint also, we understand the tremendous financial burden that you’re under, considering the fact you’re not getting any benefits now.

So feel free to give us a call. We encourage you to watch our videos. We have so many on our website about Mutual of Omaha, about the disability claim process. If you subscribe to our channel below, you’ll be able to get the regular updated videos, as we produce these videos on a weekly basis to provide you with helpful claim information. We appreciate you considering our law firm and we hope that we can help you with your Mutual of Omaha claim.

The disability appeal process can be crucial to your ability to recover long term disability benefits from Mutual of Omaha later, so it’s important to partner with an experienced legal team while you’re pursuing an appeal. By creating a strong administrative record that supports your long term disability claim, not only will you improve your odds of prevailing on appeal, but you’ll also be more likely to negotiate a mutually-beneficial settlement of your disability policy. Get in touch with Dell & Schaefer today to set up your FREE consultation with a member of our long term disability insurance attorneys.