Nationwide Mutual Insurance Company (“Nationwide”) wrongly denied STD benefits in Columbus, Ohio when a treating doctor set work-from-home limitations. After suffering from a car accident, Ms. Hoffman was treated for right shoulder pain, which was later diagnosed as a tear in her rotator cuff tendons. She was also diagnosed with neurogenic thoracic outlet syndrome(“nTOS”), a type of neurological syndrome.
Prior to her accident, Ms. Hoffman had worked as a Claims Specialist in the Casualty and Bodily Injury Department. Nationwide initially agreed to pay Ms. Hoffman her short-term disability benefits, but then after two months of payments, denied any future benefits.
Nationwide based its denial on notes from her doctor requiring she work from home. Even though Ms. Hoffman never returned to work, Nationwide incorrectly treated Dr. D’Eramo’s language as a release to return to work.
Ms. Hoffman appealed her STD denial on two separate occasions. She supplemented her first appeal with additional evidence, including updated medical records, a physician statement from her treating doctor, and a letter from her other doctor explaining the subjective nature of her symptoms related to nTOS. Nonetheless, Nationwide denied her appeal.
In support of her second appeal, Ms. Hoffman submitted a vocational report indicating her physical limitations. She also submitted evidence indicating she was entitled to Social Security disability benefits dating back to the date of the car accident. Again, Nationwide denied her appeal.
The second denial was based on Nationwide’s own orthopedist’s review of Ms. Hoffman’s paper file. The reviewer commented that Ms. Hoffman’s file lacked objective evidence of disability. The reviewing orthopedist also admitted his report was limited to an orthopedic perspective and refused to comment on her neurological conditions.
In this case, the court found in Ms. Hoffman’s favor. The Ohio court held that Nationwide did not apply a “deliberate, principled reasoning process” as required by caselaw. The following factors weighed in Ms. Hoffman’s favor:
- Nationwide’s failure to consider her treating doctors work from home note “a functional limitation bearing on [her] status as STD disabled under the Plan”;
- Nationwide’s failure to consider her favorable Social Security disability determination and the vocational report indicating her reduced functional capacities;
- Nationwide’s failure to supplement its orthopedist’s report with things like an in-person examination or addressing her neurological condition
Nationwide found Ms. Hoffman disabled and entitled to benefits.
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