Riemer Hess has a proven track record of successfully assisting many clients in securing their disability benefits from Sedgwick. As a major administrator of disability benefits, Sedgwick assesses – and denies – a high volume of disability claims each year. Our experience with Sedgwick’s practices gives us a deep understanding of the necessary strategies to increase your chances of claim approval.
Below we’ll discuss some of the justifications Sedgwick uses to deny long term disability claims and how you can avoid common mistakes when filing or appealing your claim.
Does Sedgwick administer many Long Term Disability claims?
Sedgwick is recognized as one of the leading providers in LTD claim administration. Their size and scope in the industry mean they handle a significant volume of claims. It’s important to note that Sedgwick is not an insurance company itself but acts as a third-party administrator for Long Term Disability (“LTD”) claims. This means they manage and process claims on behalf of the employers or insurance companies that actually underwrite the policies.
As a private company, Sedgwick operates with its own business interests in mind. This can sometimes lead to conflicts of interest when processing LTD claims, as their primary obligation may be to the companies and public entities they serve rather than the individual claimants. Their decisions on claims can be influenced by a focus on cost management and efficiency for their clients (employers and insurers).
What common tactics does Sedgwick use to deny disability claims?
Sedgwick, as a third-party administrator handling Long Term Disability (“LTD”) claims, may employ various tactics that can result in the denial of disability claims. Understanding these tactics is crucial for you to prepare and respond effectively.
Here are some common methods that might be used:
- Demanding objective medical evidence for conditions lacking objective tests: Sedgwick may request objective medical evidence for conditions like migraines, fibromyalgia, or Chronic Fatigue Syndrome (“CFS”), where objective testing is not typically available or conclusive. This demand places claimants in a difficult position, as they cannot provide the type of evidence requested. It can lead to unjust denials based on the lack of objective evidence, despite the legitimacy of the condition.
- Alleging insufficient evidence despite substantial medical support: Sedgwick may assert that there is a lack of evidence or insufficient medical support, even when you have provided extensive medical documentation. This approach can be frustrating and confusing if you have already submitted substantial medical evidence. It can lead to claim denials on seemingly unfounded grounds.
- Contacting your doctors for information without warning: Sedgwick representatives might call your treating physicians to gather information. These calls often catch doctors off guard, potentially leading to incomplete or miscommunicated information about your condition. If a physician is unprepared for such a call, they might inadvertently provide information that doesn’t fully represent your medical situation, leading to claim denial.
- Failing to consider all of the substantial and material duties of your occupation: Sedgwick may assess your ability to work based on a partial or inaccurate understanding of your job responsibilities. They may overlook or undervalue certain substantial and material duties that are critical to your occupation. This incomplete assessment may lead to the erroneous conclusion that you can perform your job, despite your disability, resulting in claim denial.
- Characterizing a physical disability as a mental health disability to take advantage of coverage limitations: In some cases, Sedgwick might classify a physical disability claim as a mental health issue. This can be a strategy to exploit common policy limitations that restrict the duration of benefits for mental health disabilities. By reclassifying your physical disability as mental health-related, Sedgwick may limit the duration of your benefits.
Have courts criticized Sedgwick’s claims-handling practices?
Yes. Courts have leveled criticism at Sedgwick for improper administration of their short and long term disability claims, such as in the following cases:
- Connor v. Sedgwick Claims Management Services, Inc., 796 F.Supp.2d 568, (D N.J., June 24, 2011): In this case, Connor sued Sedgwick for wrongful denial of her long term disability benefits. Connor prevailed, with the court holding that Sedgwick’s decision to deny her benefits was arbitrary and capricious. The court’s criticisms of Sedgwick in handling Connor’s long term disability claim under ERISA highlighted several key issues:
- Failure to Satisfy ERISA’s Notice Requirement: Sedgwick’s denial letter did not meet the requirements set by ERISA for providing clear and adequate notice to the claimant, detailing the specific reasons for denial in a manner understandable to the claimant.
- Inconsistent Treatment of Medical Evidence: The court noted Sedgwick’s inconsistent handling of the same or similar medical evidence over time, initially approving the claim and later denying it without new medical information to justify the change.
- Improper Demand for Objective Medical Evidence: Sedgwick was criticized for demanding objective medical evidence for conditions like Connor’s, where such evidence might not be typically available or conclusive, placing the claimant in an untenable position.
- Ignoring Non-Exertional Demands of Occupation: The decision failed to consider the non-exertional aspects of Connor’s occupation, such as cognitive and mental requirements, which are crucial for a comprehensive evaluation of disability.
- Mischaracterization of Disability: Sedgwick attempted to categorize Connor’s physical disability as a mental health issue, potentially to leverage policy limitations on mental health coverage, without proper justification.
- Failure to Consider All Substantial and Material Duties: The court found that Sedgwick did not adequately consider all the substantial and material duties of Connor’s occupation in its evaluation, focusing too narrowly on certain aspects.
- Lack of New Medical Evidence for Decision Reversal: Sedgwick reversed its initial decision to award benefits to Connor without the introduction of new medical evidence, which the court found problematic.
- Gallupe v Sedgwick Claims Mgt. Services Inc., 358 F Supp 3d 1183 (WD Wash, Feb. 14, 2019): In this case, the court critically addressed the denial of short term disability benefits to Gallupe by Sedgwick. The court’s ruling focused on several procedural and substantive errors made by Sedgwick in handling Gallupe’s disability claim, leading to a summary judgment in favor of Gallupe. Their criticisms of Sedgwick included:
- Abuse of Discretion in Rejecting Treating Physicians’ Opinions: Sedgwick was criticized for its rejection of the opinions of Gallupe’s treating physicians regarding her disability, which the court deemed an abuse of discretion. This indicates that Sedgwick did not adequately consider the medical evidence presented by healthcare professionals who were directly involved in Gallupe’s care.
- Conclusion of Lack of Objective Evidence: The court found that Sedgwick’s conclusion that there was a lack of objective evidence to support Gallupe’s disability constituted an abuse of discretion. This criticism points to Sedgwick’s failure to appreciate the nature of mental health conditions, which may not always produce the type of objective evidence Sedgwick demanded for physical conditions.
- Decision Not to Physically Examine the Claimant: Sedgwick’s decision not to have a physician examine Gallupe in-person before denying her claim was criticized as an abuse of discretion. This reflected a significant oversight in the claims evaluation process, suggesting a lack of thoroughness in assessing the claimant’s condition.
- Failure to Consider the Claimant’s Job Description: The court found that Sedgwick’s failure to meaningfully consider the requirements and duties of Gallupe’s job before denying her claim constituted an abuse of discretion. This indicates that Sedgwick did not properly assess whether Gallupe could perform her job functions given her disability.
- Procedural Errors: The court noted procedural errors in how Sedgwick handled Gallupe’s motion for judgment on the administrative record, treating it improperly and thereby failing to resolve the dispute through the appropriate legal mechanisms.
- Holzmeyer v Walgreen Income Protection Plan for Pharmacists and Registered Nurses, 44 F Supp 3d 821 (SD Ind Sept. 4, 2014): In this case, the plaintiff Holzmeyer sued the defendant under the Employee Retirement Income Security Act (“ERISA”) for the wrongful termination of his long term disability benefits. Holzmeyer contended that Sedgwick, the plan’s claims administrator, improperly terminated his benefits. The District Court found in favor of Holzmeyer, granting his motion for summary judgment and criticizing Sedgwick on many fronts, including:
- Violating ERISA’s Reasonableness Mandate: Sedgwick was found to have violated the ERISA mandate for procedural and substantive reasonableness by terminating Holzmeyer’s long term disability (“LTD”) benefits based on the record review opinions of retained physicians. These opinions either ignored or misconstrued Functional Capacity Evaluations proffered by Holzmeyer’s treating physicians, failing to address inconsistencies.
- Failure to Articulate Job Description Interaction: The court found it procedurally unreasonable that Sedgwick did not articulate how its own assessment of Holzmeyer’s work capabilities interacted with his job description. This indicates Sedgwick did not consider whether Holzmeyer could actually perform his specific job duties given his disability.
- Ignoring Social Security Administration’s Finding: Sedgwick’s denial of Holzmeyer’s appeals without mentioning that the Social Security Administration (“SSA”) had found him permanently disabled under a more stringent standard was deemed procedurally unreasonable. This oversight suggests a disregard for relevant, external determinations of disability that could impact the assessment of Holzmeyer’s claim.
What strategies work best against Sedgwick?
When filing, appealing, or litigating a claim with Sedgwick, there are a number of ways you can help circumvent Sedgwick’s common denial tactics. Some of these strategic approaches include:
- Obtain detailed medical documentation: Given Sedgwick’s demand for objective medical evidence and their history of ignoring or misinterpreting medical evidence, you should ensure that your medical documentation is comprehensive, detailed, and clearly supports your disability claim. It’s important to include both objective and subjective evidence of disability, especially for conditions where objective evidence may be limited.
- Seek consistent treatment from your healthcare providers: Since inconsistency in treatment or documentation can lead to denial, maintaining consistent medical treatment and ensuring all medical records are up to date and thoroughly document your condition and limitations can be crucial.
- Provide comprehensive evidence of your job duties: Sedgwick’s failure to consider the non-exertional demands of an occupation or to accurately assess a claimant’s ability to perform their specific job functions highlights the importance of clearly defining and providing detailed descriptions of your job duties and requirements. This can help in establishing the impact of the disability on your ability to perform your occupation.
- Include your Social Security Disability (“SSD”) determination: If you have been determined to be disabled by the Social Security Administration (“SSA”), including this determination and any related documentation with your claim can be beneficial, given Sedgwick’s criticized practice of ignoring SSA findings. While not binding, SSA determinations can provide substantial support for your claim.
- Undergo a comprehensive Functional Capacity Evaluation (“FCE”): If you experience disabling physical symptoms, it can be very helpful to undergo an FCE. Since Sedgwick has been criticized for ignoring or misconstruing FCEs, obtaining a comprehensive FCE that clearly outlines your physical limitations concerning your specific job functions can be critical.
- Consult with an ERISA attorney: Considering the complexities involved in filing a claim and the potential for procedural and substantive errors by Sedgwick, seeking legal representation familiar with ERISA claims and Sedgwick’s practices can be advantageous. A knowledgeable attorney can help navigate the claims process, ensure compliance with all requirements, and advocate on your behalf.
By implementing these strategies, you can strengthen your disability claim, address potential areas of contention, and improve your chances of securing the benefits you are entitled to under your LTD policy managed by Sedgwick.
How can Riemer Hess help with my Sedgwick long term disability claim?
If you are facing a long term disability claim with Sedgwick, Riemer Hess can help. Our firm has helped many clients secure their LTD benefits with Sedgwick, despite Sedgwick’s attempts to deny or terminate their claims. We understand how to navigate the complex and often frustrating claims and appeals process with Sedgwick, and we have the experience and resources to challenge their decisions and present strong evidence in support of your claim.
Riemer Hess: Client Case Study
Here’s one example of how we’ve helped a client against Sedgwick’s tactics:
Victoria, an executive professional with a successful career in a high-pressure corporate environment, faced a challenging situation when she developed a severe chronic pain condition related to her spine. This physical disability severely limited her ability to perform her job, which required not only physical presence but also intense cognitive effort and decision-making skills. When Victoria filed for Long Term Disability (“LTD”) benefits through her employer’s insurance policy, administered by Sedgwick, she expected her physical condition to be adequately recognized. However, Sedgwick only approved her benefits by attributing her symptoms to mental health issues rather than her physical spinal condition. This would severely limit the duration of her benefits.
In response to this decision, Victoria sought the assistance of Riemer Hess with her appeal. Riemer Hess quickly identified the misclassification of Victoria’s disability and embarked on a strategic plan to appeal Sedgwick’s decision. The firm’s first step was to reinforce the medical evidence of Victoria’s physical condition. Riemer Hess gathered a comprehensive set of medical records, including detailed notes from her physicians and results from diagnostic tests, which all underscored the physical nature of her disability. Additionally, Riemer Hess referred Victoria to undergo a Functional Capacity Evaluation. The FCE results affirmed the incapacitating nature of Victoria’s condition and its physical basis.
Alongside medical reinforcement, Riemer Hess coordinated with Victoria’s employer to obtain a detailed description of Victoria’s job responsibilities. Riemer Hess also referred Victoria to a vocational expert, who provided an analysis demonstrating how her physical disability directly impeded her ability to perform specific functions of her executive role.
One of the key challenges in Victoria’s case was Sedgwick’s characterization of her disability as mental health-related. Riemer Hess prepared a strong rebuttal to this claim. They included evidence from the mental health professional who had treated Victoria, clearly differentiating her physical symptoms from any mental health issues. Furthermore, Riemer Hess crafted a compelling legal argument to submit with this new evidence, highlighting Victoria’s eligibility for benefits under the Sedgwick policy.
The appeal submitted by Riemer Hess was thorough and persuasive. Confronted with the robust evidence and legal arguments, Sedgwick ultimately reversed their initial decision, acknowledging the physical nature of her disability and approving her for LTD benefits due to her spinal condition. Victoria, grateful for Riemer Hess’s assistance, retained the firm to monitor her ongoing claim.