Sedgwick Claims Management is notorious for abusing its discretion when determining whether a claimant qualifies for disability benefits. The most common ways in which Sedgwick abuses its discretion includes, the failure to consider treating doctors’ opinions, failure to consider a favorable determination by the Social Security Administration, failure to speak to treating doctors regarding the claimants’ disabling conditions, failure to have the claimant examined and relying solely on paper reviews of paid doctors. A court in the Northern District of California addressed some of these very issues resulting in a very favorable outcome for the Plaintiff.
The Plaintiff in James v. AT&T West Disability Benefits Program et. al, was seeking disability benefits under an ERISA plan administered by Sedgwick. The Court found that Sedgwick carved out the Plaintiff’s disability into discrete parts stating “because the evidence for any single ailment did not support a finding of disability, she was not disabled under the terms of the Plan”. Sedgwick failure to consider the Plaintiff’s overall disability as a whole and how the combination of mental and physical symptoms prevented her from working was an abuse of discretion.
The Court also held that Sedgwick abused its discretion when it failed to have its hired peer review physicians speak to the Plaintiffs treating doctors to discuss her disabling conditions. It was brought to the court’s attention that Sedgwick’s doctors placed calls to James’ treating physicians with instructions to return the call within 24 hours or a report would be submitted without their input. The court stated that most physicians have very busy schedules and allowing only 24 hours for a return call is unreasonable. James’ doctors were very familiar with her condition and would have been able to shed light on her multiple disabling issues. Sedgwick’s failure to provide a fair opportunity for these consultations to take place was arbitrary and capricious.
Sedgwick further failed to consider James’s subjection complaints of pain, requiring objective medical evidence that was impossible to provide, an abuse of discretion that occurs frequently with claimants suffering from conditions such as fibromyalgia. Finally, the Court slapped Sedgwick on the wrist yet again for failing to conduct an IME of a James, relying solely on a paper review, when its own policy allows for such an examination to take place.
This decision is a definite win for Plaintiff’s who have been denied disability benefits by Sedgwick as well as insurance companies that have denied their claims for similar reasons.