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.
Continue Reading Plaintiff Awarded Benefits when Sedgwick Abuses its Discretion

As disability insurance attorneys that help disability claimants nationwide it is frustrating when we see a repetitive trend of denial tactics by the same company. We are contacted multiple times every day from people denied benefits by Sedgwick Claims Management. Here is a recent denial of disability benefits story we received from a claimant that was denied by Sedgwick:

Continue Reading A Common Sedgwick Short Term Disability Denial Story

A Puerto Rico court rules in favor of the claimant and finds that denial of her STD benefits made her ineligible for LTD benefits, thereby exhausting her administrative remedies for LTD benefits. Continue Reading Sedgwick and Walgreens Deny STD benefits, But Puerto Rico Court Rules That Pharmacist Can Seek LTD Benefits without Exhausting ERISA Appeal

Quite often, insurance companies create a maze of entities that could confuse the most cautious policy holders. One entity may own the fund. Another entity may administer the fund. So who should a plaintiff sue when these corporate entities conspire to break a promise to pay disability benefits? Fortunately, skilled disability lawyers know these insurance company tricks and can figure out who is ultimately responsible for a wrongful denial of disability benefits. Sometimes, it depends on bringing the right claim against the right party.

The case of Franklin v. AT&T Corporation is a prime example. The plaintiff worked at AT&T as a systems analyst for eleven years. She had long-term disability benefits under the AT&T Long Term Disability Plan for Management Employees ("the Plan") that were administered by Metropolitan Life Insurance Company ("MetLife’). Sedgwick Claims Management currently handles all AT&T disability claims. In 1999, the plaintiff filed for and received the long-term disability benefits arising from a number of causes including Crohn’s disease, breast cancer, chemotherapy, chills, night sweats, nausea and depression.

Three years later, MetLife reevaluated the plaintiff’s eligibility for long-term disability benefits. MetLife had demanded that the plaintiff apply for Social Security disability insurance benefits and, when she obtained them, reimburse the Plan for all the social security benefits she received when the Social Security Administration agreed she had been totally disabled since 1999. Soon after cashing the check, MetLife determined that the plaintiff was not in fact totally disabled and stated she could return to full-time work in other occupations. This conclusion led MetLife to deny the plaintiff’s claim for continued long-term disability benefits.

The plaintiff sued, arguing that her long-term disability benefits were wrongfully denied by MetLife and the Plan. Both defendants filed a number of motions. MetLife challenged the plaintiff’s ability to hold the insurance company accountable for its role in denying coverage because AT&T had fired MetLife as the plan administrator more than a year and a half before the plaintiff filed suit. The Plan claimed that the denial was within its discretionary authority.

The Court Awards Disability Benefits for What MetLife Did

A federal court in Dallas ruled that the plaintiff was entitled to long-term disability benefits and that MetLife was entitled to be dismissed from the lawsuit as it was merely the administrator. The plaintiff could only recover the disability benefits from the Plan because it had not brought a claim against MetLife for breach of the duty of good faith and fair dealing, which requires Texas insurance companies to treat policy holders in a certain manner. Nonetheless, MetLife’s actions were the central focus of why the court held the Plan responsible. The court specifically noted:

  • MetLife had distorted the opinions of treating physicians when it characterized the plaintiff as able to return to full-time work;
  • MetLife had not given adequate consideration to the determination for Social Security purposes that the plaintiff was totally disabled; and
  • Though relying on the availability of leave under the Federal Medical Leave Act to claim that the plaintiff could be absent from work to accommodate her illness, MetLife failed to recognize that, as a new employee, the plaintiff was not eligible for leave under the FMLA for twelve months.

While MetLife wasn’t financially responsible to the plaintiff in this case, other companies may think twice before employing MetLife as a plan administrator in the future. The federal court held that MetLife had "cherry-picked" facts in the administrative file to support its position and, for this reason, MetLife had acted in an arbitrary and capricious manner. These wrongful actions persuaded the federal court to order the Plan to reinstate the plaintiff’s long-term disability benefits. Ironically, the plaintiff could have prevailed against MetLife as well (above and beyond the disability benefits recovered against the plan) had the plaintiff’s lawyer brought a claim for breach of the duty of good faith and fair dealing.

Franklin v. AT&T Corp., No.03:08-CV-1031-M, 2010 WL 669762 (N.D. Tex. Feb. 24, 2010) 

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FAQ: Appeals & Lawsuits:
If my long term disability benefits are governed by ERISA and I win at trial, does the insurance company have to pay me for the remainder of the policy life, or a lump sum amount?

Should your case go to trial under an ERISA governed disability plan and you win the insured is only entitled to an award of disability benefits that have not been paid by the insurance company. This is further contingent on whether the insurance company denied your claim under the “own occupation” or “any occupation” definition of disability…

The Plaintiff, Christopher L., with the help of his Texas Disability Attorney, has filed this lawsuit against Sedgwick Claims Management Services , Inc. (Sedgwick), Administrator of the Hewlett-Packard (HP) Company Disability Plan.

In Christopher L. v. Sedgwick Claims Management Services, Inc., Plaintiff has filed this lawsuit to regain all short-term and long-term disability payments that were wrongfully terminated.

Plaintiff’s Rights of Disability Benefits Under The Plan

Plaintiff is a 44 year old man who is a citizen and resident of Tomball, Texas. Sedgwick was responsible for funding and administering the Plan, which Plaintiff was entitled to the benefits of based on his employment with HP as a Project Manager.

Plaintiff was forced to cease work on April 25, 2008 due to bipolar disorder, schizophrenia, chronic fatigue, diabetic neuropathy, memory loss, sleep issues, fibromyalgia, depression, vision problems, high blood pressure, and sunlight sensitivity.

Plaintiff filed applications for short term and long term disability benefits. Plaintiff’s claim for short term disability benefits were granted by Sedgwick. Plaintiff later filed for long term disability benefits, which were initially granted by Sedgwick on December 1, 2008.

Sedgwick Changes Decision And Denies Future Long Term Disability Benefits

On August 20, 2010, Sedgwick denied further long term disability benefits to the Plaintiff. Plaintiff had 180 days to appeal this decision. The disability standard to apply in order to approve or deny a claim was being unable to perform "Any Occupation." If the application was approved, the Plan would pay a monthly benefit of $4,351.72.

Plaintiff requested an administrative review of the denial of benefits on December 6, 2010. Plaintiff included medical records to show his total disability, and thus, his argument for being approved for further long term disability benefits. In addition, the Social Security Administration issued a fully favorable decision on Plaintiff’s claim for disability benefits under Title II and Title XVI of the Social Security Act.

Despite this, Sedgwick upheld its original denial on March 17, 2011. Sedgwick also informed Plaintiff that he had exhausted all administrative remedies. Due to this, Plaintiff has filed this lawsuit against Sedgwick.

Lawsuit Filed Against Sedgwick

Plaintiff filed a lawsuit against Sedgwick because Sedgwick discounted the opinions of Plaintiff’s treating physicians, of others, and of the documented limitations that the Plaintiff suffers from due to his medical conditions, thereby preventing him from fulfilling the duties of any occupation and entitling him to the long term disability benefits as detailed under the Plan.

Plaintiff claims that Sedgwick failed to give proper weight to the evidence submitted to them regarding Plaintiff’s condition and his inability to work. Plaintiff also claims that Sedgwick did not properly define disability as outlined in the terms of the Plan, calling it "unreasonable, arbitrary, and capricious." Plaintiff claims that Sedgwick failed to fulfill its contractual obligations to provide disability benefits to the Plaintiff.

The Relief Sought

Plaintiff wants a judgment against Sedgwick for the following:

  • All short term and long term disability benefits that have not been paid as of yet
  • All future short term and long term disability benefits according to the terms of the Plan for so long as the Plaintiff meets the terms of the Plan
  • All reasonable attorney fees and expenses due to the filing of this lawsuit
  • All other relief that the Court deems just and proper 

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. To request a free legal consultation call 800-411-9085.

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UnitedHealth Group, Inc. Recruiting Manager suffering from depression and anxiety denied benefits

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