Employees in Chicago whose long-term disability benefits are administered by Sedgwick frequently get frustrated when Sedgwick denies their claim. Most often, Sedgwick hired doctors to review your medical file, and they disagree with your doctors. Your doctors say you are disabled, but Sedgwick’s doctors say you are not. Here are important considerations and steps to succeed in your claim.
Because Sedgwick is not an insurance company, but a third-party claim manager, it acts as a fiduciary for large employers’ self-funded long-term disability plans. These plans always contain discretionary clauses, and they are not subject to state insurance laws banning discretionary clauses. That means when you sue under ERISA § 502(a), a court reviews the denial, the denial must be arbitrary and capricious for you to win. If there is mere disagreement among Sedgwick’s doctors and your doctors, Sedgwick will often meet that minimum threshold to win.
Most claimants’ strategy in challenging a long-term disability denial is to just get opinions from their doctors. Unfortunately, this is the same strategy used by most disability lawyers, especially those handling high volumes of cases nationwide. But under an abuse of discretion standard, this rarely works to secure a judgment, and merely creates an opportunity to settle for a small fraction of what you are owed, at best. Such was the case in Alves v. Hewlett Packard Enterprises Comprehensive Welfare Benefits Plan, No.16-9136, 2021 WL 1788398 (C.D. Cal. May 4, 2021). There, Alves’ doctors opined he was disabled, and Sedgwick’s doctors came to different conclusions. That was sufficient to rule in Sedgwick’s favor, even if Sedgwick’s doctors’ opinions were not as convincing.
If you have important symptoms, demonstrate exactly how they impact your ability to work. Otherwise, you cannot credibly argue Sedgwick failed to consider the evidence. This also happened in Alves’ case. Alves submitted evidence of edema in his legs. He argued Sedgwick failed to consider it, but the judge disagreed because Sedgwick’s doctors stated they considered all the records. What Alves could have done better was specify how much of the day his legs needed to be elevated due to the edema and at what degree angle elevation. From that a vocational expert could explain that one cannot perform sedentary work with such a limitation.
If Sedgwick denied your long-term disability claim, call an experienced ERISA long-term disability attorney.