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Sedgwick Reinstates Long Term Disability Claim Following Appeal

Attorney Stephen JessupAuthor: Attorney Stephen Jessup

Like many disability claimants, our client’s experience in dealing with Sedgwick was less than a pleasurable experience. After finding himself unable to continue to perform the very physically demanding duties of his occupation as a Traveling Field Engineer for Avaya due to Chronic Pain stemming from multiple lumbar and thoracic spine conditions he filed a claim for short and long term disability benefits under his employer’s plan, which was administered by Sedgwick CMS.

The Initial Denial of Benefits

In reviewing his initial application for benefits Sedgwick had our client undergo an Independent Medical Examination. Despite a plethora of objective medical evidence, such as MRIs and physical examinations noting restriction and limitations, Sedgwick’s doctor indicated that there were no “objective medical exam findings” to support his inability to perform the duties of his job. In light of Sedgwick’s IME doctor’s opinion, Sedgwick denied our clients short and long term disability claims. Upon receipt of the denial letter he contacted Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup.

The First Appeal

Attorney Jessup requested a complete copy of our client’s claim file from Sedgwick to assess the level of review conducted by Sedgwick and to determine what information would be needed to strengthen our client’s claim on appeal. The largest glaring inadequacy noted in Sedgwick’s review came in its evaluation of our client’s occupational duties. The only reference to our client’s job description was a four line blurb that gave a generalized overview of his duties as a field engineer. As his policies defined his “own occupation” to mean how it is performed in the national economy, Attorney Jessup turned to various governmental occupational information resources to gather additional information with respect to the physical demands of our client’s occupation. Admittedly, many occupations fall within “sedentary” and “light” demand level, but according to the Department of Labor our client’s occupation was in the Very Heavy demand level. Sedgwick turned a blind eye to this and instead reviewed his claim as if it only entailed his ability to do desk work.

Attorney Jessup then arranged for our client to undergo a Functional Capacity Examination to verify his inability to perform “Very Heavy” work and to further eradicate Sedgwick’s position that there was a lack of objective evidence to support an inability to perform his occupational duties. The results of the testing clearly documented our client was not able to return to his occupation as a Field Engineer. Following receipt of this report our client’s administrative appeal was finalized with additional Attending Physician’s Statements and updated diagnostic testing and then submitted to Sedgwick.

Approximately two months after the appeal was submitted, Attorney Jessup was advised by Sedgwick that it was overturning the denial of our client’s claim for short term disability benefits. Although this was certainly positive news Attorney Jessup quickly focused his attention to the status of the long term disability claim, which had been appealed at the same time as the short term disability claim. Two weeks after notice that the short term disability claim had been approved, Sedgwick sent a letter indicating that our client’s long term disability claim had been denied.

The Appeal for Long Term Disability Benefits

In denying the long term disability claim it became clear that Sedgwick’s sole focus was to discourage our client from pursuing his rights under this employer’s policy. However, he and Attorney Jessup were not deterred and prepared an appeal of the long term disability denial. Attorney Jessup argued that the same information used by Sedgwick to approve our client’s claim for short term disability was the same information now being used to deny benefits for long term disability benefits despite the information being contemporaneous to the period of long term disability. The lack of logic in Sedgwick’s denial was appalling, and Attorney Jessup set out to systematically address each and every contradiction in Sedgwick’s denial. Following the submission of the long term disability appeal Sedgwick was again left with little choice but to approve our client’s claim for long term disability benefits.

If history is any indicator we are confident that this will not be the last attempt by Sedgwick to try to deprive our client of his benefits.