After three long years of struggling with no income due to Sedgwick’s failure to approve her benefits, the claimant is finally awarded the disability benefits she was rightfully owed. The claimant worked for Walgreens for approximately 11 years and was a dedicated employee who loved her profession. In early 2011 she began to feel fatigued and experienced pain in her muscles and joints. She was very concerned for her health and sought help from several physicians and specialists in order to find some answers. Her doctors ran every test under the sun; they ordered blood work, CT scans, Lyme tests, MRI’s, which all came back negative. The claimant was examined and treated by eleven doctors within a 6 month period at the prestigious Mayo Clinic in Jacksonville, Florida, who all confirmed her diagnosis of Fibromyalgia.
Her condition continued to deteriorate and in September of 2011 she was no longer able to work as a pharmacist. At that point, her physicians notified her employer Walgreens of her inability to work due to severe, progressive Fibromyalgia with bodily pain, chronic fatigue, chronic daily headaches, papilledema secondary to pseudotumor cerebri, sleep and urinary dysfunction, neuromuscular pain, numbness and tingling of the bilateral upper extremities, frequent episodes of irritable bowel syndrome and secondary depression and anxiety. Sedgwick, a third party administrator hired by Walgreens to make claim determinations, failed to have her examined by a physician and merely conducted paper reviews of her medical records ignoring her treating doctor’s opinions that she was too ill to work in her occupation. The basis of Sedgwick’s denial of her claim was that she failed to provide objective evidence of her disability.
Judge Rules Sedgwick Was Wrong for Requiring Objective Proof of Fibromyalgia
Fibromyalgia is a type of muscular or soft tissue rheumatism that affects muscles and their attached bones and is also accompanied by fatigue, sleep disturbances, lack of concentration, changes in mood or thinking, anxiety and depression. Fibromyalgia can be severely disabling and can only be diagnosed by an examination of the patient. There is no objective test that exists that can show that a patient is suffering from Fibromyalgia other than performing a trigger point examination, which also relies on the patient’s subjective complaints. Therefore, it is impossible to provide objective proof of an illness such as Fibromyalgia when none exists. Therefore, it was improper for Sedgwick to require the claimant provide objective proof of her illness when Sedgwick knew it was impossible to do so.
In oral argument on the claimant’s summary judgment motion, Attorney Alters argued that Sedgwick’s demand for objective proof of the claimant’s was unreasonable and arbitrary and capricious. Sedgwick’s basis to deny the claim rested solely on the lack of objective evidence to support the diagnosis of Fibromyalgia. It is well established that there are no objective tests that exist to confirm or rule out whether someone is suffering from Fibromyalgia. A person can undergo MRI’s, EEG’s CT’s all day long, but none of these tests and studies can establish a diagnosis of Fibromyalgia. The Judge in this case agreed it was wrong for Sedgwick to require such objective evidence as it is impossible to provide, granted partial summary judgment in favor of the claimant and remanded the claim back to Sedgwick to conduct a proper review without requiring objective proof of her claim. The Judge further suggested that Sedgwick conduct an IME of the claimant by a rheumatologist to determine whether she was truly disabled.
Sedgwick Overturns Decision to Deny Benefits After Conducting Fourth Review
On remand, the claimant provided Sedgwick with additional medical records and several opinions from her treating physicians, including a rheumatologist, all supporting her inability to work. Sedgwick took the court’s advice and sent the claimant to a rheumatologist to conduct an independent medical examination. The rheumatologist who conducted the IME found that the claimant was clearly disabled as a result of fibromyalgia and stated as follows:
The patient’s condition required restrictions and limitations beginning from 09/19/13 through the present. Based on my evaluation on 04/20/14, the patient does have significant fatigue along with cognitive impairment and inability for sustained activity. Her Fibromyalgia is also complicated by frequent migraine headaches as well as other comorbidities like a depression and anxiety as well as other somatic symptoms of frequent urination from interstitial cystitis as well as interruption from irritable bowel syndrome.
Her restrictions and limitations have not changed since original disability date of September 2011. She has restrictions in lifting weights more than 10 pounds. She has restrictions in sustained sitting more than two hours at a time with a total of six hours in an eight-hour time period. She can stand only up to an hour at a time with a total of four hours in an eight-hour time period. She has difficulty in bending more than occasionally. She has also restrictions in reaching above the shoulder repeatedly and can do those maneuvers only occasionally. She has difficulty with repetitive movements involving the hands and she has difficulty reading constantly because of her neck pain. She has mental fatigue as well as cognitive dysfunction partly from the medication she is on and partly due to her Fibromyalgia conditions. Their restrictions and limitations have not changed since September 2011.
After conducting its fourth review of the claim, Sedgwick finally overturned its decision to deny the claimant’s benefits. Attorney Alters is in the process of filing a motion for attorney’s fees and costs and will take the position that the claimant had clear success on the merits of her claim and is entitled to fees. Attorney Alters will also continue managing her claim to help ensure she receives benefits as long as she remains disabled.
Read about other Fibromyalgia disability claims on this page.