• Sedgwick Ignores Medical Records and Denies Disability BenefitsSedgwick Ignores Medical Records and Denies Disability Benefits
  • Sedgwick Claims Management Services Disability Benefit ClaimsSedgwick Claims Management Services Disability Benefit Claims
  • Third Party Administrator Role in Disability Insurance ClaimsThird Party Administrator Role in Disability Insurance Claims

Court Agrees with Sedgwick and Finds Plaintiff’s ERISA Lawsuit is Time-Barred

The case of Allison Pfifer v. Sedgwick Claims Management Services, Inc., teaches claimants the importance of complying with the terms of their disability insurance policy. The specific terms at issue here are: 1) the need to support claims with substantial medical evidence; and 2) complying with contractual deadlines established by the insurance policy for short-term disability (STD) benefits and long-term disability (LTD) benefits.

Factual Summary

Pfifer was employed by 3M as a “Lead Proposal Writer” when she quit work and applied for disability benefits through 3M’s STD Plan administered by Sedgwick. On May 12, Sedgwick sent Pfifer the necessary forms to be filled out and returned to it by May 27, 2016. The letter included a clause that said the “Failure to meet the eligibility requirements for Short-Term Disability Benefits or failure to timely submit the required forms will result in delay or denial of benefits.”

On May 27, one of Pfifer’s treating physicians left a message with Sedgwick that it would not be able to complete the forms on time, so on May 31, 2016, Sedgwick sent Pfifer a letter telling her that her claim had been denied since there was insufficient information submitted to support her claim that she was unable to perform the duties of her regular and customary occupation.

Pfifer filed an administrative appeal and submitted office notes from her treating physician, Xinmin Tang, along with a radiology report. Dr. Tang also submitted an Attending Provider Statement in which he noted that Pfifer reported severe right knee pain, including the inability to sit without elevating her knee.

Sedgwick sent the medical record for review to Dr. John Evans, a board-certified orthopedist. In addition to his review, he contacted two of Pfifer’s treating physicians. Dr. Evans opined that the limited medical records submitted by Pfifer did not support her claim for STD benefits. He reported that her customary occupation was a “sedentary position and not a demanding job”.

On June 22, 2016, Sedgwick notified Pfifer that the denial of her claim for STD benefits was upheld. It also advised her of her right to file a civil action, but also informed her of the contractual limitations period at which her right to file the action would expire.

On March 16, 2017, Plaintiff filed a claim for LTD benefits claiming, once again, to disability due to her right knee. On April 7, 2017, Sedgwick denied her claim for LTD benefits on the grounds that Pfifer was ineligible for LTD benefits since she did not exhaust her STD benefits as required by the LTD plan.

On October 3, 2017, Pfifer sought to appeal the denial of her LTD benefits. On October 10, 2017, Sedgwick upheld its denial of LTD benefits and informed Pfifer of the contractual limitations period governing her right to file a civil action.

On April 25, 2018, Pfifer filed an ERISA action against Sedgwick claiming Sedgwick erroneously denied her STD and LTD benefits. Sedgwick filed a Motion for Summary Judgment which was granted by the United States District Court for the Southern District of Texas, Houston Division.

Contractual Limitations Periods Govern Pfifer’s Claim for Benefits

Sedgwick argued that Pfifer’s claims for STD and LTD benefits were both time-barred according to the contractual limitations provided for in both the STD and LTD Plans. Pfifer did not disagree, but argued instead that equitable tolling should apply due to Sedgwick’s “procedural unreasonableness.”

The District Court relied on Fifth Circuit precedent which had found a 90-day period for filing a civil action reasonable. The Court concluded the six-month contractual limitations period in this case “reasonable and, thus, enforceable.”

Since Pfifer missed the deadline following the completion of her administrative appeal for STD benefits and the denial of her appeal for LTD benefits, and finding no “extraordinary circumstances” to justify “the application of equitable tolling,” the Court held that her “claims are time-barred.”

Even if Not Time-Barred, Administrator Did Not Abuse Its Discretion in Denying Pfifer’s Claims for Benefits

The Court concluded that If the Administrator’s denial of benefits is based on substantial evidence, “it must remain undisturbed.” The Court also concluded that substantial evidence supported Sedgwick’s denial of the claim.

Dr. Evans reviewed the very limited medical file and spoke with two of Pfifer’s treating physicians. Based on this, the Court concluded that Dr. Evan’s assessment “provided a definitive opinion on plaintiff’s functional capabilities.”

In its conclusion denying Pfifer relief, the Court stated, “Against this background, this Court cannot say that Sedgwick’s decision to deny the plaintiff’s claim for STD benefits was arbitrary or capricious. Nor can it say that Sedgwick’s decision to deny the plaintiff’s claim for LTD benefits was incorrect, as it remains undisputed that the plaintiff failed to exhaust her STD benefits.”

If you have any questions regarding your own claim for either STD or LTD benefits, contact one of our attorneys at Dell & Schaefer for a free consultation.

DISABILITY INSURANCE COMPANY INFORMATION
Videos, Questions, Resolved Cases, Lawsuit Summaries & Company Reviews

disability insurance companies complaints

FAQ

Do you help Sedgwick claimants nationwide?

We represent Sedgwick clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Sedgwick disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Sedgwick. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Sedgwick.

How do you help Sedgwick claimants?

Our lawyers help individuals that have either purchased a Sedgwick long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Sedgwick:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Terri E. (Maryland)

The process has been exactly how I had hoped it would be. Disability is a scary, unfriendly process, even for those of us who have worked in the claims administration area. It seems to be designed to deny benefits with complicated rules, burdensome documentation requirements, and constant requests for information to the beneficiary and my doctors. As a patient/beneficiary, you can feel like you are all alone and that you spend too much time jumping through hoops for the disability provider.

After a few months of doing it myself, I realized I wanted an advocate who could advocate for me with the provider and answer all of my questions on the Erisa process and rules. I interviewed one attorney in Maryland who was actually adversarial with me (his future client) so it was an awesome breath of fresh air when I interviewed Stephen Jessup. He was polite, extremely knowledgeable, upbeat, and calm! He helped me to understand the process and where I stood in it.

He and Vanessa communicate and keep me apprised of events within my case and make recommendations on actions I should take to proactively help my case win approval (e.g., Functional Capacity Evaluation). They are truly my safety net and well worth every penny because they help manage the disability provider and my doctors as well as ensuring I am on track in the process. I don’t think I would have survived this without them.

Read 424 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us