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.


Did you find this helpful?
Unhelpful (0)

Resources to Help You Win Disability Benefits

Disability Benefit Denial Options
Submit a Strong Appeal Package

We work with you, your doctors, and other experts to submit a very strong appeal.

Learn more

Sue Your Disability Insurance Company

We have filed thousands of disability denial lawsuits in federal Courts nationwide.

Learn more

Protect Your Benefits
Get Your Disability Application Approved
We help claimants throughout the entire application process.

Learn more

Prevent a Disability Benefit Denial
We manage every aspect of your disability claim following claim approval.

Learn more

Negotiate a Lump-Sum Settlement

Our goal is to negotiate the highest possible buyout of your long-term disability policy.

Learn more

Sedgwick Reviews
(642)

Policy Holder Rating

1 out of 5
Read 9 reviews
0%would recommend
5
0%
4
0%
3
0%
2
0%
1
100%
Timely Payments
1.2out of 5
Handling Claim
1.0out of 5
Customer Service
1.2out of 5
Dependable
1.1out of 5
Value
1.1out of 5
Showing 8 of 642 Reviews
Sedgwick

AT&T Was Great and Sedgwick Horrible

Reviewed by From a great job to a complete nightmare on March 20th 2024   Verified Policyholder | March 2024 date of disability
My Physician recommended that I take some time from a toxic environment after several deaths in my family coupled with AT&T trying to run tenured employees out of the door... read more >
Sedgwick

Lame

Reviewed by Dennis T. on December 11th 2023   Verified Policyholder | March 2022 date of disability
My experience with Sedgwick and personell is as follows: Unhelpful, unprofessional and an overall unpleasant experience.
Sedgwick

I was disabled 2003 by SS. I got SSDI 7 years too late.

Reviewed by Bunny on August 9th 2023   Verified Policyholder
I believe if Sedgwick would have moved on my Claim. They absolutely did everything not to answer my calls, change dates. I had already been through WV comp. Ins. Sold out,... read more >
Sedgwick

They falsify documents and avoid contact as much as possible.

Reviewed by Jeff Allsop on July 27th 2023   Verified Policyholder | February 2023 date of disability
They avoided sending the documents needed for the claim for two weeks. I had to escalate with a call from my company's HR and Sedgwick (the only way I was ever able to get... read more >
Sedgwick

Not getting paid

Reviewed by Cezes on June 15th 2023   Verified Policyholder | March 2020 date of disability
I been battling Sedgwick about my claim. I was to get paid today and I did not get paid.Sledges is the worse company I ever had to deal with. I been fighting with my b... read more >
Sedgwick

You have to be well versed in your rights when dealing with them

Reviewed by Lauren on June 3rd 2023   Verified Policyholder | May 2023 date of disability
I live in CA and have a very straightforward maternity leave case. Every adjuster is unaware of CA leave laws. They’ve gotten in wrong every time. You have to advocate f... read more >
Sedgwick

Sedgewich is the worst-immediate denial of all requests for treatment. Rubber stamps DENIED ALL RFA’s

Reviewed by J on May 31st 2023   Verified Policyholder | August 2023 date of disability
Sedgewich immediately denies all RFA. They’re ur team are THEMSELVES not a independent medical team…
Sedgwick

Very very slow to respond

Reviewed by Steve on May 31st 2023   Verified Policyholder | April 2023 date of disability
Very very slow to respond to reply to questions they put you on a timeline, but they can bend their timeline.
Answered Questions by Our Lawyers
(1)
Showing 1 of 1 Answered Questions

Q: Sedgwick denied my STD appeal, is there anything I can do to get my money back?

Answered on June 15th 2023 by Attorney Gregory Dell
A: Vicky: You need to file a written appeal of your Sedgwick Disability Denial. Sedgwick will have someone review... Read More >
Helpful Videos
(875)
Showing 12 of 875 Videos
Disability Benefit Tips
(330)
Showing 8 of 330 Benefit Tips

Disability Benefit Denial Reason #5 – Your Medical Evidence is Weak

If you're seeking long term disability benefits from an insurance company, you may be concern... Read More >

Disability Benefit Denial Reason #4 - Your Doctor Is Misled By the Disability Company

When you're seeking disability benefits under a long term disability policy, your medical rec... Read More >

Disability Benefit Denial Reason #3 - Video & Social Media Surveillance

One thing many long term disability claimants don't know about (or expect) from the claims re... Read More >

How Do You Fight a Long-Term Disability Denial?

Getting a denial letter from your disability insurance company is one of the ultimate insults... Read More >

Disability Denial Reason #2 - Change of Disability Definition & Vocational Review

One of the top reasons for terminating a claimant's long term disability benefits involves th... Read More >

Disability Denial Reason #1 – Paper Review & IME

At Dell Disability Lawyers, we've seen insurance companies give countless reasons to deny lon... Read More >

How to Apply for Reliance Standard Disability Benefits & Top 5 Reasons for a Claim Denial

At Dell & Schaefer we’ve handled hundreds of long term disability insurance claims against Reliance Standard, and have learned a few thi... Read More >

Applying for Standard Disability Benefits? Top 5 Claim Denial Reasons

At Dell & Schaefer, we've helped hundreds of clients recover long term disability benefit... Read More >
Dell Disability Cases
(373)
Showing 8 of 373 Dell Disability Cases

Sedgwick Reinstates Long Term Disability Claim Following Appeal

Like many disability claimants, our client’s experience in dealing with Sedgwick was less than a pleasurable experience. After finding himse... Read More >

Nearly Three Years Later, Sedgwick Finally Pays Walgreens' Pharmacist's STD and LTD Claim

After three long years of struggling with no income due to Sedgwick's failure to approve her benefits, the claimant is finally awarded the dis... Read More >

AT&T Employee Dealing With Sedgwick Has Horrible Disability Benefit Claim Experience

Our client, an AT&T employee for more than 40 years became disabled and unable to do her job due to cervical myeolapathy neck pain, chroni... Read More >

Transportation Manager with Brain Injury Wins Unum Disability Benefit Appeal

Unum unjustly terminated our client’s long term disability claim after it had approved and... Read More >

Engineer With Depression Wins Prudential LTD Appeal

The claimant is a former Senior Technology Services Engineer for Accolade, Inc. who was force... Read More >
Disability Lawsuit Stories
(765)
Showing 8 of 765 Lawsuit Stories

Court Upholds Sedgwick's Denial of Benefits for Claimant with Chronic Fatigue Syndrome

In Griffin v. AT&T Umbrella Benefit Plan No. 3, Plaintiff worked for a few years for Wisconsin Bell, Inc. (Wisconsin Bell) as a premi... Read More >

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... Read More >

Court Remands to Sedgwick for Reevaluation of Its Denial of Claim for Disability Benefits

In Daniel T. Derichs v. AT&T Services, Inc., plaintiff, an employee of AT&T who suffered from post-traumatic stress disorder (PTSD), a... Read More >

7th Circuit Recognizes Chronic Debilitating Effects Of Fibromyalgia

In Cathleen Kennedy v. The Lilly Extended Disability Plan, plaintiff Cathleen Kennedy, an executive Director of Human Resources, had a hi... Read More >

Court Orders Sedgwick to Pay Disability Benefits to Claimant with Carpel Tunnel Syndrome Even though the Employer Offered Her Accommodations

Thornton v. Sedgwick is a fact-driven case in which a California district court ruled that Sedgwick “incorrectly determined in January 2014 ... Read More >

Court Finds Sedgwick Wrong to Deny Benefits Without Considering Claimant's Actual Job Duties

In McMillan v. AT&T Umbrella Benefit Plan No. 1, the plaintiff, who had worked for AT&T for nearly six years as a Senior IT Client Con... Read More >

Sedgwick Continues monitoring application for SSDI benefits even after terminating disability claim

Many claimants are unaware that disability carriers continue to monitor claimants' applications for Social Security disability benefits even a... Read More >

Sedgwick and AT&T sued as a result of SSDI Overpayment

A recent decision by a Federal Judge in a California ERISA Disability Lawsuit serves as a reminder to all individuals receiving disability ben... Read More >

Reviews from Our Clients

Request a Free Consultation

Our Lawyers Respond Same Day

5 Ways We Help Get Your Benefits Paid

Get Your Disability Application Approved

Our goal is to get your application for disability income benefits approved. Applying for disability benefits can be a difficult process and the information you provide is critical. Most disability insurance companies look at your application in hopes of finding a reason to deny your claim. Your disability company will ask you to complete numerous forms, interview you, request lots of information, speak with your doctors and possibly request to have you examined by their "hired gun" doctor.

Through our experience of having helped thousands of disability insurance claimants, our lawyers will guide you through the entire application process and give you the best chance to get your disability claim approved the first time.

Submit A Strong Appeal Package

If your disability insurance benefits have been wrongfully denied, then our lawyers know exactly what it takes to get your disability claim approved. You only get once chance to submit an Appeal, therefore every piece of evidence that will support your disability claim must be included. The goal is to win your disability benefits at the Appeal level, but while preparing your Appeal you must consider how a federal judge will review your disability claim if your benefit denial is upheld.

Preparing a strong disability appeal package is an art that requires you to understand how the courts interpret your disability policy language, ERISA regulations / laws, and how to strategically present evidence in support of your definition of "disability". We encourage you to contact any of our lawyers for a free immediate review of your disability denial.

Sue Your Disability Company

98% of the disability insurance lawsuits filed by our law firm have resulted in either the payment of benefits or a lump-sum settlement agreement. Our disability lawyers have filed ERISA governed and private policy long term disability insurance lawsuits against every major disability insurance company in state and federal courts nationwide and we love fighting for the "little guy" against the multi-billion dollar insurance company giants.

We have recovered hundreds of millions of dollars for our clients and we would like the opportunity to provide you with a free review of your disability benefit denial. There are many complex factors in a disability benefit lawsuit and the legal battle to win long term disability benefits can be fierce.

Prevent A Disability Benefit Denial

Approval of long-term disability is a continuous process as every disability insurance company will evaluate your eligibility for benefits on a monthly basis. You can never let your guard down and assume that your disability company will continue to pay your benefits for as long as you think you need them.

Our law firm offers a reasonable flat fee monthly claim handling service in which we handle every aspect of your long-term disability claim and do whatever it takes to make sure you are paid every month.

Negotiate a Lump-Sum Settlement

Let's discuss if a lump-sum settlement or buyout of your disability insurance claim is both available and makes financial sense for you. Our lawyers have negotiated more than five-hundred million dollars in disability insurance buyouts and we know how to get you a maximum settlement. A disability insurance company is not required to offer a buyout and not every disability company offers them.

Questions About Hiring Us

Who are Dell Disability Lawyers?

We are disability insurance lawyers that know how to get your short or long term disability benefits paid. As a nationwide law firm we have helped thousands of disability insurance claimants throughout the United States to collect hundreds of millions of dollars of disability insurance benefits from every major disability insurance company.

In more than 98% of our cases, our lawyers have been able to either get our clients paid monthly disability benefits or obtain a one-time lump-sum settlement. Our lawyers have seen it all when it comes to disability insurance claims and we know exactly what it takes for your disability claim to be approved.

We welcome you to contact any of our attorneys for a free immediate review of your disability claim. We also invite you to visit and subscribe to our YouTube channel where we have more than 700 videos and regularly provide tips to help protect your disability benefits.

Who do you help?

Our lawyers help individuals that have either purchased a long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer. We have helped individuals in almost every type of occupation with monthly disability benefit payments ranging from $1,500 to $50,000.

Our clients include all types of employees ranging from retail associates, sales representatives, government employees, police officers, teachers, janitors, nurses, pilots, truck drivers, financial advisors, doctors, dentists, veterinarians, lawyers, consultants, IT professionals, engineers, professional athletes, business owners, and high level executives.

A strong understanding and presentation of the duties of your occupation is essential for securing disability insurance benefits.

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 phone, email, fax, GoToMeeting 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 800-698-9159 or by email. Lawyers 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.