• Sedgwick Disability Benefit Claims

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), applied for short-term disability benefits. The plan administrator, Sedgwick Claims Management Services, Inc. (Sedgwick), denied Derichs’ claim. After exhausting his administrative appeals, Derichs filed this ERISA lawsuit.

At issue was the correct definition of total disability under the clause of the policy that read, “You are considered Totally Disabled when, because of illness or injury, you are unable to perform all of the essential functions of your job…” Specifically in question was whether the clause meant a claimant was disabled only if they could not perform “any” of their essential job duties, a definition proposed by Sedgwick, or disabled if they could perform some, but not all the essential functions of their job, as proposed by Plaintiff.

The Court held that the Plaintiff’s definition made the most sense and found Plaintiff would be disabled if he proved that “he was unable to perform any particular essential function of the job.” The Court remanded to Sedgwick with instructions to reevaluate Plaintiff’s claim using this definition and to do so within a reasonable time.

Court Determined Plaintiff’s Interpretation of “Unable to Perform all of the Essential Functions” of His Job Duties is Correct

The Court found the policy language ambiguous and noted that ambiguities in policy language are interpreted against the entity responsible for drafting the language at issue, in this case that was Sedgwick. After much analysis, and consideration of decisions made by other district and circuit courts, the Court determined that the inclusion of the specific language “essential functions” of the job meant that if defendant could not perform even one essential function, he would be unable to continue to perform the job as a whole and would therefore meet the definition of disabled. The Court noted that this definition is “more reasonable and more in keeping with the plan’s clear purpose of providing benefits to those who can no longer perform their jobs.”

Sedgwick Did Not Consider Plaintiff’s Disability Under the Correct Definition

Sedgwick argued that it evaluated Plaintiff’s claim under both definitions, including the one adopted by the Court. The Court disagreed for several reasons:

This case was not handled by our office, but we thought it could be helpful to those who are fighting for their disability benefits against insurers who are using the wrong definition for disability as the term is used in the particular policy. If you have questions about this, or any other aspect of your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free case consultation.

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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.

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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.

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If you have a disability insurance situation, you need a pro like Steven Dell from the start to guide, support, and battle the insurance company for you. Don’t try to take on the powerful insurance companies on your own as they have all the tactics in place to try to delay and deny your claim, no matter how legitimate. If you try to do the claim on your own, you will be at a disadvantage. Our experience with Steven Dell was exceptional. I was diagnosed with severe cardiac disease. As a result, my cardiologist and other doctors told me that I needed to cease working immediately or risk a severe heart attack or death. Unfortunately the disability insurance company did not see it that way and tried to delay and dismiss the seriousness of my illness and attempted to set up a denial.

The insurance company is on your side as long as you are paying your premiums and do not file a claim. I found out that the insurance company will try to do all that they can to deny paying a claim. Fortunately Steven Dell was on our side from the start and helped us get through this stressful and lengthly process of filing a disability claim. Steven Dell advised and guided us through each step of the way and on many instances had to go head-on with the insurance carrier. The amount of paperwork in filing a claim can be substantial. Mr. Dell’s professional staff (especially Merlin) was efficient in handling everything to ensure that all the necessary paperwork was in order and submitted to the insurance company. I owe a debt of gratitude to Mr. Dell, he was a Godsend, and we were able to win the case. If you have a disability situation you need a pro like Mr. Dell from the start if you want a successful outcome. Our lives are better now because of Steven Dell ~ Thank you Steven!

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