Court Remands to Sedgwick for Reevaluation of Its Denial of Claim for Disability Benefits
Author: Attorney Rachel Alters
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:
- Sedgwick never set forth the essential functions of Plaintiff’s job.
- Sedgwick did not directly address opinions from Plaintiff’s treating physicians that he could not perform his job duties.
On the record presented, the Court was unable to conclude that if the administrator had applied the correct standard, it would have come to the same conclusion. Ultimately, the Court held, “It is appropriate that plaintiff’s claim be remanded to the plan administrator for a new determination.”
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.