A BellSouth Customer Service Assistant, with the help of his North Carolina Disability Attorney, was forced to file a lawsuit against Sedgwick after being denied continued disability benefits.
History of the Claim
Mr. D. was employed as a customer service assistant for BellSouth Telecommunications (“BellSouth”) and was a participant in the Short Term Disability (“STD”) Plan, which was administered by Sedgwick, for BellSouth employees. In October 2008, Mr. D sought STD benefits after his doctor determined that Mr. D could no longer work due to significant mental health impairments. Sedgwick initially approved and paid Mr. D STD benefits for his mental health disorders beginning in September 2008. However, in July 2009, Sedgwick terminated Mr. D’s benefits.
Following two unsuccessful appeals of Sedgwick’s denial of benefits (and the exhaustion of his administrative remedies), Mr. D, through his disability attorney, sued Sedgwick in federal court arguing that Sedgwick had wrongfully terminated his short-term disability benefits.
After reviewing the substantial medical evidence presented by Mr. D in support of his claim for benefits, the North Carolina court determined that Sedgwick abused their discretion and wrongfully denied short term disability benefits for the following reasons:
- Out of the four professionals who actually interacted with Mr. D, none had concluded that Mr. D. could return to work.
- Sedgwick relied almost exclusively on a doctor’s questionable opinions about Mr. D’s symptoms;
- Sedgwick had arbitrarily refused to credit the evidence from Mr. D’s treating physician;
- Sedgwick ignored evidence and statements that raised serious questions as to whether Mr. D could function at any type of employment.
In reaching its decision, the court explained that there was “overwhelming evidence in the record showing [Mr. D]’s disability.” First, none of the four professionals who actually interacted with Mr. D concluded that Mr. Dr. could return to work. Mr. D’s treating physician, who had observed Mr. D over many years, had diagnosed Mr. D with Obsessive Compulsive disorder, Panic Anxiety Disorder with mild Agoraphobia, Bipolar I Disorder, Generalized Anxiety Disorder, delusional ideation and paranoia and hyper vigilance. Sedgwick arbitrarily refused to credit this evidence. Second, a vocational case manager concluded that Mr. D was not employable and issued a statement expressing her concern for “the safety and welfare of [Mr. D] and his co-workers and supervisors if [Mr. D] were to return to work.” Sedgwick again refused to credit this evidence.
Instead, Sedgwick retained a psychologist to perform an Independent Medical Evaluation (“IME”) of Mr. D who concluded that Mr. D exaggerated and over-reported complaints and symptoms. He reached this conclusion through an examination described by other psychologists to be inaccurate and the incorrect analysis to be used. Sedgwick ignored this criticism and instead relied almost exclusively on the IME provider’s questionable determination that Mr. D had exaggerated his symptoms.
The court explained that Sedgwick had improperly relied on the IME provider’s conclusion and that there was substantial credible medical evidence to support Mr. D’s claim. The court ultimately concluded that Sedgwick had wrongfully denied Mr. D short-term disability benefits.