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 premises technician. Wisconsin Bell is a participant in a disability plan administered by Sedgwick Claims Management Service, Inc. (Sedgwick). The Plan offered both short-term disability (STD) and long-term disability (LTD) benefits to qualifying participants.
Participants become eligible for STD benefits when they are employed by a participating company and miss seven consecutive days of work because of their disability. The claims administrator has “sole discretion” to determine if a participant meets the definition of disability which says that a person is disabled if due to:
“sickness, pregnancy or an off-the-job illness or injury that prevents you from performing the duties of your job (or any other job assigned by the Company for which you are qualified) with or without reasonable accommodation. Your disability must be supported by objective Medical Evidence.”
Plaintiff’s job duties were listed as requiring him to climb stairs and ladders, drive a company vehicle, work with hand tools, and lift up to 80 pounds.
LTD benefits are available if: 1) the eligible participant has received 52 weeks of STD benefits; 2) the medical providers submit all requested medical information; and 3) the LTD benefit claim is submitted within six months after the period of receiving STD benefits concludes.”
Plaintiff missed work on April 2, 2017. A week later, he applied for STD benefits (the First Claim) asserting that he had symptoms of fatigue. He provided no medical information. From then on, Plaintiff struggled with Sedgwick in his attempt to collect STD benefits. He submitted a Second Claim which was approved for a short period of time. When benefits pursuant to his Second Claim were terminated, he then submitted a Third Claim. That was also denied.
Repeatedly, Sedgwick informed Plaintiff of its need for more medical information. Repeatedly, Plaintiff failed to provide the requested information.
During one period of time, Sedgwick had several phone conversations with Plaintiff informing him of the need for additional medical information. Each time, Plaintiff was uncooperative, uttering “profanities,” and refusing to provide requested information. At one point, he even refused to provide the name or contact information of his health care provider.
On October 12, 2017, the same day Plaintiff was informed by Sedgwick that his Second Claim had been denied, Plaintiff was examined by Dr. Paul Tuttle, a rheumatologist. Dr. Tuttle provided Sedgwick with medical information which supported Plaintiff’s claim and noted that he “may” suffer from chronic fatigue syndrome (CFS). Based on information received from Dr. Tuttle, Sedgwick reopened Plaintiff’s Second Claim and approved it, awarding STD benefits from October 31 to December 17, 2017, when Sedgwick terminated STD benefits.
Plaintiff filed a Third Claim for STD benefits on January 22, 2018, based on his sleep apnea and CFS. He provided no information about how his CFS affected his ability to do his job. He did not ask for any change in his job or any job accommodations. His Third Claim was denied by Sedgwick on February 29, 2018, because he did not provide information about how his condition precluded him from performing his job duties.
When he had exhausted his administrative remedies, he filed this ERISA lawsuit in the United States District Court for the Eastern District of Wisconsin. The Court found in favor of Sedgwick holding that its decision to deny Plaintiff benefits was not arbitrary and capricious when Plaintiff failed to provide the objective medical evidence Sedgwick specifically told him it needed.
Plaintiff Presented no Objective Evidence of How His CFS Diagnosis Affected His Ability to do His Job
The Court noted that precedent “has observed that CFS ‘like fibromyalgia, poses unique issues for plan administrators since for both conditions, its cause or causes are unknown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective.’”
Even though there is no diagnostic test that can prove a person suffers from CFS or fibromyalgia, more is needed from a physician than a conclusionary statement that a claimant is disabled due to a diagnosis of CFS. This is all that Plaintiff presented to Sedgwick. Neither Plaintiff “nor his doctor presented any objective test results showing, for example, [Plaintiff’s] diminished ability to life weights, climb stairs or ladders, or perform other job duties because of his CFS.”
In a letter dated October 13, 2017, Sedgwick specifically outlined to Plaintiff what information it needed to support his claim. For example, it told him he needed his physician to “document your functional impairments” and to provide a treatment plan, including plans for return to work with or without reasonable accommodations.
Nothing in the record indicated Plaintiff had ever undergone a functional capacities evaluation or similar test to determine what he could actually do as opposed to what he claimed he could do. Plus, except for the brief time in response to Plaintiff’s Second Claim, all other reviewing physicians agreed that the medical evidence did not support Plaintiff’s claim. Therefore, the denial of Plaintiff’s claim for STD benefits was not arbitrary and capricious and the Court let that decision stand.
Previous Award of STD Benefits Does not Mean Plaintiff Entitled to Earlier or Later Benefits
Plaintiff argued that Sedgwick’s award of STD benefits for a short period of time in 2017 should be used as evidence that he was entitled to benefits both before and after that date. The Court disagreed and noted that “the previous payment of benefits is just one ‘circumstance’ i.e., factor to be considered in the court’s review process; it does not create a presumptive burden for the plan to overcome.”
Here, the Court concluded that since Sedgwick had “sound reasons to request additional objective evidence that [Plaintiff’s] condition impacted his functional ability, it did not make its subsequent denial of benefits arbitrary or capricious.”
This case was not handled by our office, but we believe it can be instructive for those who need to present objective evidence of how their subjective diagnosis affects their ability to perform their job duties. If you have questions about this case, or any question about your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.
Resources to Help You Win Disability Benefits
Disability Benefit Denial Options
Submit a Strong Sedgwick Appeal Package
We work with you, your doctors, and other experts to submit a very strong Sedgwick appeal.
Sue Sedgwick
We have filed thousands of disability denial lawsuits in federal Courts nationwide against Sedgwick.
Protect Your Benefits
Get Your Sedgwick Disability Application Approved
We help claimants throughout the entire application process.
Prevent a Sedgwick Disability Benefit Denial
We manage every aspect of your disability claim following claim approval.
Negotiate a Sedgwick Lump-Sum Settlement
Our goal is to negotiate the highest possible buyout of your long-term disability policy.
Sedgwick Reviews
(642)
Policy Holder Rating
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
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
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.
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.
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
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
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
Sedgewich immediately denies all RFA. They’re ur team are THEMSELVES not a independent medical team…
Sedgwick
Very very slow to respond
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?
A: Vicky: You need to file a written appeal of your Sedgwick Disability Denial. Sedgwick will have someone review... Read More >
Helpful Videos
(888)
Showing 12 of 888 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
(375)
Showing 8 of 375 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 >
Seven Surgeries and The Standard Still Denies Long Term Disability Benefits
Our client was employed with the State of Oregon as a Technical Support Representative. She ... Read More >
Sun Life Wrongfully Denies Disability After Paying For 23 Months
We represent a 57 year-old claimant who’s occupation was selling commercial vehicles for ma... Read More >
Nurse Denied Long-term Disability Benefits by Lincoln After the Definition of Disability Changed
Our client, a registered nurse for Dignity Health, found herself in a difficult situation aft... Read More >
Lincoln Reverses Decision to Terminate LTD Benefits of Corporate Attorney after Dell Disability Lawyers Appeals the Decision
The claimant is an 64 year old former Corporate Attorney and at a prominent Florida business ... 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 >
Disability Lawsuit Stories
(765)
Reviews from Our Clients
