• Sedgwick Disability Benefit Claims

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.

There is one comment so far

  • Sedgwick has repeatedly denied my mental health intermittent LOA although I’ve been covered for years. They have stated different reasons and when I call the staff is confused. When I ask to speak to my auditor I am treated rudely and with indifference.

    Dana Mar 11, 2022  #1

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