What will it take for Sedgwick to stop wrongfully denying disability benefits to AT&T employees? AT&T appears to want to bury their head in the sand and act like they don’t know what Sedgwick is doing. We personally think AT&T is happy with the conduct of Sedgwick as the more denials; the more AT&T can keep its money.
The disability denial lawsuit discussed below is an example of the lengths Sedgwick Claims Management will go to in order to deny a claimants benefits. A claimant may have an extraordinary amount of objective medical support including opinions from qualified physicians stating that he or she is disabled and unable to work as well as positive MRI’s and CT scans, yet the plan administrator (Sedgwick) can completely ignore such evidence and fabricate their own opinions that are completely contrary to the information stated in the records. Since this occurs often, it is extremely important to ensure that you retain an attorney with the experience to ensure that the administrative record is complete before the case ends up in a court of law. Once the final appeal is filed and the administrative records is closed, no additional information may be added or presented to the court. Had the Plaintiff in the case described below failed to retain an attorney to ensure that all of his medical records and doctors opinions were submitted during the appeals process as well as ensured that he underwent additional objective medical testing, the Court may not have ruled in his favor.
In this instance, AT&T and Sedgwick failed to get away with their abusive treatment of the claimant. Often times, companies get away with this behavior as many claimants feel they are powerless over these large companies and do not believe they can win. They give up, return to work in a disabled condition, or attempt to file an appeal on their own, which is exactly the outcome the insurance companies are hoping for. However, this abusive behavior can be curtailed with the help of a disability insurance lawyer whose role is to help ensure that the insurance company does not abuse its discretion and the claimant receives the disability benefits they are rightfully owed.
Northern District of California Court Orders AT&T to pay STD benefits to Claimant
In June of 2012, the Northern District of California granted Plaintiff’s motion for summary judgment. Plaintiff was a Retail Sales Consultant for AT&T who received STD benefits as a result of severe knee pain due to arthritis. His employer required him to be on his feet 8 hours a day and would not allow him to sit during that 8-hour shift. He was initially approved for STD benefits, but his benefits were later terminated when Sedgwick, the Claim Administrator, determined that he was no longer disabled.
Three Reasons The Sedgwick Disability Denial Was Abusive And Unreasonable
The Court ruled that AT&T abused its discretion in terminating Plaintiff’s benefits based on the following reasons:
- It Was Illogical To Deny Continued STD Benefits Where the Medical Evidence Showed No Change in Plaintiff’s Condition
AT&T initially found Plaintiff to be disabled based on his physicians medical records and opinions that he could not work due to severe knee pain. According to the Court, the updated medical records did not reflect any significant change in Plaintiff’s symptoms. To the contrary, the Plaintiff’s physicians reported continued knee pain stating the Plaintiff could only work 4 hour shifts and might need a chair- an accommodation that was not available. In addition an MRI supported the diagnosis of arthritis as well as degeneration. The Court held that none of the updated medical records offered any reasonable basis for concluding that Plaintiff’s condition had improved compared to the initial periods of STD benefits. AT&T tried to justify cutting off the Plaintiff’s benefits by claiming he was no longer disabled. After reviewing all of the medical records, the court determined that the Plaintiff’s knee had not gotten better it in fact had gotten worse.
- The Denial was Arbitrary Because Peer Review Physician (AT&T’s hired doctor) did not Explain Why he Rejected the Findings of the Treating Physician Who Examined the Plaintiff
The plan administrator based its denial of Plaintiff’s appeal on a paper review of the record by the peer review physician. The peer review physician failed to explain why he disagreed with the conclusions of all the physicians and care providers who examined the Plaintiff. The peer review physician also failed to speak with any of Plaintiffs treating doctors and left messages stating that if they did not return his call within 24 hours their opinions would be disregarded. The Court ruled that the plan administrator may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.
- The Denial was Arbitrary Because the Plan Administrator Failed to Conduct an Independent Medical Examination and Ignored Plaintiffs Subjective Complaints of Pain
According to the Court, a plan administrator cannot get away with ignoring and/or rejecting a claimants subjective complaints of pain without a principal reason, especially when there is objective proof of a disease that could cause such pain. In this case, the Plaintiff complained of severe knee pain which was universally documented in his physicians’ records and underwent an MRI that revealed degenerative changes as well as arthritis. AT&T completely disregarded the Plaintiff’s complaints of pain and MRI results stating that he was perfectly capable of returning to his regular occupation. Furthermore, the Court stated that the plan had the right to arrange for an independent medical evaluation, but chose not to do so, relying on its hired physician’s paper review of the claimant to make the determination that he was no longer entitled to benefits.
Based on all of the considerations above, The Court concluded that the Plan abused its discretion when it terminated Plaintiffs STD benefits. The Court remanded for an award of benefits retroactive to the effective date of denial for the full 22 week period for which benefits would have been available as well as attorney’s fees and costs.
This case was not handled by Attorneys Dell & Schaefer. However, this is an example of how important it can be to retain an experienced disability attorney to ensure that your administrative record is complete. Without effective counsel, the above decision could have been very different. Contact our firm for a free consultation to discuss your disability insurance claim.