Sedgwick Disability Help

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.

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Q: Sedgwick denied my STD appeal, is there anything I can do to get my money back?

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I am a physician in my 30s who was practicing in my hospital based medical specialty until my Multiple Sclerosis diagnosis began to severely limit my physical ability to work.

My husband and I were obviously in distress at these very unwanted life changes and frankly overwhelmed with the possibility of a long and traumatizing legal battle ahead of us. We knew we were legally entitled to benefits through the separate private individual and employer based ERISA disability insurance policies we had, but even cursory research and discussion with colleagues made it clear that insurance companies will strategize with their own legal teams to find ways to not pay out benefits. We found many before us who had fallen unwittingly into legal pitfalls that prevented them from ultimately obtaining benefits. We realized we needed to seek legal counseling.

We found Dell Disability Lawyers through their YouTube channel where their partners have videos discussing the legal intricacies and latest developments in private disability law. I was impressed by their dedication to the field and reached out through their website to request a free consultation.

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We have not been disappointed in our expectation and have, in fact, been consistently very impressed. Steven Dell is clearly both knowledgeable and wise about dealing with these issues but more importantly, has shown kindness and impeccable honesty at each step of the way.

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For over 7 months, we have been working closely with Steven Dell and Merlin Bryan from Dell Disability Lawyers as they have guided us through the process of review and initial application for benefits from our two insurance policies (Hartford and Ameritas).

We are happy to announce we just received approval of claim from the Hartford insurance company.

At this time we are still working with this firm as we await the final decisions from Ameritas policy that we are hopeful will have a similar outcome.

As anyone with a chronic and progressive illness can tell you, time becomes a very precious commodity. Through their representation, Dell Disability Lawyers has allowed us to focus the majority of our time enjoying the time and function I have left while resting assured that our disability case laid in competent and caring hands.

The truth is that no amount of money can make up for what we have lost, but it is a huge comfort to have a team like Dell Disability Lawyers at our sides to help us ensure we will be able to continue to care for ourselves and our families.

We highly recommend Dell Disability Lawyers, Mr. Steven Dell and Ms. Merlin Bryan to handle your disability insurance claim.

Thank you Steven, thank you Merlin!

We will certainly plan on leaving another review for completeness once we have our final decision from Ameritas.

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I have been working with Dell Disability Lawyers for the past 5 years concerning my disability as it pertained to my employer. I have been more than pleased with them the entire time. They have always kept me informed of any paperwork needing completed or any changes coming ahead. Nothing has been a surprise. I would recommend them to you to help with your disability case if you’re trying to dip into the policy you’ve been paying for.

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I am a physician who has been disabled for over 10 years. During this time I have been represented by Cesar Gavidia and his assistant, Danielle Lauria. Their representation on my behalf has allowed me to concentrate on dealing with my disability/disease process and all associated complications and not having to deal with all the things that are necessary in a disability insurance claim. Based on my personal experience from many years of practicing medicine I would consider their work product, insight and effort in the disability insurance claim procedures to be superior. I would recommnend them, which I have done, with my highest level of confidence. In short, you will be well served with this practice.

Dan P.

I had to retire from my career due to a bad back that restricted me from performing my duties. I had LTD insurance and after a few years of receiving monthly benefits from this insurance company, they notified me that my benefits were terminated stating that I don’t qualify due to my duties not fitting into some “national job description” and a nurse had deemed me eligible to go back to work. It’s a crushing feeling to have this told to you over the phone with hardly any information given. Luckily, I came across Dell Disability Lawyers and spoke with Attorney Palamara who calmed me down and stated they would take my case. Within a couple of months my benefits were restored, and I had piece of mind. I cannot thank Attorney Palamara and the staff at Dell Disability Lawyers enough for their professionalism, no nonsense approach, personal and timely communication and quick ability to litigate my case.

Jen S.

I wanted to thank Mr. Symonds and his legal assistant Sonia for their professionalism, guidance and dedication towards my LTD insurance claim. Going through the denial process on my own was going to get me sicker and I knew it was time for help right away. I reached out to Dell Disability Lawyers for assistance and not too long after my call, I was connected with Sonia. Soon after that, I was talking about my case with Mr. Symonds. After a long and tedious process with the LTD insurer, we won the case. The wait can absolutely be lengthy, but in the end, it was all very much worth the fight. Thank you both so much for all that you have done for me! I also want to thank those who assisted in keeping me updated, as needed. Highly recommended for anyone who is going through the brutal process of an LTD denial.

Carl G.

I would like to thank Dell Disability Lawyers for taking care of my case and help me get the insurance coverage that I was rightfully in need of. Specially, I would like to thank Attorney Alexander Palamara and right-hand legal assistant, Sonia Nogueira, who made this process less stressful. They answered all my questions and kept me informed every step of the way.

Don’t get me wrong. They never promised or told me that I was going to win my case, as no one can guarantee that for you. What they did do, was letting me know that they were working hard for me and to keep positive. Something that I recommend everyone to do is to subscribe to their YouTube channel. That will give you an idea on how they operate and why they (for most of their cases) win their cases.

Since I was awarded disability, I am still having surgeries and thanks to them, I’ve been able to cover all those expenses.

Warm regards to everyone at Dell Disability Lawyers!

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Awesome team. Jay and his team, Sonia and Francesca, truly care. This team is very professional and quick to respond. Jay always provided answers in detail to my questions. I strongly recommend Jay Symonds.

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