A disability attorney recently filed a federal ERISA lawsuit against both UnitedHealth Group Long-Term Disability Benefit Plan (UHG) and Sedgwick Claims Management Services (Sedgwick) after the client was wrongfully denied long term disability benefits.
The plaintiff, John Doe, was employed by UnitedHealth Group, Inc., who provided short-term and long-term disability benefit plans to the Plaintiff. By virtue of his employment, the plaintiff was covered by UnitedHealth’s Short-Term and Long-Term Disability Group Policies.
The Facts of the Case Against UnitedHealth Group Long-Term Disability Plan and Sedgwick Claims Management Services
Plaintiff worked as a recruiting manager for UnitedHealth Group, Inc. beginning in 2006. UHG is a group of health care companies with its principal place of doing business being located in Minnesota.
Plaintiff was a participant of UHG’s short-term and long-term disability benefit plans.
Terms of the Plans include:
- Short-Term Disability Plan provided income protection and pay benefits to disabled UHG employees for up to 180 days after the disability occurs.
- The Plan was funded by UHG and administered by Sedgwick.
- Long-Term Disability Plan provided income protection and pay benefits to disabled UHG employees after a 180-day waiting period and during their periods of disability up to certain maximum benefit periods.
- For the first 24 months, the LTD plan was funded by UHG and administered by Sedgwick.
Other Terms of the LTD Plan included:
- Participant is “Disabled” if he/she is unable to do the Material Duties of his/her Own Occupation due to a medical condition and is unable to earn at least 80% of his/her adjusted Earnings after inflation from working in his/her Own Occupation.
- The “Medical Condition” needed to be proven with clear documentation from the Physician supporting Participant’s Disability.
- Limited benefit payments to a maximum of 24 months for disabilities that were caused or contributed to by a mental disorder unless the patient was confined to a hospital at the end of the 24-month period, in which case, Participant would receive benefits as long as he/she remain hospitalized and under age 65.
Plaintiff developed anxiety and depression that became more severe as he worked with UHG. His mental health conditions were complicated further by the fact that he had to take many medications that were prescribed for his mental health conditions.
Plaintiff’s mental health providers recommended that he take a disability leave. As a result, Plaintiff left work after November 24, 2009.
Plaintiff applied for STD benefits and received them for the entire 180-day period of STD benefit entitlement.
Denial of UnitedHealth and Sedgwick Disability Benefits Claim
On November 23, 2010, Sedgwick terminated Plaintiff’s LTD benefits as of November 1, 2010 because the medical evidence no longer indicated that the Plaintiff was disabled. Sedgwick mentioned that Plaintiff had 180 days to file an appeal.
Plaintiff talked with Sedgwick’s representatives on November 23, 2010 and November 29, 2010, telling them the LTD plan required that he provide objective information to support his claim.
On or about December 2, 2010, Plaintiff submitted his appeal form to Sedgwick. Plaintiff included letters from both mental health providers that he was still disabled due to severe depression, which led to weight loss, poor appetite, poor energy, poor concentration, and feelings of hopelessness and helplessness.
On or about December 22, 2010, Sedgwick had a board certified psychiatrist to review the Plaintiff’s report. This doctor’s report on the Plaintiff was made on or about December 30, 2010, agreeing that the Plaintiff was disabled from full-time work, but also stating that the Plaintiff was capable of part-time work.
Sedgwick’s doctor’s addendum on January 3, 2011 added that the Plaintiff has been compliant with treatment of his condition except for turning down a referral to an IOP program that could accelerate improvement in the Plaintiff’s mental health symptoms.
On January 17, 2011, Sedgwick upheld the termination of the Plaintiff’s LTD benefits mainly due to the fact that Plaintiff turned down a referral to an IOP program that could accelerate improvement in the Plaintiff’s mental health symptoms. Sedgwick alerted Plaintiff that he could file a second appeal.
On or around January 25, 2011, Plaintiff was found disabled by the Social Security Administration and awarded SSDB benefits as of May 2010. Plaintiff notified Sedgwick of this development.
On February 4, 2011, Plaintiff filed second appeal to Sedgwick.
On February 7, 2011, Sedgwick notified Plaintiff that it had made a mistake in stating that the Plaintiff had the right to a second appeal, as Plaintiff’s plan did not provide for a two-level appeal process.
On February 8, 2011, the revised appeal denial letter to the Plaintiff no longer allowed for a second appeal.
On or about February 9, 2011, Sedgwick and Allsup recovered $12,030.00 from Plaintiff because of the receipt of SSDI benefits for periods of time that coincided with Plaintiff’s receipt of LTD benefits.
Disability Lawyer Files Lawsuit Against UnitedHealth And Sedgwick
According to this lawsuit, Plaintiff claims that
- He should have received LTD benefit payments from Sedgwick according to the terms of the LTD plan.
- Sedgwick denied the Plaintiff those benefits, causing it to be in breach of the Plan and ERISA for failing to provide those benefits.
Relief Sought By The Plaintiff In The UnitedHealth And Sedgwick Lawsuit
Due to Sedgwick’s actions, Plaintiff requests the following relief from the Court:
- Pay Plaintiff all past due LTD benefits, along with interest.
- Reinstate Plaintiff to the LTD plan.
- If there is time left on the 24-month period for mental illness benefits, the Plaintiff should receive the monthly LTD benefits according to the terms of the Plan.
- Plaintiff should receive costs, disbursements, and other expenses connected to this lawsuit, as well as reasonable attorneys’ fees and experts’ fees.
- All other relief that the Court judges to be just and proper.
In the above referenced case our firm did not represent the Plaintiff and had no involvement in the case. The plaintiff in this case was or is represented by a Minnesota Disability Lawyer that is not in any way affiliated with our firm. The information in this post comes from our review of a Complaint that was filed in Federal Court as a public record. This post has been modified from a previous version.