Sedgwick Disability Claims

Sedgwick Disability Claims

If you’re dealing with Sedgwick Claims Management Services, you may have run up against some roadblocks and frustrations in your disability insurance claim. Sedgwick is notorious for its handling of disability claims, and tends to use preset formulas when evaluating claims. Below, we discuss what to expect when it comes to Sedgwick disability claims and how you can get the benefits you deserve.

What Is Sedgwick Claims Management Services?

Sedgwick Claims Management Services is not an insurance company. It is one of the country’s largest “third party claims administrators.” In other words, Sedgwick does not pay claims with their own money,but they help other companies decide which claims to pay and which ones to deny.  Most of Sedgwick’s clients are companies with “self-insured” disability plans, meaning the employer is paying claims out of its general assets, or, in some cases, a trust established from corporate assets.

Many of Sedgwick’s clients are Fortune 500 companies, including Delta Airlines, HP (Hewlett-Packard), Target, General Electric (GE), and AT&T. Sedgwick also administers claims for some smaller insurance companies that have limited claims processing capabilities.

When a company hires Sedgwick, it gives its claims administrators authority to review and either approve or deny claims. When Sedgwick approves a disability claim, the self-insured plan or insurer will start paying benefits. When it denies a claim, the disabled worker has the right to appeal. Big companies love Sedgwick because it eliminates their involvement in complicated disability claims — and because Sedgwick saves them money by denying a significant number of claims.

Sedgwick Takes a High-Tech Approach to Denying Disability Claims

When you file a long-term disability claim with one of Sedgwick’s clients, you’ll have to complete a variety of questionnaires and forms. You’ll also be assigned an adjuster or claim representative who will review your medical records, information provided by your physicians, and consult with their own medical experts. However, Sedgwick uses some additional tools to assess eligibility.

Sedgwick representatives have broad latitude in determining which claims to pay and which claims to deny.  Most disability claims stand or fall on the medical evidence. Sedgwick maintains relationships companies providing doctors who review disability claims for a fee, and Sedgwick and its corporate clients maintain that those doctors are always independent, free from bias, and qualified to make the medical judgments in question.  In our experience, that is all debatable, at best.

Courts are typically deferential to the decisions of Third Party Administrators like Sedgwick, at least in the absence of compelling evidence that the investigation and analysis has been flawed.  For that and many other reasons, it is crucial to build the strongest possible claim possible when you’re dealing with Sedgwick.

Certainly Sedgiwck’s claim processes are not fool-proof. Sedgwick frequently denies valid disability claims for a variety of reasons. Some, of course, are due to honest mistakes. But there have also been cases where Sedgwick’s fairness has been called into question, too.

Among the reasons Sedgwick might give to deny an otherwise valid claim:

• Alleging that a condition was pre-existing, and therefore excluded by the disability plan, when the insured merely had a precursor or a medical risk of developing the disabling condition.
• Applying the incorrect definition of disability.
• Disregarding credible medical opinions from a claimant’s physician or medical provider.
• Failing to obtain and review a claimant’s complete medical record.
• Favoring medical opinions from its consulting physicians (who never examine the claimant) over more detailed and credible treating physician opinions.
• Ignoring favorable decisions from the Social Security Administration.
• Pressuring physicians to change their stance on a claimant’s ability to work.
• Skewing a claimant’s training and qualifications so that it appears that they are capable of work.
• Terminating long term disability benefits when there has not been a change in the claimant’s condition.

Sedgwick has also acquired a surveillance company, so it frequently tracks and monitors claimants, looking for reasons to deny their claims. (So, if you feel like you’re being watched, you may be right.)

What Should I Do If My Claim Is Denied?

First of all, you need to act quickly. ERISA itself allows disability plans to impose incredibly short appeal deadlines on denied claims — as little as 180 days. Once this deadline expires, you may be unable to file an appeal and dispute Sedgwick’s denial of benefits.

It’s also important to consult with an experienced disability insurance lawyer during the appeal process. Sedgwick disability claims are sometimes difficult to develop. Unless you have a skilled long term disability lawyer at your side, you may make mistakes that cannot be fixed later, and which could cost you valuable benefits or a fair settlement. To learn more about appeals, read our article Should I Handle My Own Appeal?

Filing a disability appeal is a complicated and rigorous process. For example, if your claim is covered by ERISA, you’ll need to make an administrative appeal (with Sedgwick Claims) before you file a lawsuit. If you miss this step, or ignore a filing deadline, you may lose your right to long term disability benefits. You’ll also have a limited amount of time to submit evidence in your claim — once your appeal reaches a federal court, you will probably lose the ability to submit additional evidence — even if it strongly supports your claim and you didn’t hire a lawyer for the early stages of your appeal.

Consult With a Sedgwick Disability Claim Lawyer

If you’re battling Sedgwick Claims Management Services, you don’t need to fight this battle alone. At Robinson & Warncke, our team knows how to handle Sedgwick disability claims. We understand the company’s tactics and can help you respond accordingly. To learn more about our services and to request a free consultation, contact us today.