Sedgwick - Everything You Need to Know about This Disability Carrier

Welcome to Season 4, Episode 28 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Sedgwick." 

Host Nancy L. Cavey, a seasoned attorney with extensive experience in disability claims, discusses everything you need to know about a disability carrier named Sedgwick. Are you insured by, or do you have a disability policy through Sedgwick? Well, today is your day - Nancy will be covering Sedgwick's denial tactics (including their use of in-house medical evaluators), walking through some of their more infamous cases, and more. Even if you're not insured through Sedgwick, this episode will provide valuable insights into the general workings of disability carriers - information you will want to know if and when you are fighting for your disability benefits.

In this episode, we'll cover the following topics:

1 -  Should You Find out if You Must Be Paid Out Your Short-Term Disability Benefits before You File a Claim for Long-Term Disability Benefits?

2 - Can an ERISA Claim Administrator like Sedgwick Get Away with a Denial Based on a Non-Specialty IME in an RSD Claim?

3 - Court Slams Sedgwick’s Use of the Infamous Dr. Gratton in Overturning Wrongful ERISA Disability Claim Denial

4 - What Happens When the Workers’ Compensation Records Are Considered, but Sedgwick Selectively Removes Portions of the Workers’ Compensation Records from Your File When Your Claim Is Denied or Terminated?

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Resources Mentioned In This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://caveylaw.com/get-free-reports/get-disability-book/

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Need help with your Long-Term Disability or ERISA claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Speaker A [00:00:14]:
 Hey, I'm Nancy Cavey, national ERISA and individual disability attorney. Welcome to. Winning isn't easy. Before we get started, I've got to give you a legal disclaimer. This podcast is not legal advice. The Florida bar tells me that I've got to say this, so I've done it. But nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games the carriers play, and what you need to know to get the disability benefits you deserve. So off we go.
 
 Speaker A [00:00:45]:
 Have you ever gone to Sedgwick's website? You might be surprised to read that they say on their website that taking care of people is at the heart, the heart of everything we do. Every year, millions of people around the world contact Sedgwick when they face an unsettling, unfamiliar, stressful event most likely caused by them. Whether a catastrophe, an accident or absence request, or any other type of scenario, they can count on us to listen, no, to respond, denied, to protect them and to help make things right. Well, not so much. The reality, quite frankly, is much different. Sedgwick is not an insurance carrier. They're a third party claims administrator who gets hired to act as an administrator or claims adjuster by a company who is self insured and who just doesn't have their own claims department. They are supposed to be neutral, but in fact they aren't because the reality is that they have a contract with the employer, the administrator.
 
 Speaker A [00:01:50]:
 Now, by the way, they work with big companies like AT and T, General Electric, United Healthcare, Delta Airlines, and I see them on these types of cases. And what I'm going to be talking about today is the huge difference between what Sedgwick says it does and what it really does in ERISA disability claims. I'm going to talk about four things. The first thing is, should you find out if you're going to be paid out your short term disability benefits before you file a claim for long term benefits? Two, can an ERISA claims administrator like Sedgwick get away with a denial based on a non specialty ime in a RSD claim? The third thing I would talk about is how the court slammed Sedgwick's use of the infamous doctor Grattan in overturning a wrongful ERISA disability claim denial. And lastly, I'm going to talk about what happens when workers compensation records are considered sort of, but Sedgwick selectively removes portions of the workers comp records from an ERISA claim to deny or terminate benefits. So let's take a quick break before we get started on these topics. Got it. Welcome back to winning isn't easy.
 
 Speaker A [00:03:22]:
 Ready to get started? Now I'm going to pose a question that may seem odd, and that is, should you find out if you're going to be paid out your short term disability benefits before you file a claim for long term disability benefits. Why is that odd? Well, because most people assume that if they're being paid short term disability benefits, that they're going to be paid long term disability benefits, particularly since it's potentially the same carrier or in the case of Sedgwick, the same administrator. But the problem is that many long term disability policies require that you be paid out all of your short term disability benefits before you become eligible for long term disability benefits. Sounds simple, but it can be complex depending on the terms of your short and long term disability policy or plan. I bet you thought that would be an easy answer. So before you stop working, apply for benefits. I think you should get a copy of both your short and long term disability policy or plan and read them cover to cover. Now, what's important is that they don't always say the same thing, and in fact, they may even use a different definition of disability, strange as that may sound.
 
 Speaker A [00:04:30]:
 So if you screw this up, you can screw up your long term disability claim, and that's hard to fix after the facts. So let me tell you the story about Dennis Claybrooks, who worked for the Eaton Corporation. He was enrolled in both their short and long term disability plans that were administered by Sedgwick. The short term disability plan provided that an employee would be entitled potentially to benefits for 26 weeks if they had a covered disability that prevented them from working. So simple so far, but the plan defined covered disability as occupational or non occupational illness or injury that prevented you from performing the essential duties of your regular position with the company or the duties of any suitable alternative position with the company. Starting to get complex now, short term disability payments could end when you no longer had a covered disability under the plan, were unable to provide satisfactory medical evidence of a covered disability, or began working at Eaton for wage or profit, or with another employer, or was working through self employment. Now it's really starting to get messy. If the employee was disabled longer than 26 weeks, they would be eligible for benefits under Eaton's long term disability plan.
 
 Speaker A [00:05:53]:
 So what were the eligibility requirements for the long term disability benefits? The Easton employee had to have a covered disability, which was defined as the inability to work in any occupation or any other occupation because of illness. The person had to be totally and continuously disabled and unable to perform the essential duties of their regular occupation. Now, again, what's important here is that the plan also provided that you had to have exhausted all of your short term disability benefits. Are you confused yet? Well, it can get really confusing. You got to diagram this out. So what it says would do to screw Claybrooks on May 15, 2019, Clay Brooks was injured on the job when he was struck in the head by a piece of metal, a worker's comp case. While his physical exam was unremarkable, he was diagnosed with a traumatic brain injury. He sought follow up care for headaches and low back pain.
 
 Speaker A [00:07:01]:
 Claybrick submitted a claim to Sedgwick for his short term disability benefits, which were paid from May 23, 2019 through November 11, 2019, just nine days before he would have satisfied the six month requirement. Now, this is a common game played to deny a policyholder or plan beneficiary their long term disability benefits. Nonetheless, Sedgwick suggested he apply for long term disability benefits, which Clay Brooks did. But then, of course, Sedgwick denied his long term disability claim on the basis that he hadn't satisfied the six month payment of short term disability benefits because they terminated his claim. Clay Brooks appealed, as he should have, the denial not only of the short term disability, but the long term disability claim. Sedgwick reversed the denial of the short term benefits because they had a better reason to deny the long term disability claim based on the terms of the plan. Okay, plan B. To screw Claybrooks, Sedgwick had payroll records documenting he had worked without approval part time for five months as a custodian, two days per week during the period of time from January 19, 2020, to May 19, 2020.
 
 Speaker A [00:08:13]:
 So Sedgwick denied the claim. What did the court do? Well, he argued that his employment with a temporary agency after the denial of his claim could not reasonably render him ineligible for benefits. The court found that where the claimant's failure to comply with the requirement of a plan is a direct result of the administrator's arbitrary and capricious denial of benefits, the claimant had no continuing responsibility to comply with the terms of the plan. In other words, because Sedgwick screwed him and terminated his benefits and he then attempted to earn income, the court said, look, Sedgwick can't benefit from their own bad acts. The court found that it would have been futile for him to ask the plan to pay his benefits, which he did, or to approve a rehabilitation program, and as a result, the denial was reversed. So you can see how Sedgwick plays the policy or the plan to its benefit, not to the benefit of the employer's employee policyholder plan beneficiary. Got it? Let's take a break.
 
 Speaker B [00:09:18]:
 Robbed of your peace of mind by your disability insurance carrier, you owe it to yourself to get a copy of robbed of your peace of mind, which provides you with everything you need to know about the long term disability claims process. Request your free copy of the Book@kvlaw.com today.
 
 Speaker A [00:10:03]:
 Welcome back to winning isn't easy. Can an ERISA claim administrator like Sedgwick get away with a denial based on a non specialty ime in an RSD claim? Well, I will tell you, in my opinion, the 6th Circuit got it wrong in the case of Avery versus Sedgwick claims. And I think this is a lesson to be learned for all because you can't depend ultimately on courts to save you from bad acts of people like Sedgwick. Avery developed advanced peripheral demyelination and polyneuropathy of the lower legs as a result of an ankle fracture. Her disability policy was administered by Sedgwick, who, as we know, administers claims in a biased fashion. After she was paid benefits for two years, the standard of disability changed from an inability to do her own occupation to an inability to do any occupation. Now, the game that's played by carriers and claims administrators at this stage is to create medical evidence that a policyholder or plan beneficiary can do sedentary work. So how do they do that? Well, they use liar for hire medical reviewers and not so independent medical evaluators to give them an opinion that the policyholder or plan beneficiary can do sedentary work.
 
 Speaker A [00:11:17]:
 That basically means sitting six out of 8 hours, lifting no more than ten pounds with minimal walking. Now what happens is if in that case, the policyholder or plan beneficiary has to appeal a wrongful denial, and if they're not successful on appeal, they have to file a lawsuit in federal court. What happens in federal court depends on what the standard of review is, and the worst standard of review is arbitrary and capricious. Now that sounds easy, but basically it is a golden handcuff on judges who are really limited as to what they can do in overturning a wrong denial or termination. Now, the preferable standard of review is de novo, and that's where the judge can look at the evidence and reach their own independent conclusion as to whether the denial or termination is legally correct. ERISA regulations regarding claims handling were designed to give policyholders and plan beneficiaries protections. But many times, courts will use what's called a substantial compliance test. This is a court created test.
 
 Speaker A [00:12:25]:
 It's not in the statute, it's not in the ERISA regulations. And they'll use this substantial compliance to say, well, you know, they sort of substantially complied. So my hands are tied. I'm going to uphold this denial of termination. In my opinion, substantial compliance, and I'm going to use a legal term, is bullshit. In Avery's case, Sedgwick had her undergo a liar for hire Ime doctor. Not uncommon. The physician was not a neurologist or specialized in RSD.
 
 Speaker A [00:12:54]:
 Reflex sympathetic dystrophy should be a problem. They had the IME report and her medical records reviewed by neurologists who opined, da da da da. She can do sedentary work. The 6th Circuit ruled that since Sedgwick had a paper review by a neurologist and didn't really review on the non specialist IME doctor, it had substantially complied with the ERISA regulations. Really? ERISA regulations require that a plan consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in medical judgment. And it's not just when you deny the claim. It's during the appeal process. And even if you try to make up reasons, you should be having at least an expert in the field of medicine involved rendering an opinion.
 
 Speaker A [00:13:44]:
 So in my view, the non expert's opinion that was used in the denial was inappropriate. And the court said, well, he wasn't consulted during this appeal. He. His training and experience was procedurally irrelevant. But the problem is that the whole foundation of this denial was based on the non expert. That's where it started. Yeah, they got an IMe. They got an IMe from.
 
 Speaker A [00:14:14]:
 From someone who, again, was not necessarily competent or qualified. And so what we really have, in my view, was a whole denial predicated on non expert opinions. Yeah, you might be a neurologist, but what experience did this neurologist have with reflex sympathetic dystrophy? I tell you, it's a highly specialized diagnosis which is not treated by every physician, much less a neurologist. The court's unwillingness to acknowledge this and to frame their decision is procedurally irrelevant. I think ignores the reality of Erisa claims, where the games are played with the purpose and intention of creating a denial. Remember, Sedgwick said, hmm, they can count on us to listen, to respond, to protect and help make things right. Bullshit. Not in this case.
 
 Speaker A [00:15:07]:
 The court let Sedgwick get away with robbery. Let's take a break. Welcome back to winning isn't easy. The court slams Sedgwick's use of the infamous doctor Grattan in overturning a wrongful Erisa denial claim. Now, again, according to Sedgwick's website, caring counts. For more than 50 years we've been committed to doing the right thing, and we do that by living by our core values of empathy, accountability, inclusion, collaboration and growth. The reality is they do the right thing for them and their shareholders by living their core value of putting profit above what's right for ERISA policyholders or plan beneficiaries. They're not in the business of paying disability benefits, and one of the primary tools that carriers and peer review and people like Sedgwick use are the services of an alleged independent physician to review medical records and determine the policyholder or plan beneficiaries, restrictions and limitations notwithstanding what the treating physician might have said.
 
 Speaker A [00:16:53]:
 Now, really, if you're interested in doing the right thing, you should be listening to what the treating physician has to say and making a decision. Not on that. On that. Not by hiring liar for hire peer reviewed doctors or liar for hire ImE doctors who are giving you a paid opinion to let you deny or terminate benefits. Now, when a denied arrested disability claim ends up in front of a federal judge, the first thing the judge has to do is determine the standard of review. And there are two standards of review. The first and the more favorable one is called the de novo standard of review. I wish everything was de novo.
 
 Speaker A [00:17:30]:
 That means that the court and the judge can substitute their judgment for that of the disability carrier plan. The second and less favorable one is the arbitrary and capricious standard of review. And the question is not whether the decision is right or wrong. Got that? The question is not whether the decision is right or wrong, but whether the denial is arbitrary and capricious. So one of the ways that the disability carriers or plans argue that the denial was not arbitrary and capricious is the fiction they create for the court by securing a liar for hire medical opinion that create the reason to justify the claims denial. Now, one of those physicians is Doctor Howard Grattan, and he's commonly used in the ERISA disability word. You can just do Google scholar and you'll see him. You don't have to take my word for it.
 
 Speaker A [00:18:18]:
 But let's talk about the case of Chaco versus AT and T. Chako was a software engineer who began working for AT and T in 1997 and 20 years later began experiencing severe pain and ache in her eyes, neck, shoulder and in both arms, as well as blurred vision. Sedgwick claims management services is the servicing agent for at and t. They paid her short term disability benefits and after three months of paying long term disability benefits, they denied her claim on the basis that the medical evidence does not support ongoing disability. And guess who rendered that opinion? The infamous doctor Howard Grattan. He's got quite a track record. And the court noted that track record in this particular case. In fact, the judge noted that and suggested that Doctor Grattan harbored a bias in favor of the plan, which warranted a moderate level of skepticism about the good doctor Grattan's medical opinions.
 
 Speaker A [00:19:18]:
 Now his track record suggests that he is more than just biased. The judge noted that Doctor Grattan found that only eight out of the 61 claimants who had filed disability claims under the AT and T plan were disabled, just 13%. And remember, of course, Sedgwick is all about doing right all the time. Grattan found that 50 of the claimants, 82%, were not disabled. I want you to check out this opinion. Check out Google Scholar. What do you think? You can see that doctors like this are tools, tools for the disability carrier or for the TPA. And they make a really good living giving carriers what they want to create and justify a claims denial or termination.
 
 Speaker A [00:20:04]:
 The judge overturned the claims denial and you can be assured that I added this decision to my laundry list of cases that we cite when we're dealing with an appeal involving the good doctor Grattan. Remember, Sedgwick said they can count on us to listen, to respond, to protect and help make things right. The court, and not Sedgwick, made it right. Let's take a break.
 
 Speaker B [00:20:28]:
 Are you a professional with questions about your individual disability policy? You need the disability insurance claims survival guide for professionals. This book gives you a comprehensive understanding of your disability policy with tips and to dos that will assist you in submitting a winning disability application. This is one you dont want to miss. For the next 24 hours, were giving away free copies of the disability insurance claim survival guide for professionals. Order yours Today@disabilityclaimsforprofessionals.com. dot.
 
 Speaker A [00:21:28]:
 Welcome back to winning isn't easy. What happens when the workers compensate? Compensation records are considered in an ERISA disability claim, but a TPA or carrier like Sedgwick selectively removes portions of the workers comp records from the file to deny or terminate benefits. Now, are you surprised? Many claims for risk of disability benefits can arise out of a worker's compensation claim. And the question becomes, should your workers compensation records be part of your ERISA disability carriers file? Now, this is a hard question to answer. I am also, in addition to being an ERISA disability attorney, Social Security attorney, a workers comp attorney, and I know, based on my years of experience doing both claim and defense work, that work comp doctors are not supportive of a workers comp claim. Having defended many workers comp claims, I know that defense doctors know where their butter, their bread, and their bread is buttered, if you will. They know who pays. They know who is going to be sending them a stream of clients.
 
 Speaker A [00:22:37]:
 They know that their income depends on doing basically what the work comp carrier wants them to do. Now, if the work comp doctor is supportive, then certainly we want those records to be part of the long term claim. But the general principle is that the disability carrier is going to obtain the workers comp records and they're going to consider those in making a claim determination, and they may even selectively remove portions of the records when they produce your claims file to us in the course of ERISA litigation. If you don't think that happens, you're wrong. And hiding things and removing things in the claim file is common practice. Now, under ERISA regulations, the administrative record is to be produced in litigation, and the court reviews what was considered. All of the documents, the records, other information, the Social Security file, the medical records. In fact, under ERISA regulations, documents, records and other information that were relied upon in making the benefit determination were submitted, considered, or generated in the course of making a benefit determination without regard to whether the document record or other information was relied on, needs to be produced, and there has to be a demonstration of compliance with administrative processes and safeguards required by ERISA.
 
 Speaker A [00:24:00]:
 So that's the starting framework. But how does this work in reality? So again, let's talk about the Chaco case, Chako versus at and T. Chako was a software engineer who began working for at and t in 19, 97. 20 years later began to develop problems with her neck, her shoulders, and both of her arms with tingling and numbness. Sedgwick claims management services just so happened to be the servicing agent for their workers compensation claims and their short and long term disability claim. Now, Sedgwick paid her her short term disability benefits, and after several months of paying her long term disability benefits, denied the claim on the basis that the medical evidence did nothing support ongoing disability. Well, guess who tried to hide the ball when the case ended up in litigation. Sedgwick claims management services.
 
 Speaker A [00:24:57]:
 They had the workers compensation file in its possession when it decided the long term benefits, and it explicitly relied on certain parts of the workers comp file when it denied her claim. When Sedgwick produced her claims file in litigation, they didn't include 147 pages of records from the workers comp file, which included medical records in the form of progress reports and work status reports. Well, how did Chatko know that Sedgwick was hiding the records and took the records out? Well, Sedgwick sent her medical records to a peer reviewed doctor who summarized all the missing records in this part of his report. Obviously, Chaka wanted the federal judge to review all those records as part of the lawsuit and filed a motion with the court saying, look, the records should be supplemented with these records that they removed. And guess who objected? Not only didn't they want the judge to review the records, they didn't even want them to consider them. As I said, Sedgwick was the workers comp carrier for the employer and the work comp progress reports were sent to Sedgwick as the workers comp administrator. It had Chaco's workers compensation file in its possession and in fact used it in denying the claim, didn't necessarily directly quote it. That would have given up the game that they had the file.
 
 Speaker A [00:26:21]:
 It was only again through the peer reviewed doctor that we all that they all found out and I was not involved in this case about the workers comp file. Now the judge was not impressed, particularly since the peer reviewed doctor reviewed and considered these reports. In preparing his report that Sedgwick relied on in denying her long term claim, the judge granted Chaco's request to expand the record to receive the workers comp records. So if you suspect that you're a risked disability carrier or plan or the plan administrator is hiding the ball, it's time for you to consult with an experienced ERISA disability attorney because all relevant material evidence needs to be submitted as part of an appeal. And if the denial is upheld, then you certainly do need to hire an experienced arrested disability attorney because you'll have the need to file a lawsuit in federal court. And as I've said, as part of the lawsuit, they have to produce the claim. Now the claims file, they also have to produce the claims file during the appeal process. And I will tell you, I often look at that claims file that they produced during the appeal and the claims file they produce in litigation.
 
 Speaker A [00:27:36]:
 Do you think that they're the same thing? No. Another fertile ground for arguing that a denial or termination was inappropriate I hope you've enjoyed this week's episode of Winning isn't easy. Please like this page, leave a review, share it with your family or friends, subscribe to this podcast, and that way you'll know when an episode comes out. Please tune in next week for another insightful episode of Winning isn't easy.