More on Sedgwick, P2

Welcome to Season 5, Episode 2 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "More on Sedgwick, P2."

Join attorney Nancy L. Cavey, a seasoned expert in disability claims, as she takes a deep dive into Sedgwick, a prominent disability insurance carrier. Nancy unpacks Sedgwick’s approach by analyzing real-life cases - each with unique backgrounds and experiences. Through these stories, you'll uncover valuable insights and key lessons about how Sedgwick manages disability claims. 

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

1 - The Story of Ms. Foster

2 - The Story of Ms. Brock

3 - The Story of Ms. Castor

4 - The Story of Mr. Keaton

5 - The Story of Ms. Knott

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.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Navigating Your Social Security Disability Claim. Give it a listen: https://wiessdpodcast.buzzsprout.com/


Resources Mentioned in This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

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

Nancy Cavey [00:00:00]:
 Foreign welcome to Winning Isn't Easy. I'm Nancy Cavey. I am a nationwide individual disability and ERISA disability attorney. Before we get started, I've got to give you a legal disclaimer. This podcast is not legal advice. The Florida Bar association says I've got to tell you that. So now that I've done that, nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that disability carriers or plans play, and what you need to know to get the disability benefits you deserve. So, off we go.
 
 Nancy Cavey [00:00:43]:
 Today I'm going to be talking about Sedgwick. Now, I've talked about Sedgwick once before, but what can I say? When carriers or servicing agents don't do what they need to do, they're the subject of litigation. So let's talk about Sedgwick once again. Now, they were once a very large British insurance broker who were bought out by Marsh McClellan in 1998. And they are, among other things, a risk management company. And what that means is that they were helping to manage risk. And that can be done in a way that minimizes the expenses or exposure of an employer or a carrier or a plan. Get the hint here.
 
 Nancy Cavey [00:01:33]:
 Now, Sedgwick is also a third party administrator of disability claims. What does that mean? That means that the employer has set up a disability plan and they've hired a third party to administer the claim. Now, if you aren't doubting me, go and Google Sedgwick and what you're going to see is their disability and abstinence management page. They brag about the Sedgwick difference, and that's not a difference. That is good for you as a policyholder or plan beneficiary. Now, what they brag about is how they manage absences for the benefit of the employer and not the disabled plan participant, despite what they say on their site. And again, if you don't believe me, I would suggest you just Google complaints about Sedgwick. What I'm going to be doing today is going through an overview of Sedgwick by examining a number of cases.
 
 Nancy Cavey [00:02:24]:
 These cases have different stories, different origins, and different interactions with Sedgwick. But the common thread, I think, are the lessons that you can learn about how Sedgwick, as the third party administrator, handles claims. Now, what we talk about today is also applicable, in my view, about how disability carriers and plans handle these claims. It's not necessarily unique to Sedgwick, but Sedgwick has a few twists that we'll talk about. Got it. So we're going to talk about five things today and I'm going to be telling stories. I'm going to tell five different stories about different people who had claims that were involved with Sedgwick. So I guess this is going to be the story time version of Sedgwick.
 
 Nancy Cavey [00:03:09]:
 Got it. Let's take a break for a moment before we get started with my storytelling. Welcome back to Winning in Isn't Easy. I'm going to tell you about the story of Ms. Foster and her dealings with Sedgwick. Now, she was sort of a beneficiary, if you will, of a short and long term disability plan that had been created by SunTrust. This was administered by Sedgwick SunTrust. Short term disability benefits were paid from SunTrust General Assets and required objective medical evidence of disability.
 
 Nancy Cavey [00:04:05]:
 So in other words, any benefits were paid out of the pocket of Sun Trust, her employer. Now, ultimately what happened was that her claim for short and long term disability benefits were denied and this case ended up in federal court under the ERISA statute. SunTrust, however, argued that the short term disability plan was exempt from ERISA since it was a plan that was paid for by the general assets of the employer and was entirely separate from an employee benefit plan. Now, the court agreed and found that ultimately it was a payroll practice which was exempt from erisa. Now, normally that's a good thing because ERISA is not necessarily a friendly place for a disabled plan beneficiary or policyholder to be. It's really slanted, I think, in terms of the benefit of the disability insurance carrier or the plan. And one of the things that you'll see is that every circuit in the United States and there are 11 plus the district of Columbia, have their own way of interpreting the ERISA statute. So that means that there are potentially 12 different ways that this statute can be applied, and it is applied differently in different districts.
 
 Nancy Cavey [00:05:26]:
 In this case, because it was not an ERISA plan, the judge was able to look at what they did. What did Sedgwick do in administering the plan? And unfortunately, the court upheld the denial of the claim on the basis that there wasn't objective medical evidence as required by the terms of the plan or the policy. And ultimately, of course, this can make it difficult for you to get the disability benefits you deserve. One of the things I always want to do from the very beginning when a person consults with me about filing a disability application for them or to file an appeal of a denied claim is to look at that policy or plan to see exactly what it is. The proof is you, the policyholder, the plan beneficiary, have the burden to prove whatever the policy or plan requires you to prove. Generally, you have to prove that you are disabled, as that term is defined. And it could be defined as the inability to do the material and substantial duties of your own occupation. It also could require objective evidence.
 
 Nancy Cavey [00:06:35]:
 For example, the FedEx plan requires objective evidence and in that instance the FedEx or in this case SunTrust is going to have their administrator look at the medical evidence and determine whether or not there is one objective evidence, and then two, whether or not that objective evidence proves that the plan beneficiary meets the standard of disability. So the terms of the policy, of the plan can make all the difference. And in this case, the court agreed with both how SunTrust and Sedgwick handled the claim. Got it. Key here is let's look at the policy or plan and determine one, whether or not it's covered by erisa. And then two, let's look at what the policy, plan or the policy or plan provisions say about the definition of disability and what you have to prove to get the disability benefits you deserve. Got it. Let's take a quick break.
 
 Speaker B [00:07:39]:
 Have you been 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.
 
 Nancy Cavey [00:08:05]:
 Welcome back to Winning isn't Easy. The get out of jail free card and a discretionary clause in a Sedgwick administered plan. This is the story of Ms. Brock. So, as I have repeatedly said in the course of this podcast series is that you really need to understand the terms of the policy or plan because that policy or plan will define for you things like the definition of disability, the definition of occupation, and it will explain to you the standard of proof. Do you require objective medical evidence? Are benefits limited? Do you to just two years for subjective medical conditions or mental nervous condition limitations? But one of the most important clauses in a policy or a plan is what I call the get out of jail free card known as the arbitrary and capricious standard of review. Now I want you to make no mistake about it. You are not on a level playing field with any carrier or administrator if the plan or policy has the arbitrary and capricious standard of review.
 
 Nancy Cavey [00:09:14]:
 The arbitrary and capricious standard of review is not what it sounds like, and here in the 11th Circuit, the standard of review is a multi part step. But I'm going to boil it down to the three primary steps. First, the judge has to determine whether or not they agree with the decision. If they agree with the decision, you lose. If the judge says, I don't like this decision, the analysis as a practical matter goes on to the question of whether there was enough stuff in a carrier or plan administrator to justify that claim's denial. And this is where we start getting into the arbitrary and capricious standard of review. If the judge agrees with Sedgwick, for example, in this case, then you're going to lose. But if the judge says, hey, I don't like this decision and there's not enough material that justifies this decision, at least in the 11th Circuit, we go on to the question of bias.
 
 Nancy Cavey [00:10:13]:
 And that is, was that Sedgwick decision influenced by their role as the decider of the benefits and their role as the administrator? What happens here is if standard review finds that Sedgwick's interpretation was in any way reasonable, it doesn't matter how, how much evidence you've submitted in the appeal, you're going to lose. So let me illustrate that. And remember, please, this holds true in any policy or plan that has the arbitrary and capricious standard of review. How it might be interpreted in your circuit is a different matter by circuit to circuit. But in this case, Ms. Brock worked for AT&T in a sedentary position as a clerk, and she became disabled as a result of essential tremors and neuropathy. She filed a claim for short term disability benefits, was denied, and on appeal, two liar for hire peer review providers opined that there was no objective medical evidence that she was disabled and they attempted to talk to her treating provider, Dr. Kumar.
 
 Nancy Cavey [00:11:18]:
 Dr. Kumar never indicated in his medical records that she was disabled and noted that her symptoms were controlled with medication. Now, obviously that's not very helpful when your physician isn't willing to address in your medical records your restrictions and limitations and note things that are indicative of, or could be indicative of an ability to work. So ultimately, she files an appeal that's denied, she files a lawsuit. And she claimed that Sedgwick's decision was arbitrary and capricious because it was only based on of those liar for hire peer review doctors who never examined her. Now, this case found that Sedgwick's reliance on the on the file review standing alone was not arbitrary and capricious. The file review would be considered inadequate when it would be established that the physicians really did not review the full record or summarily objected. Sorry.
 
 Nancy Cavey [00:12:19]:
 Rejected treating physician's opinion without providing reasons for that rejection. Now, you have to understand there is no treating physician rule in an ERISA disability case. This arbitrary and capricious clause really gives a license, a license to steal to the disability carrier or the plan. The court noted that the lack of a physical examination was not a determining factor as to whether or not the denial was arbitrary and capricious when the plaintiff, Ms. Brock, hadn't shown how the physical exam would result in a different decision. Now, I think this case might have been different if the physical exams as reported by her treating physicians showed objective findings that would corroborate her claim that she was disabled. But in this instance, her doctor never addressed that particular issue. So it was a very difficult road, I think, for Ms.
 
 Nancy Cavey [00:13:14]:
 Brock to prove that this decision was arbitrary and capricious. And as a result, the court upheld this denial. Are you beginning to see a pattern? Let's take a break for a moment. Foreign welcome back to Winning isn't easy. The standard of review is crucial. So let me tell you the story of Ms. Castor. As I've pointed out, Sedgwick has a nasty habit of denying benefits during a short term disability period.
 
 Nancy Cavey [00:13:59]:
 And it's particularly true just as the claim starts to transition from short term to long term disability. That's a pattern I've noticed over the many years that I've been involved in handling ERISA disability claims. So let me tell you the story of Castor versus AT&T umbrella benefit plan. Castor was a 15 year employee of Ohio Bell Telephone Company and she became disabled as a result of abdominal and intestinal problems. She filed a claim for short term disability benefits. And just as she recovered from the infection involving her digestive tract, she was hospitalized for congestive heart failure and atrial fibrillation. Now, just before her 52 weeks short term disability benefits expired, her cardiologist suggested that she had improved and she could return to work. So guess what? Sedgwick did a file review and their lie for hire peer review doctor and that she could have returned to work weeks before having difficulties with her heart.
 
 Nancy Cavey [00:15:06]:
 Now, instead of challenging the denial on the basis that she still remained disabled as a result of either the gastroenterological problems and the cardiological problems or the gastroenterological problems alone, she changed tacts. And she now claims she was disabled as a result of a psychological issue. When you look at the medical records, there was nothing. The psychological symptoms. And of course, you would expect that Sedgwick's paper review doctors would say that she would be able to work from a psychological standpoint, and that's exactly what happened. So she files a claim, ultimately, that's denied. The appeal was denied. And then she files a lawsuit claiming that it was improper for Sedgwick to use the same doctor who had reviewed the file at the time of the initial denial second time around.
 
 Nancy Cavey [00:15:55]:
 So the same doctor got his second bite at the denial, but for a different reason. And what the court said was, well, look, just because Sedgwick used the same doctor on the appeal to review this new claim of psychological issues isn't arbitrary and capricious, particularly since Sedgwick actually had two new doctors review the psychiatric aspects of her case, and, as expected, they felt she was capable of working. Now, she also claimed that this was arbitrary and capricious, which is really a handcuff on judges. And she argued that the judge should overturn this denial because the peer review doctors did not have the full information about her occupational duties. And again, this was not a well thought out case, I think, because the peer review records actually did address the occupational issues in her case. So I think it takes an understanding of the games that plan administrators like Sedgwick engage in. They're going to be using this arbitrary and capricious standard of review to create evidence that will support a denial that will be upheld by the court. And arbitrary and capricious isn't what you think it means.
 
 Nancy Cavey [00:17:23]:
 It's not that it's arbitrary and it's not that it's capricious. It's basically in English. Means that is not supported by something in the record. And, of course, that something is something that the disability carriers have created through their liar for hire people, peer review doctors. That isn't to say cases can't be appealed, but you've got to understand the game. And you can see in this case, it was an easy win for Sedgwick, and the court upheld the denial. Got it. Let's take a break.
 
 Speaker B [00:17:55]:
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 Nancy Cavey [00:18:35]:
 Welcome back to Winning Isn't Easy. Let's talk more about the arbitrary and capricious hammer that Sedgwick will use and the story of Mr. Keaton. As I have repeatedly said, it's really key that you understand the terms of the disability policy or plan because there are traps within this, the language of the policy, of the plan. One of the things that you will see, and Sedgwick is famous for this, is when they become the plan administrator, which means that they're going to manage the claim. They want to make sure that in the plan language, there's language that gives them the discretion to interpret the terms of the plan and to make a decision as to the person's entitlement to benefits. That's called the arbitrary and capricious standard of review. And Sedgwick makes sure that that that language is in the plan and in the documents that give them authority to administer the claim.
 
 Nancy Cavey [00:19:32]:
 And that's ultimately a handcuff on a federal judge because the judge has to apply the arbitrary and capricious standard of review in looking at whether a denial or termination of benefits was correct. And arbitrary and capricious doesn't mean what you think it means. So let me explain. I'm going to tell you the story of Keaton v. Sedgwick claims and Time Warner Cable. Keaton was a major account executive who became disabled as a result of multiple medical conditions, including coronary artery disease. Now, his doctor said he couldn't work in any capacity as he was recovering from a cardiac catheterization. Sedgwick, as they always do, had this claim reviewed by 2 liar for hire peer reviewed doctors who said he was clinically stable and there was no objective evidence supporting his disabling claim, disabling symptoms.
 
 Nancy Cavey [00:20:23]:
 So the other game that they play is they will deny the claim just before the end of the short term disability period and before it transitions to ltd. That's important because most of the plans that Sedgwick administer require that a person exhaust their short term disability benefits before they become eligible for long term disability benefits. So his claim for long term disability benefits was denied because he didn't meet the elimination period, wasn't paid the full period of his short term disability benefits. Now, ultimately he filed suit claiming that Sedgwick was wrong in denying his claim because they never requested medical records he authorized them to obtain, didn't have an IME and only made the decision based on the attending physician statement forms that his doctor filled out. So what does the judge do? Well, the judge gets out that plan language and sees that the, in this case, the plan had given Sedgwick the sole authority to determine benefits and to determine and interpret the entitlement to the interpretation of the plan language and to make that determination of disability. So the judge understands that there's a handcuff on what they can do because Sedgwick has the sole authority. And the only way that they can overturn it is if it's arbitrary and capricious. So the next thing that the judge does was looks at the attending physician statement form that the physician completed, and the physician only certified disability for 31 days.
 
 Nancy Cavey [00:22:02]:
 Now, Sedgwick had reached out to his treating physicians to clarify this, and they physicians didn't respond. The liar for hire peer review doctor who opined that this was, you know, that he could work, outlined the multiple medical records that they had available for the review. So Sedgwick had the sole authority to decide. They reviewed the medical records, they concluded that it didn't support his claim, and then they hung their hat on the APS form that only certified disability for 31 days. And again, the games that Sedgwick play are enumerated again in this case. But you can see the result is the same. Once again, I think that the proof wasn't there and should have been there if they could get it from the treating physician or get an IME to address this issue. But it was clear from the beginning of reading this case what the result was going to be.
 
 Nancy Cavey [00:23:03]:
 Got it. Let's take a break. All right. The story of Ms. Knott and Sedgwick's use of the appeal process. Now, I will tell you that in an ERISA case, you have to file an appeal. If the claim has been denied, you have 180 days in which to appeal. And that is the trial of your case.
 
 Nancy Cavey [00:23:42]:
 There is no real trial like you see on tv. Ultimately, if parties don't resolve the case, it's decided on what's called a motion for summary judgment. A bunch of pleadings we lawyers write, and the judge ultimately decides whether the person is entitled to their benefits. Now, in writing the appeal, you have to understand the terms of the disability policy or the plan. Among those are, what's the definition of disability? What's the definition of occupation? What's the nature of the proof? And by the way, what's the vocational evidence and medical evidence that they're relying on in, in creating this denial or termination? And if you don't understand any of this, and you certainly don't have a copy of the claims file, it's going to be really hard to write a winning appeal letter. So let me tell you the story of Ms. Knott and how the claim was doomed. She worked for Allegiant Technologies and she was paid 52 weeks of own occupation benefits.
 
 Nancy Cavey [00:24:49]:
 What will happen normally is that after one or two years, benefits will change from an inability to do your own occupation to an inability to do any occupation. And when she filed the lawsuit, she subsequently tried to introduce new evidence that was outside of the claims file, including a letter from her treating provider disputing that he had had a call with Sedgwick's providers, as alleged in the final denial letter. Now, the court said, no way, I'm not letting that in. And they did that on the basis that under the arbitrary and capricious standard of review, the court can only look at what was in the administrative record, the claims file, through the, you know, through the appeal process. Now, in this particular instance, this alleged conversation was first mentioned in the, in the final denial letter. Um, but, and I quite frankly think that was problematic. But hopefully that letter could or should have been submitted before the time deadlines, because, remember, have 180 days in which to file an appeal. They have two 45 days, 90 days in which to respond.
 
 Nancy Cavey [00:26:03]:
 And certainly under ERISA regulations, you do have the right to respond to that type of evidence. But in this instance, the court said no. There's been a review of the file by the liar for hire doctor. They reviewed the peer review reports, they reviewed the vocational report, they considered evidence. And the fact that there was this little telephone conference mention between the treating provider and the peer review doctor isn't, is not arbitrary and capricious. It's just one of those factors in the myriad of evidence and analysis they did in arriving at the basis for the denial or the termination. Now, I think that that analysis was absolutely wrong, but that's ultimately, of course, what the court did. You can see the games that are played by disability carriers and plans like Sedgwick.
 
 Nancy Cavey [00:27:01]:
 The first key is they're going to try to have an arbitrary and capricious standard of review. They're going to give the TPA like Sedgwick or the carrier or the plan administrator, the discretion to determine what that language in a policy or plan means. They're going to give them the authority to determine entitlement to benefit. They're going to plan, play games with this transition period from short to long term disability benefits. So that they can argue that the policyholder plan beneficiary is not entitled to the balance of their short term disability benefits and is not entitled to long term disability benefits. They're going to use the language of the policy or plan. If there is an objective evidence requirement. They are going to be looking at those medical records with a fine tooth combination looking for objective evidence that they can attack or hanging their hat on the lack of objective evidence.
 
 Nancy Cavey [00:28:01]:
 And they're going to create a web, if you will, a tale of what are the reasons for this denial or termination of benefits. They're going to create a story and you need to be able to create your own story that rebuts what's going on. You've got to argue that their activity is arbitrary and capricious, that they have misinterpreted the terms of the policy or plan, that the evidence that they have created or the reasons that they have created for the denial or termination are arbitrary and capricious by attacking the basis of the opinion, what information they may have had, what speculation they they their peer reviewed doctors are making in denying the claim. So you want to argue the totality of their their actions. There are 12 circuits, federal circuits in the United States, the 11th and the 1st to the 11th and the district of Columbia. Each of them have their own standard of review. And so part part of the reason why you should have a lawyer is because the lawyer will understand what that standard of review is and what that particular circuit court is looking for to make a successful argument that the decision to deny or terminate your benefits were arbitrary and capricious. We've had a lesson today in Sedgwick claims handling, but also, I think, in the claims handling of disability plans and carriers.
 
 Nancy Cavey [00:29:34]:
 I hope that you have enjoyed this week's episode and you've learned something about the games that disability carriers or plans will play. If you've enjoyed this episode, please like our page, leave a review, share it with your family and friends. And of course, subscribe to this podcast. This way you'll know when our next episode comes out and you can tune in. Thanks and we look forward to talking with you next week for another insightful episode of Of Winning Isn't Easy.