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One of the first things you notice when you visit Sedgwick’s website is their claim that “taking care of people is at the heart of what we do.” Sedgwick is not an insurance company itself. It is a claims administrator, helping self-insured companies decide whether to grant or deny benefits. Even though Sedgwick is not writing the check itself, it acts the same way any insurance company will.
When you need to file a claim with Sedgwick, you want a long-term disability insurance lawyer from J. Price McNamara ERISA Insurance Claim Attorney on your side.
We have faced off with companies like Sedgwick since 1995, and we have obtained six and seven-figure settlements and verdicts for our clients. Learn how much we might obtain in disability benefits for you by consulting with our legal team, as every case is unique.
Sedgwick claims that it has “expert operational and national practice teams” to “support human resource professionals with compliance and benefit administration solutions.” Sedgwick states that:
“Our clients count on us to support and improve the health and productivity of their workforce and consumers in a cost-effective, efficient, and caring way.”
Sedgwick works with many Fortune 500 companies that may not want to pay premiums to an insurance company to provide a policy. To be clear, Sedgwick’s service does not pave the way for your claim and make it easier for you to receive long-term disability benefits.
Also, you are not Sedgwick’s client, nor are you their concern. Sedgwick is about helping its clients make money and pay out less in claims. If Sedgwick were too permissive in granting benefit claims, their large Fortune 500 clients might not be their clients much longer because they look to claims administrators to do their dirty work while saving them money. If Sedgwick “costs them” too much money, they may shift their business to a benefits administrator who has “better claims management practices.”
You can count on Sedgwick to scrutinize your claim with a fine-tooth comb. Your relationship with them can be adversarial because they are not on your side. Even though it is not their money on the line, their relationship with their clients is. In a sense, a benefits administrator acts as a guard dog for their self-insured clients. They play the heavy and the bad guy for a fee, leaving you to fight when they wrongly deny your claim.
When dealing with a company like Sedgwick, you must make sure that your claim is extensive and error-free when you first file it. You should understand that Sedgwick is just looking for a reason to deny your claim. The law favors companies like them, and they only need a credible reason to deny your benefits.
Therefore, you must expend the necessary effort to build as strong a case as possible when applying for benefits. Consult our experienced ERISA long-term disability attorney before you file the claim to file a more robust application.
Here are some things to consider when you are filing an ERISA long-term disability claim:
Even if you do everything right, Sedgwick may deny your claim. Even though the benefits administrator does not have their own money on the line, they like to tell their clients the value they add. That value is not to you. Benefits administrators can be every bit as difficult as an insurance company. They can be even worse in some ways because they do not want to lose a significant account.
Sedgwick may deny an ERISA long-term disability benefits claim because it claims:
These long-term disability plans are still an employee benefit, and they are subject to ERISA. The law gives you appeal rights, even though the system established by the law is not extremely helpful to claimants.
Here is what you should do if the administrator denies your claim:
As the claims administrator, Sedgwick also has the first-line responsibility to review your appeal. They get to decide whether they made a mistake in the first place, even if this seems like a formality that you have to go through before you can go to court.
While you may have a chance of persuading Sedgwick to reverse their denial and grant you benefits, they may not be your ultimate audience. The record you put together to appeal your denial to them is the same one the judge will review if your case goes to the next step of the appeals process.
You only get one chance to build the record that supports your entitlement to benefits in an ERISA appeal. It comes at the insurance company appeals phase of the process. At that point, the record is essentially locked down. The federal judge cannot let more information into the record without an excellent reason. Therefore, if you get a late start on your appeal or do not take the process seriously enough, you may not have enough to persuade the judge.
Many cases will end up in federal district court because that is where the law tells you that you can go there next if you do not get any relief from the insurance company. The exact standard of review depends on the language of your disability policy. In most cases, the judge will look to see if Sedgwick committed an abuse of discretion. This term refers to a clearly reasonable error of judgment by the insurance company.
Many people focus on the fact that the insurance company gets some deference if your case goes to court. Do not get caught up in words. If the insurance company has made a mistake in wrongfully denying you benefits, the federal court will reverse the denial and grant you benefits.
While we cannot assess your chances without a case review, federal judgments can overturn ERISA long-term disability denials with critical decisions that call out the insurance company’s errors.
Companies like Sedgwick are not above the law. They often lose appeals in federal court because flimsy reasons for denial do not hold up in front of a judge.
If the federal judge does not rule in your favor, you have yet another chance to receive benefits. You can go to the federal court of appeals. It will review the decision reached by the judge to see if they made a mistake.
You do not want to face a company like Sedgwick alone. The exact point of their being is that they have the infrastructure that they have built to help companies deny more claims. They are an outsourced hired gun to make your life more difficult. Their “solutions” are to solve problems for the companies that pay them instead of helping you. Sedgwick has a fundamental conflict in evaluating claims, yet the law allows benefits administrators a wide degree of latitude.
One thing that they cannot do is wrongly deny your claim. The tricky part is to persuade the judge that Sedgwick made a mistake when they said no to your benefits application. You need an attorney who can take the medical information, build upon it as necessary in the appeals phase, and persuade the judge that you deserve benefits.
You cannot count on getting a fair shake from Sedgwick, even when you appeal the claim. The only way to have your position honestly heard is to hire an attorney who can tell your story and demonstrate precisely why Sedgwick was wrong.
Here are some questions that clients often ask us about long-term disability claims. Contact our office if you have questions about your specific situation.
Unfortunately, your ERISA claim is a federal matter, and the case is in federal court. Insurance companies have protection against bad faith claims that they may face in state court. While the court may order an insurance company to pay you benefits, you cannot get more from them directly. There have been some instances of class-action lawsuits against insurance companies for their wrongful actions in denying claims.
When you appeal your denial, an attorney will usually receive a percentage of the amount that you can recover from the insurance company. You will not need to pay a retainer for a lawyer’s services upfront or hourly bills. These are similar to personal injury claims handled on a contingency basis. In some cases, courts have ordered insurance companies to pay attorney’s fees when they have lost an appeal in front of a federal judge.
It all depends on your particular situation. Settlements may work for some claimants based on their circumstances, while they may not work for others. The one certainty is that you should not settle your claim for less than it is worth because companies like Sedgwick use the settlement process to find “efficiencies” for their clients to save the company money.
If you need help with a potential long-term disability claim or have received a denial, you can call us at (504) 420-6962 or reach out to us online to discuss your case. We offer free consultations to prospective clients.
This has been a very difficult time for myself and my family. Mr. Mcnamara did his best to be as empathetic and compassionate as possible. He is very knowledgeable and a man of great integrity.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts