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.
Table of Contents
- Sedgwick Works for its Corporate Clients and Not for You
- Don’t Give Sedgwick a Reason to Reject Your Claim
- What to Do Before Filing Your Claim?
- Why Sedgwick Denies Many Long-Term Disability Claims?
- What Happens When the Administrator Denies Your Claim?
- Call a Sedgwick Long-Term Disability Attorney for Help
Sedgwick Works for its Corporate Clients and Not for YouSedgwick 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.”
Don’t Give Sedgwick a Reason to Reject Your ClaimYou 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.
What to Do Before Filing Your Claim?Here are some things to consider when you are filing an ERISA long-term disability claim:
- Review your plan's definition of disability. There is no one definition of the term under ERISA law. It is set individually in the policy, and insurance companies and benefits administrators are very stringent about what meets the term's meaning.
- Make sure that your medical evidence is as extensive as possible. Even though Sedgwick may ignore your physician's statement, you should still ensure that it supports your claim that you are disabled and cannot work.
- Follow all deadlines and ensure that your documentation is correct and understandable. Sedgwick is in a position where they can read additional information into your claim if it benefits them but deny your claim for not including the required information.
Why Sedgwick Denies Many Long-Term Disability Claims?Sedgwick may deny an ERISA long-term disability benefits claim because it claims:
- You do not meet the plan's definition of "disability" as interpreted by Sedgwick. (Note that we add the word "interpreted" because claims administrators can tighten up the definition and add requirements to what they put on paper.)
- The medical evidence does not support your claim of disability - Companies like Sedgwick are notorious for using their own "independent" doctors to evaluate claims (people on the insurance company payroll who have financial incentives to downplay your condition) while ignoring your medical record and doctor's opinion.
- You can still work with some modifications - Some long-term disability insurance companies even think that an ergonomic chair is an answer to a permanent and debilitating neck injury that keeps you from working.
- You suffer from a pre-existing condition - You can only receive long-term disability benefits for a "new" injury or condition.
- You did not meet the paperwork requirements for the plan.
What Happens When the Administrator Denies Your Claim?Here is what you should do if the administrator denies your claim:
- Call an experienced ERISA long-term disability lawyer to handle your appeal if you do not have an attorney already.
- Review the information provided by Sedgwick when they denied your claim - new federal rules require claims administrators and insurance companies to provide more detailed information when they deny a claim that more fully allows you to understand the basis for the denial.
- Add additional information to your file to address Sedgwick’s concerns and give your claim a better chance of being approved.
You Must First Ask Sedgwick to Overturn its DenialWhile 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.
A Federal Judge Will Review Sedgwick’s DecisionMany 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.
Sedgwick Long-Term Disability FAQsHere are some questions that clients often ask us about long-term disability claims. Contact our office if you have questions about your specific situation.
Can I sue Sedgwick directly for wrongful actions in denying my claims?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.
How much will it cost to appeal my ERISA long-term benefits denial?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.
Should I accept a settlement of my long-term disability claim?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.
Call a Sedgwick Long-Term Disability Attorney for Help
- Price McNamara ERISA Insurance Claim Attorney is here to take the fight to powerful companies like Sedgwick when they do not respect your legal rights under your long-term disability policy and ERISA. We hold companies like this to account when they deny you what you deserve.
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