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Court Finds Sedgwick to be Arbitrary and Capricious

Friday, June 7th, 2013

A Federal Court in Florida has found that Sedgwick, a third party administrator for long term disability insurance claims, acted in an arbitrary and capricious manner in the handling of a claim for long term disability benefits. The claimant suffered from a myriad of medical conditions including Chronic Fatigue Syndrome, Fibromyalgia, and other co-morbid conditions.

Sedgwick utilized well known insurance pandering doctors to review the claim, engaging Elite Physicians, Ltd. for its medical review. The reviewing doctor found there to be a paucity of objective findings supporting impairment, despite the fact that these same medical findings were sufficient to support entitlement to benefits during the short term disability claim. On the basis of this paper medical review, Sedgwick denied the long term disability insurance claim. The claimant appealed and provided additional medical support, which was reviewed by Sedgwick again with a paper reviewing doctor, who failed to meet, examine or treat the claimant. This doctor recommended a Functional Capacity Evaluation (“FCE”) to appreciate the extent of the claimant’s impairments.

Sedgwick did not undertake to secure an FCE — and instead upheld its prior claim determination.

The Court determined that Sedgwick’s claim review was arbitrary and capricious, and remanded the claim back for further consideration, requiring Sedgwick to properly consider the medical evidence, and to better consider the occupational issues in the claimant’s ability to work.

We have been seeing a lot of Sedgwick claims — as they have been aggressive in handling as a third party administrator disability claims for many employers. If you have a claim with Sedgwick as the reviewing entity, caution must be taken, and it would be wise to consider hiring a long term disability insurance attorney to work with you on your claim.

Hall v. Sedgwick

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