Our 49-year-old client was a healthy, active woman who enjoyed a successful career as an Oncology Nurse Specialist, traveling extensively and dedicated to providing oncology patients with compassionate care. Her life changed drastically in 2015, when she was diagnosed with multiple severe and debilitating co-morbid conditions, including Pan Ulcerative Colitis, (colitis affecting the entire large intestine), Von Willebrand’s Disease (a chronic bleeding disorder where the blood does not clot) and anemia, ultimately resulting infrequent and irregular bowel movements, abdominal cramps, urgency, intermittent incontinence, and overall fatigue and lethargy. Our client consulted with multiple physicians and specialists, all of whom were extremely supportive of her decision to file for long-term disability benefits.
Our client tried very hard to continue to work despite her symptoms, but eventually came to realize she could not perform the tasks and duties of her profession. Like many claimants, she thought she would have no problem being given short-term disability benefits and filed a claim on her own, without experienced guidance. She was almost immediately denied her short-term disability benefits due to technicalities regarding the date she became disabled. The third-party claims management company picked over her medical records, found minor issues and arbitrarily denied her claim, despite clear medical evidence of disability.
Overwhelmed and frustrated, she engaged Frankel & Newfield to fight for her and develop further support for her claim and submit an appeal that would overturn Sedgwick’s wrongful denial. One of the major problems with her claim exploited by Sedgwick was that her diagnostic reports showed her condition to be “in remission” – despite active and debilitating symptoms and continued impairment.
We worked with her medical team to overcome this hurdle and several other hurdles. Our appeal presented more than sufficient support as to why she could no longer work on a full-time sustained basis in both a physically and cognitively demanding career. We also developed a powerful articulation of her occupational duties and how and why they were impacted by her condition, including the need to travel.
We also worked closely with her team of doctors and providers in challenging and undercutting Sedgwick’s biased and unreliable peer reviews, conducted by unqualified physicians who were ultimately “hired guns” – basically biased vendors whose reviews are known to be favorable to their own clients – insurers and administrators like Sedgwick. We recognize that these doctors need to produce an outcome to benefit the insurance company to ensure repeat business. Our comprehensive appeal contained clinical and subjective medical support, narrative reports from her treating physicians and a plethora of medical literature to substantiate the severity and co-morbidity of our client’s conditions. We further buttressed this with personal support statements from our client and those close to her, who were able to identify anecdotes to illustrate the challenges faced by our client.
Sedgwick is known for pushing back on claims even in the face of overwhelming evidence proving disability but we were aggressive and relentless. It took four rebuttal submissions, steady attacks of each and every peer review secured by Sedgwick, but our efforts paid off. Sedgwick finally acquiesced and overturned our clients wrongful claim termination. Her benefits were released. allowing her to focus on her health.
Jason Newfield is a founding partner of the disability insurance law firm Frankel & Newfield. He has spent the majority of his legal career advocating for the rights of disabled workers. He has lectured other professionals, worked on a Federal Advisory committee, and published many articles in the field of disability insurance claims and litigation.
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