Sedgwick Claims Management Services (“CMS”) is a “third party” claims administrator, which means that it is the entity that administers claims for employee welfare benefit plans and has authority to grant or deny claims. As a third party administrator, Sedgwick CMS does not actually pay out any approved long term disability benefits. Instead, the employee benefit plan or insurance company that hired Sedgwick pays the disability benefits if Sedgwick approves the claim. In many cases, the employee benefit plan has little – if any – involvement in the disability claims process.
If your employee benefit plan uses Sedgwick CMS as a claims administrator, then Sedgwick CMS is responsible for managing your LTD claim and deciding whether the disability claim is approved or denied.
Sedgwick CMS’ corporate headquarters are in Memphis, Tennessee. Sedgwick is one of the largest and most powerful third party administrators in the United States. Many Florida employers hire Sedgwick CMS to serve as their claims administrator for employee benefits, including long term disability benefits.
Employee benefit plans that currently use or previously used Sedgwick CMS include Ascension Health, AT&T Integrated Disability Service Center, Comcast, Delta Airlines, Eli Lilly & Company, Franciscan Alliance Inc., General Electric, Greyhound, Hewlett-Packard, International Paper, Office Depot, PepsiCo Inc., SPX Corporation, UnitedHealth Group, Xerox, Walgreens, and many others.
The Claims Review Process
If you are an employee of one of these companies (or any other company that uses Sedgwick CMS) to apply for long term disability benefits, Sedgwick CMS is responsible for reviewing, managing, and processing the claim and ultimately decides whether benefits should be paid.
Like disability insurance companies, Sedgwick begins the review process when an employee files a claim for long-term disability benefits. Sedgwick will have the claimant fill out a questionnaire and will request the claimant’s medical records. Sedgwick will also typically ask the claimant’s treating doctors to complete “Attending Physician Statements”. Sedgwick’s “in-house” staff, including nurses, doctors, vocational analysts, and claims handlers, will then review the claimant’s file.
Even if the claim is initially approved, Sedgwick will frequently check in with the claimant and the claimant’s medical providers, by phone or by mail, in a constant effort to obtain more information.
If the claim is denied and the claimant files an appeal, Sedgwick’s will evaluate the appeal. In doing so, it may have the entire claim file reviewed by a non-examining physician who bases his or her entire opinion on the medical records alone. Alternatively, Sedgwick may require the claimant to undergo an “Independent Medical Examination” or “Functional Capacity Evaluation”, and base its final decision on the IME or FCE report.
If your Sedgwick-administered claim for disability benefits is denied or terminated, the first thing you should do is request a copy of Sedgwick CMS’s internal “step processes” which apply to your claim. This document will explain the steps Sedgwick should take (or should have taken) in processing your claim. You can then determine whether its evaluation of your claim was consistent with the step processes.
Sedgwick CMS Denies and Cuts-Off LTD Claims
Sedgwick says, in its own words, “The vast majority of employees who file for disability or leave have never had a previous need for these benefits. It is a new and often troubling experience for them. We treat each employee with compassion and respect, and believe we play a key role as an advocate for the overall health and wellness of the individual.”
Unfortunately, despite its purported “compassion and respect” for employees, Sedgwick CMS does deny disability benefit claims unfairly. Even where Sedgwick initially approves claims, it may improperly cut-off benefits at a later time. There are many errors that Sedgwick CMS can make during the claims or appeals processes. Some errors or omissions include:
- Sedgwick’s failure to obtain all medical records and documentation from the claimant’s treating medical sources;
- Improperly denying the claim on the grounds that the claimant’s medical condition is (purportedly) barred by a pre-existing condition exclusion;
- Improperly rejecting the opinions of treating providers in favor of non-examining, record-reviewing physicians;
- Improperly asking doctors to change their opinions (i.e., contacting the reviewing doctor to ask him or her to change his or her opinion – generally, to better support a denial of benefits);
- Terminating a claim even though there has not been any change in the claimant’s medical condition (i.e., a cut-off triggered by the recommendation of a Sedgwick supervisor instead of new information about the claimant’s medical condition);
- Failing to adequately consider a fully favorable disability determination by the Social Security Administration;
- Failing to properly consider the claimant’s job duties and responsibilities, or transferable skills; and
- Improperly applying the definition of “Disability”, as that term is defined in the disability policy.
These are just some of the errors committed by Sedgwick CMS. There may be others. You must address these errors immediately, as your appeal of Sedgwick CMS’ denial of your disability benefits is time sensitive. The time limits to appeal are defined by your LTD policy, but the time limit is typically 180 days.
If you have applied for long-term disability benefits and Sedgwick CMS has denied your claim, contact long term disability attorney Nick A. Ortiz immediately. Mr. Ortiz Law Firm has successfully represented many disabled individuals in appeals and lawsuits against Sedgwick CMS. Mr. Ortiz is familiar with Sedgwick CMS’ claim tactics and can help you receive the disability benefits you deserve. Please call 850-308-7833 for a free consultation.