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Denied Disability Claimant Says “Fight Back”

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Washington, DC: Courtney had to take a month off work due to severe asthma so she applied for short-term benefits, but her insurer, Sedgwick, denied disability. Courtney believed she had a wrongly denied disability claim, fought the appeal, and won.

Denied Disability Claimant Says “Fight Back”Sedgwick paid her one month’s salary, but not before Courtney did a lot of methodical groundwork. “In my case it wasn’t worth hiring an insurance attorney because I was only asking for one month’s pay,” she says, “but I would have definitely hired a denied disability attorney if I was looking at more compensation. There wasn’t that much at stake.”

Fortunately, Courtney has an analytical mind and thinks logically; she works as a business analyst. Even though she read on the LawyersandSettlements website and other sites online that most appeals are not in your favor, she was pro-active, fought back and appealed her case.

“I understood that if you are denied once, chances are slim that the insurance company’s decision will be overturned,” Courtney says. “But six weeks after I sent my appeal, I got a voice mail message from my case manager at Sedgwick and she said that my denial had been overturned - woohoo!”

Last May 2012, Courtney was hospitalized with severe asthma and during that time she was diagnosed with congestive heart failure. Her doctor told her to take a month off work, so Courtney applied for short-term disability. She points out that heart issues were not mentioned in the medical report…

“A nurse at Sedgwick (I found on the LawyersandSettlements website that they are the second-worst insurer for bad faith and wrongly denied claims) provided me with two main reasons for denial,” Courtney explains. “First, I was living with asthma and working (they didn’t technically say pre-existing) and second was about my blood oxygen saturation, which is how they test people who have breathing conditions. Mine registered 91 at the last appointment. She said that is normal for me because I am obese and have COPD. But in my appeal, I provided the insurer with earlier doctor’s records that showed a normal saturation level for me was 94, so they couldn’t say that 91 was my baseline.

“And I don’t have COPD. It wasn’t in my records so they couldn’t use that reason for denial - I have no idea where they even got that information. Incidentally, they considered the congestive heart failure a non-issue.

“After they denied me, I got all my medical records from my doctor - Sedgwick had copies of all the records. It took me a few days to get everything together before I filed an appeal and then I waited for their decision. Apparently there was supposed to be a peer-to-peer review (their independent medical examiner was supposed to talk with my doctor) but I don’t know if that ever happened. I do know that my denial was based on their assumptions.

“I was very analytical in this appeal; it is something I know how to do. Sedgwick gave me reasons for denial and with those reasons that didn’t make sense I asked them to re-send in a more literal format (the nurse I first dealt with was very difficult to understand). I then took each sentence apart, numbered it and responded in a logical manner. You have to be absolutely clear and understand what they are thinking, where they are coming from. These insurance companies are in the money-making business and you have to put yourself into their headspace.

“The most important point I want to make is this: If you have been denied short- or long-term disability benefits, you should appeal and not be afraid, and if you aren’t an analyst like me, get an attorney.”

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