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Denied Disability Claimant Says “Fight Back”

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Washington, DCCourtney 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.

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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READER COMMENTS

Posted by

on
Sedgwick is a nightmare. They denied me benefits when I was 8 months pregnant. My doctors recommended a light duty job with a restriction of 25 lbs to lift. The light duty job consisted of lifting a skid of 41 lbs. Therefor the doctor placed me on STD. So Sedgwick denied me. I am currently filing a appeal.

Posted by

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Agree with you all. Sedgwick sucks. They lose paperwork, one friend I know had injury reported it per requirements within 15 minutes yet they said well you know you need to report it within 24 hours. Basically accused the person that got hurt a liar. The original caseworker either quit or got fired. They got on Sr's case about not getting paperwork & after lengthy phone call said oh never mind we found it. Somehow get into from dr after they admit NO medical release form was signed.
If therapist requests additional treatment you get transfered to a nurse case mgr who reviews everything with a medical director . Who first says ok to more physical therapy then 2 or less days rescinds treatment. For second opinion if you aren't in major city, they send you to a one time referral with someone who is only in area once a month.. love answering message. Will get back to you at my earliest convenience. Like the other person says they aren't trained. Think the nurse & med. Director are idiots graduated at the bottom of their class. Think it a way to stop from paying. A girl at work cut her leg doesn't know how. And no issues. But heaven forbid a real injury like soft tissue or worse they treat you like crap.
Heaven help them if they get hurt and have to deal with people that work for the company. The only heaviest thing they lift is their asses off their chair. When they go home. The doctors or pa's they use may have that degree but are just as stupid.

Posted by

on
Been fighting for STD for two months now after being denied due to lack of medical evidence according to Sedgwick. I'm at home on IV therapy every 12 hours. The process itself takes about 4 hours each time! I have a PICC line in my arm, but yet they claim no medical evidence.... I have Lyme disease, fibromyalgia, migraine, insomnia, chronic fatigue syndrome, etc.... My next step is to sue. I've paid for this benefit for 12 years and have never made a claim before. I have earned it, and paid for it.

Posted by

on
Sedgwick are #ssholes, they will cost you everything. I lost my job because of them, but they are always bullsh#tting around on theirs. With their stupid #ss "nurses".

Posted by

on
The company I work for uses Sedgwick for STD and LTD. I have been off sense September 1, 2016 and they keep asking me and my doctor for more info. My company only gives a window of 21 days to complete the STD and today is the day. I tried to get ahold of them... and it is the same thing of getting transferred and not getting the correct person. I did get a call this morning that they wanted to deny my claim and that there was not enough supportive findings (per their nurse). OMG Back in May and June I had 4 people in my life pass away, I have to say that this has been the hardest time in my life!! I had a breakdown in front of a large group of co-workers while I was giving a speech. I realized then and especially afterwords from my manager, saying that I have been so disconnected and withdrawn from my job that she will need to put me on a disciplinary action plan.(Are you kidding me! With everything that I am trying to get through!) I needed to get myself back into balance again and take a leave of absence!! I have had such anxiety, depression and everything else that has been kicking my butt, especially my Ulcerative Colitis , my doctor told me to go on FMLA and STD. So that is what I did! Now I am so stressed out on the fact that I am not getting a benefit that I have been paying for thru my company (not getting paid during my leave) - Here my doctor told me to do this and Sedgwick says I am not "clinically sick enough" - what? Who made them GOD to tell me that I am not sick enough???? There is such a cliche about mental illness and it comes in many forms as we can all see right now on the news!!
Do I have to hurt myself and then that would be the ticket to getting this approved? I am really thinking I will need to get an attorney involved :( All I want to do is get better!!

Posted by

on
our employer uses sedgwick for std and ltd, and these guys are total asshats. they dont send paperwork to fill out in a reasonable manner, lose paperwork quite frequently, and it appears noone there is trained properly. you can talk to one person and get one answer, then talk to someone else with the exact same problem and get a completely different answer. these guys arent doctors, but yet will deny you for serious life threatening issues. in turn, many of us will be seeking legal help to deal with these clowns. good luck to anyone dealing with these morons

Posted by

on
I'm fight with Sedgwick for STD. I have been out of work since August 15. And they keep saying they don't have enough information from the doctor to support my claim. The doctor has referred me to a surgeon and they are still say they don't have enough information. Saying there's no record besides the doctor stating I'm in pain (Achilles tendinitis). When there is clearly a record of the doctor doing X-rays and a ultrasound sound fluid. The doctors want me off my foot trying to prevent surgery. I appealed and my next step is to seek out a lawyer.

Posted by

on
I am an Employee of Sedgwick and I have been out of work since July 29,2016 . This company that I work for has treated me as if I never worked for them they only give I a short time to gather a lot of paperwork. I was denied my claim for needing std . I appealed the decision but know Sedgwick is very relaxed in making a decision. This is so urgent because all of my bills are due and time is running out for me this stress makes my condition worse. I am so discouraged not only is this Company unethical and completely fake and money hungry they treat their employees like crap from the std down to the bonus that they promise and take half in taxes and about 4 months to pay out from they time they were suppose to I've seen manager lie to get accounts form Fortune 500 companies and then throw the hammer down on the employees because they can't feel the qouta because the company lied from the beginning so what happens employees are punished not able to work in other departments and their pay for performance is taken away but the managers still get bonuses this company Has proven the greed of America and how there is no safety in a job u give your whole life to
This company Sedgwick should be reevaluated by these Fortune 500 and 100 companies that they provide third party services to and really be strict on their ethics because Sedgwick is so greedy and cold hearted it's just not fair

Posted by

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I fell backwards down the stairs at work and I have been off since March 2016. Everytime its time for my disability payments to be sent in to Riverdide County where Ive worked for over 15 year for my payments. Theres a problem with my paperwork in Sedgwick office. Everytime. It takes me only five minutes to contact my Doctor to have the requested information faxed to Sedgwick. Its sad that their employees dont do their jobs. Sedgwick VPA is a company I would not recommend any company do business with.

Posted by

on
I need back surgery Sedgwick gives a short time to have paper work done. My Dr. Said they won't be rushed it would get done. Sedgwick denied me disability so no back surgery and no job now I lost my job because Sedgwick wouldn't extend the time to get papers.

Posted by

on
Yes, I remember these horror stories with Sedgwick when I was applying for LTD several years ago. I was suffering from PTSD after a trauma I experienced left me unable to function and maintain employment.
Because I was so confused, frightened, and unable to manage my daily affairs, I was never quite sure what was really happening. I could no longer be certain if it was me who failed to communicate, or complete and return their 'forms that were critical to their decision'. But it seemed to me like they kept making me do the same things over and over! I remember stressing the importance of details they would leave out or ignore the first time they rejected me, it was again left out when I was rejected the 2nd time.
Then, as someone else mentioned, it was suddenly about a "pre-existing condition" exclusion to deny me.
I finally reached out to the state Ombudsman for assistance and was eventually approved back my original application date, BUT I NEED TO SAY THAT THEIR RUNAROUND, DOUBLE-TALKING PROCEDURES ONLY ADDED INSULT TO INJURY!! I always felt like I was at their mercy to decide what was real, and what wasnt, and it was excruciating going through the same forms and detailed explanations again and again. I began to fear the mailbox.
But, on the positive side, once approved, and acknowledging my demands for another representative ( said the first guy reminded me of the movie "American Psycho" where the meticulously groomed wall street pencil pusher was a methodical serial killer with no remorse for the victims he coldly tortured and mutilated. Lol!
But it took a long time not to fear their calls, correspondence. I had been trained to expect failure and confusion from them.
I no longer experience the torture, and I'm treated with respect and humanity.

Posted by

on
I have been denied short term disability because of the verbage used in the doctors notes when I filed the initial claim, I was under a lot of stress and anxiety due to a possible lung tumor which turned out to be COPD, he wrote me out due to stress while I was undergoing testing and they have deemed it work related because the note stated that my job was aggravating my condition. Have been out of work for 5 months and not a dime have I received, HELP!!! Any input would be great!!

Posted by

on
i was rewarded short term disability and when I told the sedgwick res she sounded a little shocked~ SW is a supplemental ins to pick up the variance in the difference. Have spoke to her 3 times on the phone only using languge that made zero sense to me and telling me the doctor did not fill out the form properly, although having saw today, every line was filled in to a T. she said the doctors showed no reason I can't work, so the no work for a minimal of 60 days, flew over her head with the rest of the disease codes.!! she intentionally made no clear sense in her sentences, having to pick apart word by word her meanings, as she would then laugh if you were persistent enough to not her BS go. So, today i got approved for my short term dis, but still waiting for the dissection of her outcome of my doctors' response~ Rude does not even begin to describe this woman VJ. as if you are not feeling sick enough to now have to prove our medically documented facts set before them! Appalled to say the least

Posted by

on
Self insured County of Los Angeles/third party administrator Sedgwick denied my claim for long term disability.
I have bronchotracheamalacia (an extremely rare disorder where your bronchial and trachea collapse). In 2008 stents were placed to hold my airways open. I had infections become more frequent and severe leading to other surgeries, fibromyalgia, common variable immunodifficiency. I resigned in 2011 to live with my sister as my health was failing and I thought it would be better to live closer to family. Because the complexity of my health and the rare disorder, few doctors knew how to treat it. Had I known in 2011 I should have filed for long term disability then, I would have. I took years later and other doctors, and now I have a slew of them besides the federal govt who say I am disabled. Help!

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