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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Posted by pattie h
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 Susan Camden
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 Elle
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 Laurie J Briggs
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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