United Health Group employee suffering with Fibromyalgia is denied short term disability benefits and loses her battle with Sedgwick Claims in a Virginia court.
In the case of Day v. United Health Group, Inc. Short Term Disability Plan, the plaintiff sought disability benefits against the defendant, a self-funded plan that was administered by Sedgwick, due to complaints of abdominal pain and body pain resulting from fibromyalgia. This case is a prime example of why it is imperative to ensure that a claimant’s medical records provide actual “objective” medical evidence of their inability to perform the material and substantial duties of their occupation. It may seem logical that the opinion of one’s treating physician should take precedent over a third party reviewer hired by Sedgwick.
However, according to many disability policies, it is not sufficient for a claimant’s physician to conclude that they are unable to perform the material and substantial duties of his or her occupation, or even document symptompatolgy that explains such an inability. Without “objective” medical evidence of such a condition, some courts are concluding that the denial of benefits based on the lack of such evidence is reasonable.
Sedgwick Has Exclusive Rights and Discretion with Respect to Claims and Appeals
The Plaintiff in the above case argued that the Plan contemplates that, for purposes of short term disability benefits, it will rely on a report reflecting “Your Physician’s support of inability to perform your own occupation.” However, the Court held that the Plan’s definition of disability does not vest her treating physician with the authority to determine her disability status. Rather it requires her treating physicians to provide medical evidence that actually supports her inability to perform her occupation. “The authority to determine whether the medical evidence in fact supports such a finding, and to make the ultimate disability determination, is Sedgwick’s.”
In Order to be Considered Disabled, Employees Must Satisfy Four Criteria
– You have been seen face-to-face by a physician about your disability within 10 business days of the first day of absence related to disability;
– Your Physician has provided Medical Evidence that supports your inability to perform the material duties of your own occupation;
– You are under the Regular and Appropriate Care of a Physician; and
– Your Medical Condition is not work-related and is a Medically Determinable Impairment.
Medically Determinable Impairment is defined as an impairment that results from anatomical, physiological or psychological abnormality which can be shown by medically acceptable clinical and laboratory diagnostic techniques, not only by the individual’s statement of symptoms.
ERISA Does Not Require Plan Administrators to Accord Special Deference to the Opinions of Treating Physicians
When an ERISA benefit plan vests the plan administrator (in this case Sedgwick) the discretionary authority to make eligibility determinations, the Court may review the decision under an abuse of discretion standard. This means that if the judge determines that Sedgwick’s decision was reasonable, even if the court would have decided otherwise, the court should not disturb the plan administrator’s decision. In the case at hand, Sedgwick employed an independent medical physician to perform a review of the medical records who, in turn, came to the conclusion that there was no objective medical evidence to support her treating physicians’ conclusion that she could not perform her own occupation. The Court held that Sedgwick’s decision was reasonable even in light of the myriad of medical tests and multiple doctor visits, as none of her physicians were able to attribute her symptoms to any particular medical finding. Accordingly, the Court found for the Defendant.
Dell & Schaefer was not involved in the above case, however, it is an example of how important it is to retain competent attorneys early on in your claim administration to ensure that your treating physicians are building a record that supports the language that governs your disability policy.