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.