Court Rules Against Sedgwick Claims Management and Remands for New Review

In Jennifer L. Miller v. Sedgwick Claims Management Services, Inc. (Sedgwick), Plaintiff, an account manager for American Honda Motor Company, suffered from many debilitating medical conditions, particularly fibromyalgia, which included insomnia, chronic pain, inflammatory arthropathy, and fatigue. Her last day of work was May 3, 2017.

Plaintiff applied for short-term disability benefits through a program sponsored by her employer and administered by Sedgwick. She submitted her medical records from her treating physician, including a functional capacity evaluation (FCE) the doctor had conducted.

Two physicians hired by Sedgwick reviewed Plaintiff’s medical records and both reported that her claim should be denied because there was no objective evidence to support her diagnosis. Based on those reports, Sedgwick denied her claim.

Plaintiff appealed and exhausted her administrative remedies. She then filed this ERISA lawsuit alleging, among other things, that in denying her claim, Sedgwick acted arbitrarily and capriciously by failing to credit her treating physician’s opinion. Instead, it relied on the opinions of reviewing physicians who “made credibility findings regarding her chronic pain” without ever talking to her or examining her.

The Court conducted an extensive review and found a number of errors on the part of Sedgwick, and concluded that Sedgwick’s denial was arbitrary and capricious. The Court also determined the remedy was to remand to Sedgwick with an order to conduct a full and fair review of Plaintiff’s claim.

Sedgwick’s Denial of Short-Term Disability Benefits was Arbitrary and Capricious

The Court determined the cumulative effect of many errors led to its decision that Sedgwick’s denial was arbitrary and capricious. The following factors weighed against Sedgwick.

Sedgwick relied on file reviews. The Court noted that a file review may provide enough information for a plan administrator to deny a claim. But, in this case, Sedgwick denied Plaintiff’s claim in part based on the reviewers’ credibility determinations of her symptom reporting without ever meeting her or examining her. Sedgwick could have had Plaintiff submit to an independent medical examination (IME), but it did not.

Sedgwick’s demand for objective evidence. In the context of fibromyalgia, since there is no objective medical test that can be used to diagnose fibromyalgia, an insurer can request a FCE which is a “proper form of objective evidence to support a claimant’s reports of pain.” The Court was “somewhat confused” by Sedgwick’s insistence that Plaintiff failed to submit objective evidence when she had submitted the FCE performed by her treating physician.

Sedgwick failed to credit the opinion of the treating physician. The Court concluded that the medical reviewers “cherry picked” the file, failing to “credit any of the evidence in the file supporting Plaintiff’s claim, and instead cited Plaintiff’s ‘normal’ test results as evidence of her ability to work.”

The Court concluded that all of these factors weighed against Sedgwick, and its decision-making process did not “hold water.” The cumulative effect “results in a finding that Defendant’s decision was arbitrary and capricious.

The Remedy

The Court was not convinced, based on the Administrative Record that Plaintiff was “clearly entitled to benefits,” so the case was remanded to Sedgwick “for a full and fair determination consistent with this order.”

This case was not handled by our office, but we believe it can be instructive for those with fibromyalgia when the plan asks for objective evidence of their disability. If you need assistance with a similar matter, or any other matter connected with your disability claim, contact us at Dell & Schaefer for a free consultation.