Disability Claims Denied by Sedgwick CMS

Sedgwick Claims Management Services (“CMS”) is a third party claims administrator hired by insurance companies and employee benefit plans to manage disability claims. If your employee benefit plan uses Sedgwick CMS as a claims administrator, then Sedgwick CMS is responsible for deciding whether your disability claim is approved or denied. As well as processing and adjudicating disability claims, Sedgwick holds itself out as providing the following services:

The company specializes in workers’ compensation; disability, FMLA, and other employee absence; managed care; general, automobile, and professional liability; warranty and credit card claims services; fraud and investigation; structured settlements; and Medicare compliance solutions (website last visited August 16, 2014).

Sedgwick CMS is headquartered in Memphis, Tennessee and is one of the largest third party administrators in the nation. Many Indiana employers hire Sedgwick CMS to serve as their claims administrator for employee benefits. Employee benefit plans that currently use or previously used Sedgwick CMS include Eli Lilly & Company, AT&T, Comcast, Walgreens, Franciscan Alliance Inc., SPX Corporation, Ascension Health, Hewlett-Packard, PepsiCo Inc., International Paper, UnitedHealth Group, and many others. If employees of these companies apply for short term or long term disability benefits, Sedgwick CMS is responsible for processing the claims and deciding whether benefits should be paid. As a third party administrator, Sedgwick CMS does not actually pay the disability benefits. Rather, the employee benefit plan or insurance company pays disability benefits if Sedgwick CMS approves the claim. Often, the employee benefit plan has little involvement in the disability claims process, if any.

Like disability insurance companies, Sedgwick initially reviews a disability claim by obtaining medical records, requiring the claimant’s treating physician to complete questionnaires, and having in-house staff (nurses, doctors, vocational analysts, claims analysts) review the claimant’s file. If the claim is denied and the claimant appeals, then Sedgwick’s review of the appeal will likely include the use of contracted record reviewing physicians. If the claim is approved, Sedgwick may call or write to the claimant frequently in efforts to obtain more information. Sedgwick may also require the claimant to undergo an “Independent Medical Examination” or “Functional Capacity Evaluation.”

Unfortunately, O’Ryan Law Firm has found that some individuals’ disability benefits are unfairly denied by Sedgwick CMS. There are many examples of errors made in Sedgwick CMS’ claims or appeals processes, such as Sedgwick’s failure to obtain full medical documentation from the claimant’s treating sources, incorrectly alleging that the claimant’s condition is barred by a pre-existing condition exclusion, rejecting the opinions of treating providers in favor of record reviewing physicians, failing to consider a fully favorable disability determination from the Social Security Administration, failure to properly consider the claimant’s job duties or transferable skills, and considering the incorrect definition of “Disability” as defined in the disability policy. These errors must be addressed immediately because Sedgwick CMS’ denial of your disability benefits requires an appeal and is time sensitive.

If you have applied for disability benefits and Sedgwick CMS has denied your claim, contact O’Ryan Law Firm immediately. O’Ryan Law Firm has successfully represented many disabled individuals in appeals and lawsuits against Sedgwick CMS. O’Ryan Law Firm is familiar with Sedgwick CMS’ claim tactics and can help you receive disability benefits. Please call 317-255-1000 (local) or 1-855-778-5055 (toll free) for a free consultation.