Articles Posted in FMLA

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.”
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When a disability causes someone to stop working, they may be unsure of their rights to employee protections or insurance benefits. One common question for disabled employees is whether or not the employer can terminate the employee’s job due to a disability. For some employees, they may have limited protection under the Family and Medical Leave Act (FMLA).

Under FMLA, eligible employees can take up to 12 workweeks of unpaid leave a year. FMLA also requires group health benefits to be maintained during the leave as if employees continued to work instead of taking leave. After the employee has exhausted 12 workweeks in one year, they are entitled to their same or an equivalent job if they are able to return to work. Unfortunately, if the disabled employee is still unable to return to work after exhausting their leave of absence under the FMLA, the employer may legally terminate his or her employment. More details can be found on the Department of Labor’s website.

It is very important to recognize that not all employers are required to provide FMLA protection. FMLA applies to all public agencies (including local, state, and federal employers, and local education agencies) and private sector employers who employ 50 or more employees for at least 20 workweeks in the current or preceding calendar year. Therefore, if your workplace includes less than 50 employees and your employer is private, you may not receive FMLA protection.

Additionally, employees must satisfy several requirements in order to take an unpaid leave under the FMLA. First, they must work for a covered employer as explained above. Second, they must have worked 1,250 hours during the 12 months prior to the start of leave (with special hours of service rules for airline flight crew members). Third, they must work at a location where the employer has 50 or more employees within 75 miles. And fourth, they must have worked for the employer for 12 months.

If a disabled employee is eligible for FMLA protection, they can apply for an unpaid leave of absence due to a “serious health condition.” The FMLA defines a “serious health condition” at Title 29 of the Code of Federal Regulations §825.113 as a condition involving inpatient care or continuing treatment by a health care provider. In addition, the Department of Labor commented on the meaning of a “serious health condition” in a 1996 opinion letter and stated that “‘eligible employees’ may take leave for, among other reasons, their own serious health conditions that make them unable to perform the essential functions of their position.
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