Articles Posted in Sedgwick

Michael P is a Gulf War veteran who served in special forces with the US Marines during Operation Desert Storm. During his time in combat, Michael was exposed to hazardous chemicals from burning oil wells and experienced firsthand the horrors of war.

After returning home and receiving an honorable discharge from the Marine Corps, Michael went to work as an electrician in a heavy industrial manufacturing facility in northwest Indiana. As part of his role, Michael was frequently required to work on cranes and other heavy industrial equipment high above a foundry floor in a facility in which molten steel was transported and poured. According to his job description, he was required to keep electrical equipment such as wiring motors, switches, and electrical mechanisms in good repair and operating condition; install a variety of complicated electrical and some mechanical equipment; and diagnose and remedy trouble quickly to avoid shutdowns.

In June of 2017, Michael was diagnosed with very severe post-traumatic stress disorder (“PTSD”) as a result of his combat experience. He also suffered from severe headaches, frequently lasting hours at a time. When he presented for an MRI to evaluate the cause of his headaches, his doctors noted atrophy in the cerebral cortex, a common feature of many brain diseases that is frequently associated with dementia, seizures, and impaired comprehension, often resulting from underlying traumatic brain injury.

O’Ryan Law firm has extensive experience representing clients in appeals and litigation under the Employee Retirement Income Security Act of 1974 (ERISA), which governs most claims for benefits under employer-sponsored insurance plans. Earlier this year, the US Department of Labor amended its regulations under ERISA, providing claimants with some additional rights during the process of appealing denials of benefits under plans governed by ERISA.

One important additional right granted under the new ERISA regulation is the opportunity to review and respond to any additional evidence considered by an insurance company during an appeal of a benefits claim denial. This means that if a claimant appeals a denial or termination of benefits and the insurance company sends the file to a reviewing physician, the claimant has a right to read and respond to the report of that reviewing physician before the insurance company can make its final decision on the appeal. O’Ryan Law firm recently took advantage of this new protection to obtain short term disability (STD) benefits for a client who had previously had her STD benefits terminated.

Kim M was a Repair Service Attendant at a large telecom company and was forced to stop working in early 2017[1] as a result of failed back syndrome, multilevel degenerative disc disease, lumbar facet arthritis, and spondylopathy. After she was unable to return to work, she was awarded STD benefits under her employer’s disability plan, which was administered by Sedgwick. However, Sedgwick terminated Kim’s STD benefits several months later, claiming there was no longer sufficient medical evidence to support her claim. In the letter explaining its termination of Kim’s benefits, Sedgwick relied on the opinions of two reviewing physicians who asserted that Kim was not disabled.

Fibromyalgia is a very complex chronic pain disorder that affects an estimated 10 million individuals in the United States and approximately three to six percent of the world population.  For those suffering from fibromyalgia, the disease causes widespread pain and tenderness to touch and can affect the entire body.  Fibromyalgia symptoms can include stiffness, pain, fatigue, tiredness, depression/anxiety, memory, sleep issues, concentration, and headaches including at times migraines.  Fibromyalgia symptoms can be very severe and debilitating affecting a persons’ work, social and daily life.

The criteria, established by the American College of Rheumatology in 1990, contains a history of widespread pain in all four quadrants of the body for the duration of three months or more and pain in at least 11 of the 18 designated tender points when pressure is applied.  In 2000, the American College of Rheumatology ceased using the criteria of tender points and instead focused on pain being widespread and accompanied by symptoms such as sleep problems, problems with thinking and fatigue.  Unfortunately, those who suffer with fibromyalgia typically have normal results with conventional testing. A physician knowledgeable about the disease, such as a rheumatologist, is necessary to make the diagnosis in part by ruling out other causes.

The National Fibromyalgia Institute (NFI) website states that fibromyalgia is marked by profound, chronic, and widespread pain that can migrate to all parts of the body in varying intensities.  The pain can be described as stabbing, shooting, muscle aching, throbbing and twitching.  Neurologists have noted that patients with this disease can experience numbness and tingling, aggravated by stress, weather and movements.

O’Ryan Law Firm, on behalf of Plaintiff Jo Ellen W., recently filed a lawsuit against Sedgwick Claims Management Services, Inc. (“Sedgwick”). The Plaintiff was employed as a Labor and Delivery Clinical Nurse with Franciscan Alliance which made her eligible for disability benefits under the Franciscan Alliance, Inc. Short-Term and Long-Term Disability Benefit Plans (the “Plan”).

In Jo Ellen W. v .Franciscan Alliance, Inc. Short-Term and Long-Term Disability Plans and Sedgwick Claims Management Services, the Plaintiff filed a lawsuit to gain the long term disability benefits she was entitled to under the terms of the Franciscan Alliance Plan.

Facts of the Case

At the O’Ryan Law Firm, we have represented several clients who have become disabled due to the severe symptoms of Scleroderma.

According to the American College of Rheumatology:

WHAT IS SCLERODERMA?

As one of the largest employers in Indiana, Eli Lilly covers thousands of employees under their Extended Disability Plan (“Lilly EDL Plan”). The Lilly EDL Plan is self-insured, a rarity in the long term disability world. Just a few years ago, Anthem was the claims administrator for the Lilly EDL Plan but in the spring of 2012, Lilly hired Sedgwick to administer extended disability claims under the EDL Plan. Shortly after this time, our office began receiving calls from Lilly employees whose EDL benefits had been terminated or were under investigation by Sedgwick.

One of the calls we received was from the former Executive Director of Human Resources at Lilly who had worked for Lilly for over 25 years. Unfortunately, her diagnosis of Fibromyalgia worsened over the years until she was forced to leave Lilly and apply for short and long term disability benefits in December 2007. Fibromyalgia is a disease the Seventh Circuit has characterized as “common, but elusive and mysterious.” Sarchet v. Charter, 78 F.3d 305, 306 (7th Cir. 1996). In evaluating fibromyalgia in the context of a disability claim, the court in Sarchet described the disease as:

Its cause or causes are unknown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective. There are no laboratory tests for the presence or severity of fibromyalgia. The principal symptoms are “pain all over,” fatigue, disturbed sleep, stiffness, and–the only symptom that discriminates between it and other diseases of a rheumatic character–multiple tender spots, more precisely 18 fixed locations on the body (and the rule of thumb is that the patient must have at least 11 of them to be diagnosed as having fibromyalgia) that when pressed firmly cause the patient to flinch.

Based on the severity of her fibromyalgia condition, our client was approved for EDL benefits in May 2009 and she received those benefits for over 3½ until Sedgwick abruptly terminated those benefits.
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