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A St. Petersburg disability attorney can help disabled persons in Florida challenge the wrongful denial of a disability insurance claim by a claims management company like Sedgwick Claims Management Services.
Sedgwick is a third-party administrator that handles disability insurance claims for some of Florida’s largest employers. Employers and insurance companies hire Sedgwick to manage disability claim applications and the entire claim process, including appeals.
If you need disability benefits, receiving a denial letter from Sedgwick does not have to be the end of the road. If Sedgwick has denied your claim, a St. Petersburg disability lawyer can explain how Sedgwick’s appeal process works and help you pursue the benefits you need.
How Should You Respond if Sedgwick Rejects Your Claim?
State laws typically govern individual disability insurance policies. Federal law governs most employer-provided group insurance policies. ERISA, the Employee Retirement Income Security Act, imposes strict procedures and deadlines that group insurance policyholders must follow to preserve their right to disability benefits.
In most ERISA-governed cases, you have exactly 180 days to file a formal administrative appeal with Sedgwick. If you miss this deadline, you may lose your right to sue for disability benefits in federal court. The clock begins ticking the moment you receive the denial letter from Sedgwick.
In this letter, Sedgwick must explain the specific reasons for the denial and cite the specific plan provisions that informed the decision. If you receive a denial letter, immediately contact a St. Petersburg disability lawyer who can begin preparing a formal appeal on your behalf.
What Evidence Will You Need for Your Appeal?
Your benefit denial letter will usually list the information and documents that Sedgwick claims it needs to approve your disability claim. This could include recent clinical notes, an MRI or CT scan, or a more detailed statement from your treating physician.
A successful appeal requires more than just a letter saying your doctor disagrees with Sedgwick’s decision. You must build a case that proves you meet your policy’s specific definition of disability. Compiling the following items and documents can help you build that case:
- Medical records from your specialists and primary care doctors.
- Test results, such as blood work, electrocardiograms, or neuropsychological testing.
- A “Functional Capacity Evaluation” of your physical or cognitive limits.
- Statements from loved ones and others about how your disability affects your daily life.
How Can You Challenge Sedgwick’s Findings?
Sedgwick often uses “independent” medical examiners to review disability claims. After only glancing at your medical history, an examiner for Sedwick may claim you can return to work. To counter this claim, your physicians must provide detailed statements regarding your limitations.
Simply having your doctors declare that you are disabled isn’t enough. Your doctors’ statements need to explain in detail why you cannot perform specific work-related tasks, such as sitting or standing for long periods, typing, or maintaining your focus in a high-stress work environment.
How Does the Administrative Appeal Process Work?
Submitting your appeal to Sedgwick is the most critical part of the process. Under ERISA, this is usually your last chance to offer new evidence. If your appeal is denied, and you have to file a lawsuit, a judge will likely look only at the evidence you’ve presented during the appeal phase.
You cannot typically add new medical records later in court. Your appeal package should be a comprehensive brief that addresses all the reasons Sedgwick gave you for the denial. It should point out where their examiners ignored medical evidence or misinterpreted your job duties.
Once you submit your appeal, Sedgwick generally has 45 days to make a decision, although it can request a 45-day extension in some cases. During this time, Sedgwick may ask you to undergo a medical examination or request additional records.
What if Your Administrative Appeal is Denied?
If Sedgwick upholds the denial, you have exhausted your administrative remedies, and ERISA allows you to file a lawsuit in federal court. For residents of Pinellas, Pasco, and Hillsborough counties, this usually means filing in the Tampa Division of the Middle District of Florida.
Many disability policies give Sedgwick “discretionary authority.” This means a court can only overturn a denial if it finds Sedgwick’s decision was “arbitrary and capricious.” Proving a denial was arbitrary and capricious requires the services of an experienced disability lawyer.
The Role of Disability-Focused Legal Advocacy
Suffering a serious injury or a disabling medical condition can change someone’s life forever. Unfortunately, this may extend beyond a person’s inability to enjoy their hobbies and activities. In many cases, being unable to work can quickly lead to financial hardship.
Pursuing a disability insurance claim while dealing with a chronic illness, injury, or disability is an immense burden for anyone. If you need to file an appeal or bring a lawsuit against Sedgwick, promptly contact a St. Petersburg disability attorney and retain the help you need.
You should be represented by a disability attorney with considerable experience facing and prevailing against insurance firms and claims management companies like Sedgwick, powerful businesses that hire teams of attorneys to protect their interests.
Denied by Sedgwick? Call the Law Office of Nancy L. Cavey
At the Law Office of Nancy L. Cavey in St. Petersburg, we understand the specific requirements of Florida law and federal ERISA law. When you become our client, we handle the legal paperwork, medical record collection, and court filings so that you can focus on your health.
We are one of a small group of law firms nationwide that focus on ERISA claims. We have seen what can happen when injured and disabled individuals have to seek benefits on their own. While this process may be complicated and stressful, we can work to put the law on your side.
If you need assistance obtaining the disability benefits you deserve, our law firm is here to help. You can schedule a no-cost consultation to discuss your case with our disability professionals by calling the Law Office of Nancy L. Cavey from anywhere in Florida at 727-477-3263.
