Sedgwick gets a doctor to change his opinion, deletes important information, and removes records from the claim file!

Tucker Law Group
August 16, 2016

Our client came to us after Sedgwick denied her claim for long term disability insurance benefits. Our client had and still has severe, intractable back pain following failed back surgery and had tried every treatment option out there. On a daily basis she was taking Fentanyl and Percocet, in addition to Lyrica and Soma – a powerful cocktail of medication. She recently underwent the surgical implantation of an intrathecal pain pump.

Initial Approval…Followed by Paper Reviews

Sedgwick initially approved her claim and paid Long Term Disability (LTD) benefits from July 2014 until January 2015. In making the decision to terminate her LTD benefits, Sedgwick had two doctors – “players” in the insurance field that were well known to us for their reputation handling work for insurance companies – review the paper file. Sedgewick used a common tactic that many disability insurance companies use when they hired these doctors. To make it appear that they are not involved in the doctors’ report, LTD insurers pay a third party vendor to arrange the doctor’s review and report. Disability insurers think this avoids the appearance of any impropriety with the hired doctors, but it is merely an illusion, because it ignores the fact that the vendors they use typically only hire doctors that write reports for insurance companies. Although the disability claim representatives like to say, “I didn’t communicate with the doctor” or “it was an independent review,” there is usually nothing “independent” about these doctors.

Sedgwick Tries to Gets Its Doctor to Change His Opinion That Was Favorable to Our Client!

However, one of the players that was hired in our client’s case actually found her to be disabled! You would think that would be the end, and the claim would be approved, right? Of course not.

Within five minutes of receipt of the doctor’s report, the Sedgwick disability representative had the gall to email the third party vendor, Examworks, and question the doctor’s opinion. She told the third party vendor that Sedgwick wanted the doctor to change his opinion. And Examworks somehow got the doctor to do just that!

• The doctor’s original report stated: Yes, the claimant’s symptoms do support a total disability that would prevent her from performing her job. It would not be reasonable for her to return to even modified duty at this time.

• The doctor’s “REVISED” report stated: No, the claimant’s symptoms do not support a total disability that would prevent her from performing her job. It would be reasonable for her to return to full duty at this time.

Sedgwick Leaves Out Key Parts of Medical Records Too!

As if this was not egregious enough, when the Sedgwick disability claim handler reviewed the file and summarized the treating doctor’s note, she cherry picked a portion of a quote from the treatment plan and used it against our client. The Sedgwick rep wrote that the treatment plan advised “against bed rest,” but the actual progress note from the doctor advised “against bed rest lasting more than four days.” The phrase “more than four days” drastically changes the meaning of that sentence, but Sedgwick was happy to leave that part out.
Perhaps worse, Sedgwick’s disability adjusters referenced records from 2013 and summarized an office note from 2/7/14.  However, when we got our client’s file, those records were literally not in our client’s disability claim file. This has to lead one to wonder where the records went?  The only logical conclusion is that Sedgwick removed those records from the file.

You Can’t Trust the Disability Insurance Adjuster

Our clients often wonder why we are cynical about insurance companies because “the adjuster seemed so nice.” But the way Sedgwick handed our client’s claim in this situation is all too common. The “nice” adjuster at Sedgwick 1) asked a doctor to change his opinion, which he did, 2) omitted important language from an office note, and 3) removed multiple records from the file or inserted ones from another file. Some of the adjusters are perfectly nice people, but you can never trust them, because things like this happen to good people like you.  The insurance company is not on your side!

Even After Disability Claim Approved, More Harassment by Sedgwick

We fought to get our client’s benefits paid, and she remains on claim. Yet, Sedgwick continues to hassle our client with requests for documents, often giving us as little as 10 business days to get them and submit them to Sedgwick.

Sedgwick also uses a practice we call “serial document requests” to harass our client. For example, Sedgwick required her to fill out a particular form by a particular date, and when that form was returned, Sedgwick came back with a request for a list of providers and treatment date. When that was returned, Sedgwick then requested three doctors to complete forms and submit medical records in 10 days (many of which require an office visit to complete), as if a person can make three appointments with three different doctors, get seen, and get the forms completed in 10 days, while simultaneously submit three medical record requests, wait for the invoice to be returned, pay the invoice, wait for the records to be mailed, and get that all to Sedgwick in 10 days.

Sedgwick did this all while threatening to terminate our client’s benefits for noncompliance. This is the exact reason the team of disability attorneys at Tucker Law Group continues to work on our clients’ cases even after benefits have been approved. Having experienced disability counsel keep the insurance company off our clients’ backs and handling these requests are just some of things available to you to help to prevent your benefits from being terminated.

Are you fighting Sedgwick in an ERISA Long Term Disability case? Call our experienced disability lawyers for a free consultation to learn about your rights at (866) 233-5044.