Sedgwick CMS Crime Stories

 "Killing the Claimant with Sedgwick Kindness"

 

 

ATT Sedgwick CMS Disability Scam Exposed

More from Eric

 

As an employee of AT&T you are promised “disability income protection” via a company funded program governed by a Federal Law known as ERISA.  The only catch about this program is that it has been carefully designed by the attorneys at AT&T, most likely with the help of their plan’s Third Party Administrator, Sedgwick Claims Management Services.

 

Under AT&T’s plan, after one year on Short Term Disability, the employees employment is TERMINATED” and they are placed on Long Term Disability with little to no chance of reinstatement should their condition improve.

 

The attorneys that wrote the plan carefully crafted AT&T’s plan to allow the benefits, provided to employees covered under the plan, to be denied for any number of reasons unrelated to the employee’s disability.  One has to believe that the loopholes in ERISA, that AT&T’s lawyers so cleverly exploited, are oversights in the way the law was written.  It is difficult to fathom that the legislators deliberately meant to allow the “abuses” that are currently being promulgated under ERISA’s umbrella.  For example, one of the provisions of the AT&T’s Disability Income Protection Plan is that someone receiving “benefits” under the plan is not allowed to ”travel” away from home.  Travel is defined in the plan as “beyond a 60 mile radius or overnight”.  Travel may be permitted by first requesting “prior permission from both the Claims Administrator and your Physician”.  In addition the plan states:  “Each request for travel will be determined on an individual basis”, so blanket approvals are not given.  These Administrators, in all likelihood, have no medical training and simply do not have the ability to make a fair determination whether “traveling” is prudent or not.  In fact, even though an beneficiaries’ condition permits travel with reasonable steps taken to accommodate their disabling condition, AT&T/Sedgwick CMS routinely refuses to “grant permission” for requested trips.  The granting of permission has even been withheld when a primary health care provider states that it is an integral part of treatment plan to alleviate some of the effects of the disabling condition.  One could argue that this loophole” allows “Administrators” with no medical training to prevent a primary care givers treatment plan from being carried out.  This could this be “construed” as AT&T/Sedgwick CMS “Practicing Medicine Without a License”. AT&T/Sedgwick CMS have steadfastly refused to provide a process where requests can be acted upon in a reasonable time frame.  This allows them to essentially incarcerate disabled “former employees” under a form of “virtual house arrest”.  Their “Travel Policy” is, in fact, a “You Can’t Travel Policy”.  As a result, disabled “former employees” are unable to accompany their families on even day outings and are more likely to experience depression and other detrimental side effects as a result of being in “isolation”.  Is this what our legislators had in mind when the passed the ERISA law?  If AT&T/Sedgwick CMS  learns that an employee “on benefits” is not abiding by the “rules” they make it clear that the disability benefits will be terminated.  One disabled “former employee” was refused “permission” for a requested trip, and could not get any explanation as to why the trip wouldn’t be approved.  In addition, he was only provided a copy of “AT&T’s  You Can’t Travel Policy” (after multiple requests) after his benefits were terminated under a “loophole” in the plan, not because he had recovered and was no longer disabled!

 

 

 

 

Another ploy that AT&T/Sedgwick CMS use to create a situation that will allow them to terminate the benefits of a disabled employee is to send the employee to an “Independent Medical Examiner”.  These IMEs, as they are known, are not known to “bite the hand that feeds them”.  They know full well that their services will not be required in the future if they find that the employee has a legitimate disability.  They are often doctors that for one reason or another are unable to earn a living “treating” and helping patients and are forced by economic necessity to earn their keep by rendering “opinions”, accurate or not.  They are remarkable in their ability to ignore the post operative reports and diagnoses of surgeons that have seen, first hand as a result of surgery, the physiological conditions responsible for causing the employees disability.  Of course these desirable “IMEs” are extremely difficult to find, and when one is lucky enough to find one, they must be carefully cultivated (by sending a continuous stream of unsuspecting employees for “evaluation”).  

 

AT&T/Sedgwick’s lawyers also crafted their plan so that any benefit paid to the “former employee”, under the plan, can be reduced by the amount the employee receives under SSDI.  To that end, they often hire consultants and attorneys to “grease the skids” and speed the employees SSDI application through the approval process.  Thus they often require individuals that don’t meet the strict SSDI disability definition, but do meet the lower standard defined by the plan, to apply for SSDI anyway.  This clogs the SSDI system with inappropriate claims.  This has the effect of slowing the processing of claims that are appropriate.  Once a SSDI claim is approved benefits can be retroactiveAT&T/Sedgwick makes it a practice to ensure that the retroactive SSDI benefits are returned to them!  In fact, they do their very best to convince disabled “former employees” to allow them direct access into the “former employee’s” bank account so they can withdraw any amount they feel is “appropriate”.  It appears that there have been instances where too much money was withdrawn from a “former employees account”, AT&T/Sedgwick has refused to correct the situation short of a lawsuit, and employees have suffered serious financial hardships as a result of the “overdraft” by AT&T/Sedgwick.  One can only assume that is a rare and “cagy” “former employee” that refuses AT&T/Sedgwick direct access into their personal bank account!  They do their best to persuade “former employees” to grant them “access”.

 

AT&T/Sedgwick are sometimes not content to have an employee’s benefit under the Disability Plan reduced by the amount of the SSDI award.  Although this can reduce the money they have to pay the disabled employee to a fraction of the amount before SSDI, other tactics are used to reduce their expenditure to zero.

 

The requirements to qualify for SSDI are much higher than to qualify for AT&T’s plan under ERISA.  AT&T/Sedgwick CMS want to “have their cake and eat it too”.  After a “former employee” is approved for SSDI, they can, and will, schedule additional IME exams in the “hopes” of a “finding” that the employee isn’t disabled after all.  This finding, of course, will allow them to terminate all benefits and as a “bonus”, the former employee’s employment has been previously “terminated”, so they are not obligated to reinstate them.  It’s no stretch of the “imagination” to reason that that older employees utilize both STD and LTD more frequently than younger employees; and, the way the plan is administered, it allows AT&T to cull the workforce of older employees saving both the higher wages of older more experienced employees and depriving the older and “terminated employee” the opportunity to work towards “full retirement benefits”A double win for AT&T!

 

There is, as there should be, “case law” that prevents employers from using this “scam” overtly.  The courts have recognized that Plan Fiduciaries shouldn’t be allowed to hire one party to support the fact someone is disabled to qualify for SSDI, and then hire another party to find they are not disabled to permit the termination of benefits under a disability plan.  This, of course makes a lot of sense.  AT&T, to the credit of their clever attorneys, has found a way around this.  You can find that the “employee has been uncooperative with the plan administrator” and use this as an “excuse” to terminate the benefits they are entitled to by virtue of their disability.

 

This is how this “scam” works:  First you use the “you can’t travel” policy to trick trusting “former employees” into requesting permission to travel (of course the trusting “former employee’s” doctor approves).  Then, after a naïve/trusting employee makes a request or two, these “requests” serve as justification to “question” the continued disability of the “suspected malingering” “former employee”.  It doesn’t matter if the requested outings are completed or not!  The mere fact that the disabled former employee is considering an outing of any kind is sufficient to trigger the next phase of the “scam”.  Now the “administrator” has “reasonable cause” to schedule the “malingering former employee” for not one, but two additional IMEs!  These exams can be “grueling” events that last a day or even two.  Every aspect of the “malingers” life is open to question (as far as AT&T/Sedgwick is concerned) and is to be thoroughly explored in the hope of finding a “reason” to deny benefits!  In one instance, the fact that a “malingering former employee” expressed “a clear future-orientation in hope for and pride his son graduating from college and other life issues” led the “case manager” to question the legitimacy of an exceptionally well documented, rare, and severe manifestation of neuralgias of the cranial nerves (read as chronic, severe, continuous, pain).  Apparently someone on “AT&T’s Disability Plan” isn’t allowed to have hopes for the success of their children!

 

In this particular instance, the “former employee” realized that the IMEs were not “there” to help treat or solve the problem, but to, quite simply, find the “malingerer” fit to return to work, somewhere other than AT&T!  This “former employee” had somehow, gotten a copy of the first IMEs report.  The good doctor was unable to get the height, weight, or sex of this “former employee” correct!  In addition many of the examinees comments were taken out of context, twisted, and distorted to support the conclusions that the doctor so desperately wanted to support.  The report was so riddled with factual errors that it could never be used in any court of law as the doctor would appear as a complete “idiot”.

 

So, utilizing the internet, the “suspect former employee” did some research and learned how to protect his interests during the exam.  He informed AT&T/Sedgwick, four months prior to the date of the exams that during the exams he would have his doctor present, his attorney present, would be making a sound recording of the exam, and would require copies of any tests or forms that he was required to complete as part of the exams.  He had found that although the plan and Federal law are silent on these issues a number of states have made these “rights” during IMEs and there were also decisions in Federal Court upholding these “rights”.

 

Mere hours before the exam was to take place, a Sedgwick CMS manager called and said that these steps to protect his rights and ensure there was an accurate and unbiased record of the exam, were “unauthorized” and if he insisted in recording the exam, it would be “construed” that he was being “uncooperative” with the “plan administrator”.  This, of course, was the excuse AT&T/Sedgwick was looking for to terminate his benefits. Brilliant, simply brilliant!

 

So, knowing the cards were stacked against him, the “former employee” he went to the exam, the doctor refused to allow him to record the exam, and as a result the exam was cancelled.  The AT&T/Sedgwick plan administrator had to work overtime over a weekend to ensure the “benefits denied” letter was prepared and mailed without delay.  Sedgwick can be efficient when it is in their interests.  After all, the more money they don’t pay out, the more money they make!

 

The employee appealed the “denial of benefits” citing the applicable California Laws and Federal Court decisions but AT&T and Sedgwick apparently feel they are above these laws!

 

To be continued in Federal Court and the “Court of Public Opinion”.

 

 

 

 

 

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