SCHIRO v. OFFICE DEPOT, C.A. No. 13-1156 (E.D. La. Jan. 27, 2014)
This is a claim for short-term disability benefits. AETNA LIFE INSURANCE COMPANY was the insurance company and SEDGWICK CLAIMS MANAGEMENT SERVICES, INC. was the claims administrator. Sedgwick denied the claim because it claimed the file lacked "objective medical evidence" of his inability to work. The plan defines "objective medical evidence" as "evidence that establishes facts and conditions, as perceived without distortion by personal feelings, prejudices or interpretations, and shall include x-rays, quantative [sic] tests, laboratory findings, data, records, reports from the attending Physician and reports from a consulting Physician." (emphasis added).
The Court found that Sedgwick abused its discretion in determining the facts underlying Schiro's claim for short-term disability because it ignored the treating physicians' written findings regarding Schiro's ability to work. Sedgwick ignored the doctors' written statements and instead relied on the opinions of its registered nurse examiner and Dr. Brock, neither of whom personally examined Schiro, and an unsubstantiated telephone call with someone in Dr. Truax's office.
In addition Sedgwick refused to consider Plaintiff's "Vega" submission which it received after rendering its final decision but before Plaintiff sued.