Received: November 30, 2015

Status: Pending_Post 

Tracking No. 1jz-8mjx-hkik 

Comments Due: January 19, 2016 

Submission Type: Web

Docket: EBSA-2015-0017 

Claims Procedure for Plans Providing Disability Benefits

Comment On: EBSA-2015-0017-0001 

Claims Procedure for Plans Providing Disability Benefits 

Document: EBSA-2015-0017-DRAFT-0004 

Comment on FR Doc # 2015-29295 

Submitter Information

Name: Miriam DiNicholas

Address: 

c/o CWA Local 1298 

3055 Dixwell Avenue 

Hamden, CT, 06518 

Email: mdinicholas@cwa1298.org 

Phone: 860-302-7682 

General Comment

As a union representative I represent thousands of members who in many cases have an up hill 

battle to fight in order to get their disability benefits approved while at the same time fighting 

whatever ailment afflicts them. In my experience, there In some cases where the abuse is beyond 

reason. Major problems with self-insured employers consist of non- impartiality of claims 

determinations. It is our contention that claims administrators have a strong bias when granting 

disability claims as can be seen in the example of a March 22, 2006 email from Sedgwick claims 

reviewer assuming that disability insurance claimants falsely exaggerate the severity 

of their conditions and I have attached a letter from our Attorney General Richard Blumenthal 

(Now our Senator), written on behalf of our members explaining his position on these activities. 

He details the letter and other unfair practices to the Dept. of Labor in 2001. I have 

tried to call attention to this matter for a number of years and applaud these actions to try to 

provide more objectivity and fairness to the determinations made by an employer and their TPA. 

Please keep me in formed and if there is anything I can do that will help these rules become final, 

please let me know. 
Attachments

Letter from Blumenthal to DOL
May. 21. 2001 11:21AM AGO FRAUD DEPT No.5159 V. j

State of Connecticut

Hartford

May 17, 2007

RICHARD BLUMENTHAL

ATTORNEY GENERAL

Mr. James Benages

Director, Boston Regional Office

United States Department of Labor

Employee Benefits Security Administration

JFK Federal Building, Room 575

Boston, MA 02203

Re: Claims Management Services, Inc.

Dear Mr. Benages:

I write to communicate to you a letter of protest I have received from the Connecticut 

Union of Telephone Workers (the Union) concerning the operations of Sedgwick Claims 

Management Service, Inc. (Sedgwick), the claims administrator for the short term 

disability benefits plan operated for the employees of the Southern New England 

Telephone Company (SNET). See Attachment A.

These union members complain convincingly that Sedgwick as claims administrator, and 

SNET as the plan sponsor and administrator, have violated their fiduciary duties to 

determine coverage for short term disability insurance in a fair and evenhanded manner.

On behalf of the members of the Connecticut Union Telephone Workers, and pursuant to 

29 C.F.R. 2560.502-1(a), 1 ask that you take action to require Sedgwick and SNET to 

reform their coverage determination process so that employees can receive unbiased 

consideration of their claims for disability coverage.

As you know, one of ERISA’s essential goals is to protect the interests of welfare benefit 

plan participants and beneficiaries. Congress expressly imposed certain standards of 

conduct for fiduciaries of such plans. A person is a fiduciary of a plan if he “exercises 

any authority or control respecting management or disposition of its assets. [or] renders 

investments advice for a fee or other compensation, direct or indirect, with respect to any 

moneys or other property of such plan.” 29 U.S.C. § 1002(21) (A). By nature of their 

responsibilities to the plan, trustees and plan administrators are ERISA fiduciaries; See 
Bd. of Trustees v. Weinstein, 107 .F.3d 139, 141- 42 (2dCir. 1997) (citing 29 C.F 

2509,75-8D-3 (19%) Donovan v. Mcer. 747 F.2d at 304 309 (5th Cir 1984).

A fiduciary has “a duty to deal fairly and honestly with its beneficiaries” Ballone v. 

Eastman Kodak Co.. 109 F.3d 117, 124 (2d Cit. 1997). “[When a plan administrator 

affirmatively misrepresents the terms of a plan or fails to provide information when it 

knows that its failure to do so might cause harm, the plan administrator has breached its 

fiduciary duty to individual plan participants and beneficiaries.” In re Unisys Corp. 

Retiree Med. Benefit “ERISA” Litig, 57 F.3d 1255,1264 (3d Cr 1995). “An ERISA 

fiduciary has an obligation to provide full and accurate information to the plan 

beneficiaries regarding the administration of the plan” Recher v. Long Island Lighting 

Co.. 129 F.3d 268,271 (2d Cit. 1927):

While the Union’s protest letter mentions several problem areas, T am particularly 

concerned with apparent abuses that I believe deserve your immediate attention.

In substantiation of its complaint, the Union has supplied me with documentation that 

demonstrates a strong bias by Sedgwick and SNET reviewers against the granting of 

disability henelUs. For example, on March 22, 2006 Sedgwick claims reviewer 

 sent an email to a Union advocate that suggests that Sedgwick claims reviewers 

assume that disability insurance claimants falsely exaggerate the severity of their 

conditions:

As we both are aware, the medical information relayed to a lay person (w/o medical 

background), by an employee will always sound worse than it is because:

1. Usually the employee is trying to continue out of work

2. By pleading w/you and embellishing any symptom they have, is their way of making 

you believe that they are on “Death’s door”.

3. You are the union benefit rep and it is your job to assist them. And of course, you want 

to have a positive experience w/your member and don’t want to appear the “bad guy” 

because if you can’t turn the employee’s request into a plus instead of remaining 

negative.

(Attachment B) (Emphasis added). In effect, this Sedgwick employee, and by implication 

Sedgwick reviewers generally, apparently assume that disability claimants are lying ibis 

stated prejudice against claimants is antithetical not conducive to impartial decision 

making.

Attachment C to this letter is a page from a computer case log showing communications 

between Sedgwick and SNET concerning particular disability claimants. Once again, 

these administrators state openly their belief that the claimant is lying about his 

condition. SNET and Sedgwick appear to be working together to defeat and limit the 

employee’s claim,for coverage: 
Don has had repealed discussions with the SMAART Rep to determine if and 

when will return and if he will be able to do the OND)job. We also have 

asked SMAART to follow because we believe he is not as injured as 

he says he is. SMAART has not been able to do this for us but the Rep is 

taking a more aggressive stance to move this case along.

The Union has also documented the unfairness of the Sedgwick review process and apparent 

misinformation provided to claimants. Attachment D is a Sedgwick claim denial form letter 

telling the employee, a claimant for disability benefits, that new evidence may be submitted only 

if the claimant requests an appeal: 

In order for the At&T Integrated Disability Service Center (IDSC) Quality Review Unit (QRU) 

to consider this and any additional information, you must submit a written appeal to the QRU as 

described in your denial letter. In fact, however, the Union has demonstrated that Sedgwick has 

stated that it does indeed accept and consider new medical information even where the claimant 

has not filed an appeal. The email exchange below shows that the policy described in Attachment 

I), distributed routinely to every employee whose initial claim is denied, is actually untrue:

Question: If the participant submits the appropriate medical information to Sedgwick before an 

appeal is filed; can’t there be dates of absence that could be overturned without the appeal?

[Answer): It is not necessary to file an appeal in order to get the case approved, if the 

employee has additional/new medical information] to submit. The employee has 180 days (from 

the date on the denial letter) to submit medical for review. (Attachment E) (Emphasis supplied).

By mis-representing its policy concerning the consideration of new evidence Sedgwick has 

discouraged claimants from submitting evidence unless they also file an appeal. The Sedgwick 

misrepresentation also coerces employees into filing appeals immediately, even when the claim is 

not fully documented, because the employee has been misled into believing that is the only way 

new evidence will be considered. 

An appeal submitted prematurely is more than a summary, the Union has submitted strong

evidence that the short term disability insurance coverage determination process 

administered by Sedgwick and SNET is deeply biased and unfair.

On behalf of the ERISA participants and beneficiaries involved, I ask that you exercise 

your enforcement authority and order that immediate appropriate remedial measures be 

taken.

In summary, the Union has submitted strong evidence that the short term disability 

insurance coverage determination process administered by Sedgwick and SNET is deeply 

biased and unfair. On behalf of the ERISA participants and beneficiaries involved, I ask 

that you exercise your enforcement authority and order that immediate appropriate 

remedial measures be taken.

Very truly yours,

RICHARD Blumenthal