Challenge

A power management company sought to prevent abuse while ensuring its employees received appropriate benefits based on equitable and objective decision-making processes. As an example, a warehouse worker filed for short-term disability to ensure salary continuation while he took medical leave. His paperwork indicated he was recovering from a benign tumor removal and supported a period of approval; however, additional medical documentation was vague and did not support continued benefits, so he received a partial denial. Not satisfied with the decision, he filed an appeal.

Solution

Because the company outsourced short-term disability claims determinations to Sedgwick, the national appeals unit (NAU) of our workforce absence division conducted a fair and independent review of the case. The assigned appeals specialist called several of the providers listed in the employee’s documentation and discovered he was not at the locations identified in the office visit notes on the given dates. Two of the appointment dates even conflicted with one another

Results

The national appeals unit found much of the employee’s medical information to be falsified. They turned the case over to Sedgwick’s special investigation unit (SIU) for a full investigation. Ultimately, the claim denial was upheld, and the employer was notified of the warehouse worker’s attempt to abuse the employee benefits system.

Sedgwick’s National Appeals Unit works diligently and with a critical eye to verify that the employees of our workforce absence clients receive the leave benefits due to them receive the leave benefits due to them and to prevent systemic abuse

Saved the employer

$4,000

in disability payments

Prevented the misuse of

68

days of paid leave

NAU reviews about

20,600

short-term disability cases each year