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Tina
Tina, Lawyer
Category: Legal
Satisfied Customers: 33167
Experience:  JD, BBA Over 25 years legal and business experience.
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My short term disability benefits through Sedgwick CMS have

Resolved Question:

My short term disability benefits through Sedgwick CMS have been denied for untimely submission of claim. Are there key words or standard language I should use in my appeal letter?
Submitted: 8 years ago.
Category: Legal
Expert:  Tina replied 8 years ago.
Thank you for contacting our JA team for guidance. We are happy to assist you. However, we need a little more information about your question.

 

Please let me know what state/country you are in? Do you have a copy of the policy?

 

 

Customer: replied 8 years ago.
I'm in Los Angeles County, California. I am an county employee and dont have a copy of the policy other than the brochure provided to employees. The code noted on the letter is "Los Angeles County Code Title 5 Personnel, Chapter 5.27 County of Los Angeles Flexible Benefit Plan 5.27.410"
Expert:  Tina replied 8 years ago.

I see. You really need a copy of the policy so you can address the provision for filing a late claim. There may be written exceptions, such as if you were incompacitated or otherwise unable to fill out an application within the time period required.

 

You could get a copy of it from HR or request that the insurance company provide you with a copy and citation to the provision under which they denied your claim. Then you will have a better idea of how to respond.

 

Please let me know if you need additional information.


Best regards XXXXX XXXXX

TG

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Customer: replied 8 years ago.

 

In the meantime I need to submit my letter ASAP. I won't have time to get the policy information and read it over. So my question for this moment is "Are there key words - which I should use or avoid while preparing my letter?" I have ADD and tend to procrastinate and brush over documents instead of reading them thoroughly, but again I won't have time to get this verification from my Dr. Thank You

Expert:  Tina replied 8 years ago.
I see. Is the ADD the reason for filing your claim for STD? Is it the reason you filed late as well? If not, please provide the reasons. Thank you.
Customer: replied 8 years ago.
The reason for filing my claim is due to stress and anxiety which is related to a workman's comp claim that I have filed. The reason for filing my claim late (and cutting my appeal request too close to deadline) is due to my ADD.
Expert:  Tina replied 8 years ago.

You should request that the employer and its insurer provide you a reasonable accomodation pursuant to the ADA (American's With Disabilities Act) due to your ADA and accept your late-filed claim. However, if you are being retaliated against for filing a worker's comp. claim, the insurer is unlikely to grant you benefits as this would support your argument that you are being retaliated against, which is a violation of state law.

 

If you are suffering stress and anxiety because of your injury, that would be compensable under workers' comp and not the company's STD policy. Either way, you are unlikely to be granted benefits for this.

 

However, you should retain a workers' comp attorney to represent you on a contingency fee basis so there is no fee to you unless they prevail on your behalf in obtaining compensation for your work-related injury.

 

The state bar association can provide you with attorney referrals.

 

All the best to you.

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