Is Your Virginia Worker’s Comp Claim Managed By Sedgwick? Here’s What You Need To Know

If you’ve been injured at work or developed an illness because of your job, your first move may likely be to file for worker’s compensation benefits. Once you file a worker’s comp claim in Virginia, you can expect to get a phone call or letter from a third-party administrator such as Sedgwick CMS. What is this party’s role in your claim and how can they affect your case outcome? What should you do if you get contacted by Sedgwick? Learning about this third party can be an important factor in whether or not you succeed in your claim.

What Is Sedgwick CMS?

Sedgwick Claims Management Services, Inc. is a private company that works as a third-party administrator (TPA) in compensation claims. Third-party administrators are common in Virginia workers’ comp cases. They firms manage claims on behalf of certain employers and their insurance carriers. Founded in 1969, Sedgwick is the largest TPA in the US – with $1.8 billion in revenue in 2017 – and is one of the most prominent TPAs in the world.

Many people get the impression that Sedgwick is an insurance company. It is not. It only handles the claims process for the business that hires it. If your employer contracted Sedgwick to handle claims, you will be dealing directly with this TPA throughout your case. You might be speaking with a Sedgwick claims associate, claims examiner, claims assistant, or a whole team of them. Assume that your telephone call will be recorded, legalities aside.

As a TPA, Sedgwick has great power in how your worker’s comp case is dealt with. The TPA can:

• Investigate your claim
• Decide whether your injury is compensable
• Choose your authorized treating physician or physicians
• Approve or deny doctor visits, treatments, or therapies
• Decide on prescription coverage
• Assign you a Nurse Case Manager who tracks your medical progress and attends doctor visits with you
• Decide whether you get wage loss payments
• Decide whether you get paid for permanent impairment
• Decide whether you get permanent partial disability benefits
• Audit medical bills
• Work with an insurance defense lawyer to defend their client from the claim
• Decide whether your employer should offer you a worker’s comp settlement
• And many more.

Sedgwick Is NOT A Neutral Party In Your Claim

Although it is a third party in workers’ comp cases, Sedgwick works for your employer, not as an independent go-between. Sedgwick’s own website presents itself as an ally of companies and businesses. It talks about solutions that are designed to “protect [their] brand and save [them] money.” It boasts of how Sedgwick “clients experience some of the best outcomes and lowest overall claims costs.”

Note that this particular TPA has been in the business for decades and has grown into a billion-dollar company handling claims. You can surmise that it is extremely experienced and well-prepared to get a case outcome in your employer’s favor. You’ll want to protect your interests by hiring a worker’s compensation attorney to level the playing field for you.

Real-life Examples Of How Sedgwick Manages Workers’ Comp

It is not uncommon to find injured workers sharing their unpleasant experiences with a workers’ comp TPA. In our decades of helping the injured, we’ve seen firsthand how workers’ comp claimants were kept waiting for approvals, sent to pre-selected (“benchmarked”) doctors, denied their treatments, and denied their workers’ comp benefits altogether. We know how a claims administrator could use a Nurse Case Manager to pressure an employee to get back to work before they’re healed. We know that a claims administrator could audit medical bills in a way that saves money for their client.

Take a look at these real-world cases involving Sedgwick CMS in particular:

• In 2014, the Virginia Court of Appeals sided with a Kmart worker after his employer appealed against an injury award for him. Kmart asserted that the worker had failed to file a timely claim. However, it turned out that the employee’s filing was delayed because Kmart, alongside its insurance carrier and Sedgwick CMS, had assured him that they would do all the filings on his behalf. Thankfully, the court upheld his worker’s comp award.
• Another kind of delay happened to a window factory worker in West Virginia in 2012. He had slipped on the factory floor, obtaining arm injuries for which his doctor advised immediate surgery. Instead of approving the employee’s claim, Sedgwick CMS took six weeks before sending him to their own doctor for a second opinion. Then they waited another five weeks to approve the surgery. Because of the delays, the operation couldn’t completely address the employee’s pains anymore – he had to stop regular work and needed another surgery. Sadly, because of time limits in the state, the employer is no longer responsible to pay for this additional treatment.
• In July 2008, a Virginia Beach police officer developed a hernia and a ruptured spinal disc after slipping while escorting a handcuffed man. The officer underwent three surgeries, but his persisting pain and permanent nerve damage cost him his job. Expecting worker’s compensation from the city, he had to deal with Sedgwick CMS, which was handling the city’s injury claims. But Sedgwick sent him a denial form in 2009, questioning if his injuries were indeed related to the slipping accident. The claimant fortunately did not give up his fight. It was only in November 2010 – more than two years after his injury date – when the city finally agreed to pay him several months of withheld workers’ comp payments, medical expense reimbursement, and coverage for injury-related future costs.
• Sedgwick has been involved in a number of serious legal cases across the country as well. These include a 2003 case where a California grocery worker, Charles Romano, developed a severe bacterial infection following a work-injury surgery. Sedgwick did not authorize his treatment for the infection and kept delaying his claim. Tragically, after his health continuously deteriorated, Romano died in 2008.
  This case was one of those cited by the California Workers’ Compensation Appeals Board when they alleged that Sedgwick committed labor code violations. The subsequent investigation found 75 mandatory penalties for the TPA. In 2018, Sedgwick finally settled for $1,129,600.

What To Do If Your Employer Hires Sedgwick

It can be intimidating to know that your employer uses a savvy claims administrator like Sedgwick CMS. But it is still possible to succeed in your worker’s compensation claim and even maximize your benefits. Take these crucial steps after you’re hurt on the job and when facing Sedgwick:

• Report your injury immediately. As soon as you discover your work injury or occupational illness, notify your employee in writing. Virginia law requires that you give notice within 30 days. But don’t wait a month – report the injury as soon as you can, because any delay can be used against your claim. Also keep your own copy of the notice.
• Ask for Sedgwick’s details. When you talk to your employer, ask them for the name of the Sedgwick claims adjuster, their contact number, and your claim number. But before you talk to Sedgwick or any claims administrator, it is prudent to consult a worker’s comp attorney so you don’t make any costly mistakes.
• Do not post any details about your injury on social media. You may want to tell people about the dangerous condition that injured you or of the problems you are having with your claim. Don’t. Talk to a lawyer first if you think you should post.
• File with the Commission. Under the statute of limitations, you have two years from the injury date to file your claim with the Virginia Workers’ Compensation Commission.
• Talk to a lawyer. Even a simple worker’s compensation claim can become difficult if you’re up against an established TPA. You need a reliable attorney on your side. Look for someone with a proven track record of winning on behalf of workers like you.

Call Slominski Law

Attorney Jaleh K. Slominski has been practicing law since 1991, with a strong commitment to help injured workers facing powerful companies. Your initial consultation with Slominski Law is absolutely free. Call our Lynchburg office at (434) 205-9864, or our Roanoke office at (540) 858-8603 today.