In Donald Godmar v. Hewlett-Packard Company Disability Plan, Sedgwick Claims Management Services, Inc., Plaintiff was employed by Hewlett-Packard (HP) as a customer-project manager when he severely injured his leg in a waterskiing accident. Several major bones were broken, and some ligaments, muscles, and nerves were damaged. He required numerous operations and was prescribed opioids for pain.

The record indicated that Godmar had received some short-term disability benefits through the HP benefit plan which was administered by Sedgwick Claims Management Services, Inc. (Sedgwick). At one point, Sedgwick notified him there would be no further extension of his benefits which would end on June 31, 2012. However, he was paid benefits during part of August 2012 when he was treated as an in-patient for his opioid addiction.

Plaintiff’s claim for any further benefits was denied. After he exhausted his administrative remedies, he filed an ERISA lawsuit in a federal District Court in Michigan.

The Michigan Court agreed with Sedgwick and ruled against Godmar, so he filed this appeal with the U.S. Court of Appeals for the Sixth Circuit. The Circuit Court ruled in his favor, finding that Sedgwick abused its discretion by ruling against Godmar without requiring a medical exam when the plan allowed Sedwick the discretion to make such a request.

Sedgwick’s Denial of Benefits Without an Independent Medical Exam was Arbitrary and Capricious

While pursuing his claim, including through the administrative appeal, Godmar submitted reams of medical records from his primary care doctor, his orthopedist, neurologist, physical therapist and pain management control specialist, all documenting his extreme and chronic pain as well as his related opiate addiction. All expressed the opinion that Godmar was disabled and unable to perform his job duties.

Sedgwick had the records reviewed by its own specialists whose reports were that Plaintiff was not disabled from performing the job duties of his occupation. At no time did Sedgwick ever request Godmar to undergo a medical exam by its own physician.

The Court of Appeals conducted a comprehensive review of the medical records and treating physician statements presented by Godmar. It concluded that “the consulting physicians apparently dismissed Godmar’s reported pain—and any corroborating diagnosis by his treating physicians—as inherently subjective. In so doing, Sedgwick implicitly determined that Godmar’s description of his limitations was not credible.”

The Court’s final conclusion was that since Sedgwick made this credibility determination without examining Godmar, its denial was arbitrary and capricious. It reversed the lower Court ruling in favor of Sedgwick and remanded with certain instructions for Sedgwick to follow.

Remand Was the Appropriate Remedy

The Court noted that remand is the remedy when “the problem is with the integrity of the plan’s decision-making process, rather than that a claimant was denied benefits to which he was clearly entitled.” Although it was clear Godmar was entitled to benefits up until August 28, 2012, but not clear if he was still entitled after that time, the Court remanded to Sedgwick with instructions to:

  • Remain cognizant of Godmar’s full job description, including the amount of driving he was required to do.
  • Avoid making credibility determinations without the benefit of a physical examination.
  • If Sedgwick determines Godmar is not entitled to further benefits, “explain why the evidence proffered by Godmar’s treating physicians does not meet its objective-evidence standard as of a particular date.”

This case was not handled by our office, but we believe it can be instructive to those whose claim for benefits seems to rest on credibility determinations. If you have questions about this or any other aspect of your disability claim, contact our disability attorneys at Dell & Schaefer for a free consultation.