Tips for Dealing with Sedgwick Claims for Your Personal Injury

Who is Sedgwick?

Sedgwick is a company that provides “global claims management solutions…tailored for corporations, insurance carriers, and public entities,” according to their website. For purposes of an individual filing an injury or worker’s compensation claim, Sedgwick is what is known as a third-party administrator. Insurance companies and private corporations farm out claims handling to them. In addition to that they provide handling for a number of other employer-provided benefits such as disability, FMLA, unemployment, LOA, travel, and medical assistance. Sedgwick boasts 33,000 colleagues (contractors and employees) worldwide and handles over 8.1 million new claims per year.

What is a Third-Party Administrator?

A third-party administrator is a company that handles the claims processing on behalf of another company that has a legal claim for damages made against it. who deal with claims. A third-party administrator takes the role of an insurance adjuster in investigating, auditing, and paying claims legally owed by the party hiring them. In some cases, their client is an insurance company that uses them rather than processing the claim with its own insurance adjusters. In other cases, they may work directly for a corporation that self-insures all or part of a claim. Some examples of these types of companies other than Sedgwick include Gallagher Bassett, Broadspire, ESIS, and UMR, Inc. In order to practice as a third-party administrator in Texas, the company must be licensed with the Texas Department of Insurance.

What Does a Third-Party Administrator Do in a Personal Injury Case?

Third-party administrators like Sedgwick do more than just receive claims and pay them. Their goal is to save their clients’ money. They do this by investigating the claims to determine whether they believe a jury would hold their client legally liable. They may ultimately decide to accept all, part, or no liability. If they accept all or partial liability, this is not the end of their role. The next step is to audit the medical bills to determine what they believe is reasonable and necessary.

Auditing Medical Bills

Medical bill auditing is a common practice by insurance companies and third-party claims administrators any time a bodily injury, lost income, or property damage claim is filed. The auditor carefully compares the bills to other indicators of what other providers in the area charge for similar medical services. These indicators may include insurance company rate schedules, in-house computer auditing software such as Juris or Colossus, Medicare or Medicaid reimbursement rates, Texas Worker’s Compensation Commission reimbursement rates, or other data. If the charges submitted exceed whatever schedules they are compared to, the third-party administrator will recommend a lower settlement offer based upon what they perceive as the reasonable reimbursement rate. In the case of Sedgwick, they are known for using a computer program called Juris to audit medical bills.

Dealing with Sedgwick Claims Administrators

In general, a third-party administrator for Sedgwick should be viewed the same way you would view an adversarial insurance company handling a claim against you. They are not there to help you or find reasons to pay your claim. They represent the company that you are making the claim against. If they request a recorded statement, they are not doing it to be your friend. They are looking to capture admissions that enable them to reduce or deny your claim. If they seem nice and friendly, they may be dragging things out so that the video evidence gets “recycled” before you think to preserve it.

Here are some things you and your lawyer should consider doing if you are dealing with Sedgwick:

• Make a report of the injury to the store or business promptly.
• If possible, photograph the defect or condition responsible for your injury.
• Immediately send a preservation of evidence letter to preserve a full day of video of the area if you suffered an injury due to a premises defect such as a slip and fall accident or trip and fall accident. Send it CMRRR so you have proof of the request.
• Set up your claim promptly.
• Do not give a recorded statement without talking to a lawyer about your case first.
• Seek medical care promptly for any injuries.
• Document every expense and double-check that the medical providers have included the billing codes in their bills as well as good documentation of the injuries.
• Gather eyewitness information on your own—do not rely on them.
• Prepare and send a demand letter or a Stowers demand letter if warranted.

What Texas Companies Use Sedgwick as a Third-Party Administrator?

Some examples of companies in Texas that use or have used Sedgwick as their third-party administrator for handling claims include:

• Amazon
• Home Depot
• Kroger
• Sears
• Target
• Walgreens

Large retail stores commonly use Sedgwick to evaluate slip and fall claims or other premise liability claims.

Can You Sue Sedgwick for Not Paying a Claim in Texas?

In most cases, you do not have a direct cause of action against Sedgwick for simply not paying a claim. This is because they are neither the negligent company nor the insurance company. However, they do have an obligation to process the claim in good faith, like the insurance company has. If you can demonstrate that their handling of the claim was arbitrary and/or capricious, you may have a cause of action for insurance bad faith. Speak to an insurance bad faith lawyer to determine whether you may have a claim. If the claim is related to a disability denial, you should talk to a disability denial attorney about your rights and potential case.

Talk to a Lawyer

If you have been injured at a store or place of business and you get a call from someone with Sedgwick claims, you have the right to speak to an attorney before returning that call and potentially getting tricked into harming your own case. At Simmons and Fletcher, P.C., our premise liability lawyers have been dealing with third-party administrators like Sedgwick for decades. Since 1979 the firm has fought for the rights of the injured. Call for your free consultation today at 800-298-0111.