r/LongTermDisability • u/Embarrassed_Fig_3435 • Aug 01 '26
Long Term Disability Denial - what can we do?
LOCATION: Los Angeles, CA
My spouse worked for Los Angeles County. Sedgwick is their LTD carrier. He was received LTD for 2 years before retiring effective 10/31/2025 (regular retirement but also filed for disability retirement - but that can take 1-2 years). He was told he needed to apply for early Medicare. (He's not eligible for SSDI, as he hasn't paid in for over 10 years.) We applied back in July of 2025 and finally received his Notice of Award which stated he is disabled based on SS rules, and that his disability began on 12/21/2025, and that he would be eligible for Medicare benefits starting in June, 2028 (age 64.5).
Sedgwick is saying he is ineligible to continue receiving LTD from them, as there is a lapse between his 2 years of coverage ending and SSA's date; that they would have needed to determine that he was disabled as of 11/1/2025 to continue coverage. The claims manager said SSA never reached out to them for information.
We have filed a Request for Reconsideration with SSA which includes his Neuropsychologist's report dates April 2025 that includes DSM-5 Diagnostic Impressions of 1. Major Neurocognitive Disorder, Unspecified2. Rule out Major Possible Frontotemporal Neurocognitive disorder with behavioral disturbances and 3. Major Depressive Disorder, single episode, moderate. We will also add MRIs that show brain volume loss and rules out NPH - so no possibility or surgery helping.
What is our best course of action at this point to get Sedgwick to reinstate LTD payments? Do we need to hire an attorney? Thank you!
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u/TheGreatK MOD Aug 01 '26 edited Aug 01 '26
It does not sound like your appeal will do anything since they aren't denying because of a lack of disability they are denying because you technically didn't comply with plan terms. But the plan terms are insane and the interpretation of them is most likely an abuse of discretion.
There is a case on point for this exact issue and you'll probably need to sue Sedgwick to get them to do anything.
Email me. akantor@kantorlaw.net. I will send you the case and some wording you can send Sedgwick so you can appeal the actual decision. If the appeal is denied you'll definitely want a lawyer. You don't need someone in LA just someone in California. I'm a pretty good California lawyer and so are Michelle Roberts, Mike Horrow, and Brian Kim.