If Sedgwick denies your claim, your benefits stop and a short appeal clock starts, often as little as 60 days for disability claims governed by federal law and sometimes shorter for workers’ compensation depending on your state. The denial itself is not the end of the process. It’s the start of a narrow window in which the evidence you gather and submit will likely be the only evidence any later reviewer, judge, or hearing officer ever sees. What happens next depends almost entirely on what you do in the next few weeks.
What the Denial Does to You Right Now
A denial is not just a paper decision. It has immediate financial and practical effects that get worse the longer they go unaddressed.
For a denied workers’ compensation claim, Sedgwick stops paying for medical treatment tied to the injury. Ongoing care, surgeries, physical therapy, and prescriptions become your responsibility. Wage replacement benefits end at the same time, which can create serious cash flow problems if you can’t work. People in this position sometimes delay treatment they need, and those gaps in the medical record can weaken the appeal you’re about to file.
Your job is a separate question. A denial doesn’t automatically cost you your position, but it complicates the protections you have. If you qualify for leave under the Family and Medical Leave Act, your employer must still provide up to 12 weeks of unpaid, job-protected leave for a serious health condition, regardless of what Sedgwick decided.1eCFR. 29 CFR 825.702 – Interaction With Federal and State Anti-Discrimination Laws FMLA leave is unpaid, and 12 weeks isn’t always enough. Most states also restrict an employer’s ability to fire you while a workers’ compensation claim is pending, and retaliation for filing a claim is illegal in virtually every state.2U.S. Department of Labor. Wage and Hour Division – Retaliation If your employer takes adverse action against you after you file, document the timing; that’s a separate legal issue from the denial itself.
If a denial ends up costing you your job or reduces your hours, you also face losing your employer health insurance. Termination or a reduction in hours is a COBRA qualifying event, and you have 60 days to elect continuation coverage.3Centers for Medicare and Medicaid Services. COBRA Continuation Coverage Questions and Answers COBRA lets you keep the same group plan for 18 to 36 months, but you pay the full premium plus a 2% administrative fee, often several hundred dollars a month.4U.S. Department of Labor. COBRA Continuation Coverage Read your plan carefully for one common trap: some group health plans exclude coverage for work-related injuries on the theory that workers’ compensation should pay. If the workers’ comp denial stands and your health plan carries that exclusion, you can end up in a gap where neither system covers your treatment.
Read the Denial Letter Before You Do Anything Else
The denial letter is your roadmap. For claims governed by the Employee Retirement Income Security Act, which covers most employer-sponsored disability and health plans, federal law requires the notice to state the exact reasons for the denial, identify the plan provisions the decision relies on, explain what additional information would help your claim, and describe the appeals process and its deadlines.5Office of the Law Revision Counsel. 29 U.S. Code 1133 – Claims Procedure If the decision rested on a medical judgment, the letter must also identify the medical or vocational experts Sedgwick relied on.6eCFR. 29 CFR 2560.503-1 – Claims Procedure
A vague denial that skips those specifics is itself a procedural failure you can raise on appeal. For workers’ compensation, requirements vary by state, but you should still see a stated reason and instructions for disputing the decision. Don’t set the letter aside. Everything you do next is a response to what the letter actually says.
Find Your Appeal Deadline and Treat It as a Wall
For ERISA disability claims, the plan must give you at least 60 days from receipt of the denial to file your appeal. For group health plan claims, you get at least 180 days.6eCFR. 29 CFR 2560.503-1 – Claims Procedure Workers’ compensation timelines depend on your state and can be much shorter. The specific deadline for your claim is in the denial letter. Miss it and you can permanently lose the ability to challenge the decision.
Filing deadlines are unforgiving in another sense too. If the original denial was based on a late claim filing under a state workers’ compensation statute of limitations, that’s one of the hardest denials to overturn, because the deadline is set by law rather than by plan terms.
Request Your Complete Claim File
Under ERISA, you have the right to request and receive, free of charge, copies of all documents and records relevant to your claim. That includes internal notes, medical reviews, and any consultant reports Sedgwick relied on.6eCFR. 29 CFR 2560.503-1 – Claims Procedure Ask for the full file immediately. You cannot effectively rebut a denial without knowing exactly what Sedgwick considered and what its reviewers said about your evidence. Workers’ compensation claimants generally have similar access rights under state law.
Build the Appeal Around the Stated Reason
Denials tend to fall into a handful of categories, and the category shapes your appeal.
Insufficient Medical Evidence
The most common reason is that Sedgwick concluded the medical records don’t support the claim. In workers’ comp, that usually means the records don’t clearly link the injury to a specific workplace incident. In disability, it means the records don’t show your condition prevents you from working. Often the evidence exists but the treating physician’s notes are too brief, don’t use the right terminology, or don’t address the specific functional limitations the plan requires. The fix is a detailed narrative report from your treating doctor that responds point by point to the gaps Sedgwick identified.
Pre-Existing Condition
If you had a pre-existing condition in the same body part, Sedgwick may argue the problem was already there. Most states recognize that a workplace injury aggravating a pre-existing condition is still compensable, and the employer’s insurer is generally responsible for the worsening even if the underlying condition made you more vulnerable. What matters is whether the work incident caused a genuine worsening, as opposed to a temporary flare-up that would have happened anyway. Your appeal needs medical evidence that speaks directly to that distinction.
Inconsistencies
If details in your initial claim don’t match the medical records, the accident report, or witness statements, Sedgwick will flag the discrepancies. Even small inconsistencies in how you described the injury can undermine credibility. Surveillance footage or social media activity that appears to contradict claimed limitations is another common basis, especially in long-term disability cases. Address any inconsistency head-on rather than hoping the reviewer overlooks it.
Your Employer’s Account
Sometimes the denial traces back to what your employer told Sedgwick, whether that the injury didn’t happen at work or that you weren’t performing job duties. If the employer’s version is wrong, build the appeal around independent evidence: witness statements, time records, and contemporaneous medical treatment records that place the injury where and when you say it happened.
Whatever the reason, don’t submit a stack of general medical records and hope something sticks. Under ERISA rules, the appeal reviewer must consider all evidence you submit, even if it wasn’t part of the original claim.6eCFR. 29 CFR 2560.503-1 – Claims Procedure Use that opening to attack the specific reason in the letter.
If the Denial Relied on an Independent Medical Exam
Independent medical examinations are one of Sedgwick’s primary tools for evaluating disputed claims. Despite the name, the doctor is selected and paid by the insurance company or employer, and the resulting report frequently minimizes the severity of your condition or disputes the link between your injury and your work. Exams are sometimes brief, lasting only 15 to 20 minutes, and the doctor may not have reviewed your full history beforehand.
An IME that contradicts your treating physician gives Sedgwick a medical basis to deny or reduce benefits. Refusing to attend an IME is risky; in most states, declining can result in suspended benefits or an outright denial. To fight an IME-based denial, get a detailed report from your treating physician that specifically addresses and rebuts the IME findings. If your doctor’s notes say “patient reports continued pain” and the IME contains specific range-of-motion measurements and functional capacity findings, the IME will carry more weight on appeal. Ask your doctor to match that level of specificity and to explain, based on your treatment history, why the IME conclusions are wrong.
Why Your Appeal Is the Whole Case Under ERISA
If your claim runs through an employer-sponsored disability or health plan, ERISA governs the process and creates a rule that surprises most claimants: if your appeal fails and you sue in federal court, the court will generally review only the administrative record. The judge looks at the same evidence Sedgwick had, and nothing else. Federal courts rarely allow new evidence in ERISA cases.
Whatever medical records, expert opinions, and documentation you want a judge to see must go in during the appeal. People who hold evidence back for court often find the courthouse door narrower than they expected.
How much deference the court gives Sedgwick depends on your plan’s language. If the plan grants the administrator discretionary authority to interpret the plan and make benefit decisions, the court applies a deferential standard, and you essentially have to show the denial was arbitrary or irrational on the record. Without that discretionary language, the court reviews the decision fresh. Roughly 20 states have banned discretionary authority clauses in fully insured plans, which pushes more claims in those states into the more favorable standard.
You also can’t skip the appeal and head straight to court. Before filing a lawsuit over a denied ERISA claim, you must complete the plan’s internal appeals process, and courts will dismiss cases from claimants who didn’t.7Office of the Law Revision Counsel. 29 USC 1132 – Civil Enforcement The appeal isn’t a formality. It’s your one shot at building the record.
If Your Appeal Fails
A denied appeal doesn’t have to be the last word.
For workers’ compensation, most states offer a hearing before an administrative law judge or a state workers’ compensation board. Both sides present evidence, and the judge issues an independent decision. These hearings are more formal than internal appeals and often benefit from legal representation.8U.S. Department of Labor. About the Office of Administrative Law Judges Beyond that, an adverse board decision can typically be appealed to state court, though the path varies by state.
For ERISA claims, some health plans offer an external review by an independent reviewer before litigation. If that route is exhausted or unavailable, you can file a civil action in federal court to recover benefits due under the plan.7Office of the Law Revision Counsel. 29 USC 1132 – Civil Enforcement The suit will be decided on the administrative record you built.
One boundary worth knowing: Sedgwick is a third-party administrator hired by employers and insurers to handle claims, not the insurer itself.9Sedgwick. General Liability Claims Management Most courts hold that you cannot bring a bad faith tort claim directly against Sedgwick, because bad faith requires a contractual relationship between you and the entity handling the claim, and your contract is with the insurer or plan. A bad faith claim would have to target the insurer that hired Sedgwick.
You can also file a regulatory complaint. State insurance departments regulate claims handling, and many states require TPAs to register and follow specific processing standards. State regulators can investigate and impose corrective action. For ERISA plans, you can file with the U.S. Department of Labor’s Employee Benefits Security Administration. Regulatory complaints don’t directly overturn your denial, but they can push the insurer to re-examine a mishandled claim and may surface procedural violations that strengthen your legal position.