When Can an ERISA Plan Reject Treating Doctors’ Opinions? Court Upholds Sedgwick’s Long-Term Disability Termination

In Regulus v. Ascension Long Term Disability Plan, No. 4:25-cv-00616-SRC, 2026 WL 3320297 (E.D. Mo. Nov. 3, 2026), the United States District Court for the Eastern District of Missouri granted summary judgment to the Ascension Long Term Disability Plan and its claims administrator, Sedgwick Claims Management Services, Inc., on a claim for ERISA long-term disability benefits. The court held that Sedgwick did not abuse its discretion when it terminated Plaintiff’s benefits under the plan’s “any occupation” definition of disability, and that Sedgwick gave Plaintiff adequate notice of the information she needed to support her claim.

What led to this ERISA long-term disability lawsuit?

Plaintiff participated in Ascension’s long-term disability plan, which delegated claim administration to Sedgwick. After the first 24 months of benefits, the plan defined disability as an inability, due to an injury or sickness supported by objective medical evidence, to perform any work for which the participant was reasonably qualified based on training, education, experience, and past earnings. The plan also required the participant to receive regular care from a licensed physician and follow the recommended treatment. Benefits depended on “Proof” satisfactory to the claims administrator, which the plan defined as objective medical evidence that, in the administrator’s discretion, substantiates the existence of a disability. Benefits would end if the participant no longer met the definition of disability or failed to provide satisfactory proof.

Plaintiff worked at Amita Health as a behavioral-health counselor. In 2021, she stopped working after reporting symptoms that she attributed to mold and toxin exposure during workplace renovations, and her medical providers excused her from work. She received short-term disability benefits from 2021 to 2022, and Sedgwick then approved long-term disability benefits from 2022 to March 2024. Sedgwick told Plaintiff that to continue receiving benefits after March 2024, she had to prove she could not perform any work for which she was reasonably qualified.

Leading up to that transition, Sedgwick requested more medical information from Plaintiff and her doctors, told her when it considered her submissions incomplete, and asked for more provider notes. After Sedgwick concluded that her records did not establish disability from any occupation, it arranged another medical examination and extended her benefits through April 30, 2024, to allow time for it. Dr. Liana Palacci, a board-certified internist, examined Plaintiff and found that she “should be able to perform sedentary work for any occupation after completing her current course of physical therapy.” Sedgwick also obtained two vocational evaluations, which identified sedentary occupations in Plaintiff’s geographic area that fit her background and training, with expected wages consistent with her vocational profile. In June 2024, Sedgwick terminated her benefits after April 30, 2024, because she did not meet the any-occupation definition based on the examination and vocational evaluations.

Plaintiff appealed and submitted 140 additional pages of medical records. Sedgwick sent the full claim file to two more doctors. Dr. Henry Richardson, board certified in physical medicine and rehabilitation and pain management, disagreed with Plaintiff’s treating provider that she could not return to work until she completed treatment, and agreed with Dr. Palacci that she could work with restrictions. Dr. Sandy Lee, board certified in rheumatology and internal medicine, disagreed with the treating providers’ opinions on functional impairment because of “the paucity of provider documentation provided,” finding “an absence of provider clinic notes to support … functional incapacity.”

In August 2024, Sedgwick told Plaintiff it would decide her appeal unless she submitted more information or asked for more time. Plaintiff responded that she had no more information to submit, asked for a decision that day, and waived her 21-day comment period. Sedgwick upheld the termination in a letter that set out the plan’s definition of disability and the documents it reviewed. Plaintiff then sued, and both sides moved for summary judgment.

What standard of review did the court apply to the ERISA claim?

The parties agreed that the court should review Sedgwick’s decision for abuse of discretion. Under that standard, the court explained, it must uphold a decision based on a reasonable interpretation of the plan and supported by substantial evidence, citing Ruessler v. Boilermaker-Blacksmith National Pension Trust Board of Trustees, 64 F.4th 951 (8th Cir. 2023). Relying on McIntyre v. Reliance Standard Life Insurance Co., 73 F.4th 993 (8th Cir. 2023), the court stated that it may not substitute its own weighing of the evidence for the administrator’s, that a decision is reasonable if a reasonable person could have reached a similar decision, and that the court may find an abuse of discretion only when contrary evidence overwhelms the evidence the administrator relied on.

Did Sedgwick abuse its discretion in terminating Plaintiff’s long-term disability benefits?

No. The court held that Plaintiff failed to show that Sedgwick acted arbitrarily and capriciously and that sufficient evidence supported the termination. Citing Zaeske v. Liberty Life Assurance Co. of Boston, 901 F.3d 944 (8th Cir. 2018), and Midgett v. Washington Group International Long Term Disability Plan, 561 F.3d 887 (8th Cir. 2009), the court explained that a plan administrator has discretion to choose between conflicting medical opinions and may accept reviewing physicians’ opinions over treating physicians’ opinions unless the record does not support the denial.

The court found that Sedgwick weighed the evidence and reached a decision with support in the record. Sedgwick’s letters set out the plan’s definitions of disability, the applicable standards, and the records it reviewed. Sedgwick considered Dr. Palacci’s May 2024 examination, the opinions of Drs. Richardson and Lee, the vocational evaluations, and more than seventy records from more than forty doctors, nurses, physical therapists, and other medical professionals.

Did Sedgwick have to defer to Plaintiff’s treating physicians?

No. Plaintiff argued that Sedgwick refused to accept her treating physicians’ statements about her conditions and limitations as sufficient evidence of disability, and that it ignored Dr. Palacci’s examination. Defendants responded that Sedgwick considered all of the medical evidence and reasonably relied on Drs. Richardson and Lee, who concluded that the record did not show Plaintiff was functionally unable to perform any occupation.

The court agreed with Defendants. It explained that Drs. Richardson and Lee reviewed the treating providers’ assessments and evaluated Plaintiff’s condition differently. Quoting Zaeske v. Liberty Life Assurance Co. of Boston, which relied on Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), the court noted that an administrator “may even prefer the opinion of its own consulting physician over that of an applicant’s treating physician.” The court added that it must defer to Sedgwick’s decision even when some medical providers reach a different conclusion, citing McIntyre v. Reliance Standard Life Insurance Co. and Green v. Union Security Insurance Co., 646 F.3d 1042 (8th Cir. 2011).

Did Sedgwick give Plaintiff adequate notice of what she needed to prove disability under ERISA?

Yes. Plaintiff argued that Sedgwick violated ERISA’s claims regulation, 29 C.F.R. § 2560.503-1(g), because it never told her what she needed to prove that her combination of impairments was disabling. She pointed to a nurse case manager’s statement that “[g]iven the lack of supporting medical information available disability is not supported beyond 03/13/2024,” and to a sentence in the June 2024 termination letter asking for updated objective medical documentation showing her inability to perform any work for which she was reasonably qualified.

The court found the notice sufficient. Under Kleinsteuber v. Metropolitan Life Insurance Co., 176 F.4th 1088 (8th Cir. 2026), courts consider all of an administrator’s communications with the claimant, not just one or two. The court also noted that Plaintiff’s quotation left out most of the June 2024 letter’s instructions, which asked her to submit written findings from her providers’ examinations and treatment, office visit notes from each provider, lab, radiology, and other diagnostic reports, therapy notes, behavioral health assessments, and any other objective medical evidence supporting disability under the plan.

What did the court decide?

The court granted Defendants’ motion for summary judgment, denied Plaintiff’s motion, and dismissed the case with prejudice. After considering the factors in Johnson, Trustee of Operating Engineers Local #49 Health & Welfare Fund v. Charps Welding & Fabricating, Inc., 950 F.3d 510 (8th Cir. 2020), the court denied Defendants’ request for attorneys’ fees.