Sample Ltd Appeal Denial Leter Template


Appeals Claim Examiner
CIGNA Disability Management Solutions
February 11, 2002
12225 Greenville Avenue
Suite 1000, L.B. 179
Dallas, TX 75243, TX 75423
Telephone 800.352.0611x1249
Facsimile 860-731-3211
Life Insurance Company of North America
Dear Mr.:
This letter is in reference to your claim for Long Term Disability (LTD) benefits under policy
number FLK 30007. We reviewed your claim as requested in your Notice of Appeal and must
deny your entitlement to benefits.
The denial is based on the following policy/plan provisions:
An Employee will be considered Disabled if because of Injury or Sickness:
1. he is unable to perform all the material duties of his occupation; and after Monthly
Benefits have been payable for 24 months, he is unable to perform all of the
material duties of any occupation for which he is or may reasonably become
qualified based on his education, training or experience.
Information Considered
September 14, 2001 letter from Dr. Steven D. Thompson, Orthopedic Surgeon, indicated you
were completing a work hardening program and approaching maximum medical
improvement (MMI).
September 10, 2001 office note from Dr. Thompson indicated you had not yet reached
maximum medical improvement (MMI). Neurological examination of the lower extremities
was normal with no evidence of muscle weakness, wasting, reflex or sensory change. You
were not a surgical candidate but needed more physical therapy from work conditioning to
work hardening.
February 14, 2001 office note from Dr. Thompson indicated you had a normal neurological
examination. You were still tender in the lumbar spine. MRI of the lumbar spine was negative
for herniated disc or any other pathology. You were not a surgical candidate.
February 7, 2001 MRI of the lumbar spine was normal.


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