Sample Claim File Request printable pdf download

Form 7: Sample Claim File Request

Date

VIA FAX & MAIL

INSURER ADDRESS FAX

Re:

CLIENT

DOB:

Claim No.:

Dear NAME:

We are the attorneys for CLIENT. I annex copies of authorizations authorizing me to request documents

on her/his behalf.

Please be advised that CLIENT intends to seek review of The INSURER’s DATE denial of long term disability

benefits under the above-referenced policy. However, before CLIENT could adequately present his case and

obtain a full and fair review, he must have an opportunity to review the documents relied upon by INSUER in

denying his/her claim. Accordingly, pursuant to Section 104(b) of ERISA and 29 C.F.R. §2560.503-1(h)(2)(iii), I

request copies of the following documents (in order to save paper please send all requested documents in the

form of an Adobe PDF):

(1) A copy of: (i) the Policy and any riders or schedules thereto; and (ii) the contract for long term

disability coverage between you and CLIENT’s employer;

(2) A copy of the summary plan description of the plan;

(3) All documents:

(i) relied on in making the benefit determination, including without limitation, all reports,

notes, records, test results, correspondence and curriculum vitae of any independent medical

examiner/reviewer, functional capacity evaluator, transferable skills expert, and/or vocational expert.

See 29 C.F.R. §2560.503-1(h)(2)(iii) and 29 C.F.R. §2560.503-1(m)(8)(i);

(ii) submitted, considered, or generated in the course of making the benefit determination,

without regard to whether such document, record, or other information was relied upon in making

the benefit determination. See 29 C.F.R. §2560.503-1(h)(2)(iii) and 29 C.F.R. §2560.503-1(m)(8)(ii);

(iii) that demonstrate compliance with administrative processes and safeguards designed to ensure

and to verify that benefit claims determinations are made in accordance with governing plan

documents and that, where appropriate, the plan provisions have been applied consistently with

respect to similarly situated claimants. See 29 C.F.R. §2560.503-1(h)(2)(iii); 29 C.F.R. §2560.503-

1(m)(8)(iii) and 29 C.F.R.

§2560.503-1(b)(5); or

(iv) that constitute a statement of policy or guidance with respect to the plan concerning the

denied benefit, without regard to whether such advice or statement was relied upon in making

the benefit determination. See 29 C.F.R. §2560.503-1(h)(2)(iii); 29 C.F.R. §2560.503-1(m)(8)(iv);

This form originally appeared in An Attorney’s Guide to ERISA Disability Claims.

Sample Claim File Request