Sample Ltd Claim Denial Letter Template Page 2


We also asked Dr. _______ if there was tentative return to work date set for you. He stated “from
my point of view she ought to be ready to return to work now.” He also did not specify any
limitations or restrictions on your return to work.
Based on the documentation contained in the file, the medical information does not include any
limitations or restrictions from your physician that show that you are totally disabled from
performing your occupation. As a result, we have concluded that you do not satisfy the policy
definition of disability noted in the above paragraphs.
Appeal Rights
You may request a review of this denial by writing to the Life Insurance Company of North
America representative signing this letter. The written request for review must be sent within 180
days if receipt of this letter and state the reasons why you feel your claim should not have been
denied. Please include any documentation which you feel supports your claim such as:
copies of physical therapy treatment notes,
any additional treatment records from physicians, or
actual test results (e.g., EMG, MRI).
Under normal circumstances, you will be notified of the final decision within 45 days of the date
your request for review is received. If there are special circumstances requiring delay, you will
be notified of the final decision no later than 90 days after your request is received. Please note
that you have a right to bring legal action for benefits under ERISA section 502(a) if your appeal
is denied.
Nothing contained in this letter should be construed as a waiver of any rights or defenses under
the policy. This determination has been made in good faith and without prejudice
under the terms and conditions of the contract, whether or not specifically mentioned herein.
Should you have any information which would prove contrary to our findings, please submit it to
us. We will be pleased to review any objective information you may wish to submit.
Section 2695.7 (B) (3) of the Regulations of the California Insurance Department requires that
our company advise you that if you wish to take this matter up with the California Insurance
Department, you may contact the California Insurance Department. Their address is: California
Department of Insurance, Claims Service Bureau, 11th Floor, 300 S. Spring Street, Los Angeles,
CA 90013, 213-897-5961 or 800-927-HELP.
Case Manager


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