Sample Ltd Claim Denial Letter Template (Page 2 of 2) in pdf

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.

Summary

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.

Sincerely,

Case Manager

Sample Ltd Claim Denial Letter Template Page 2