Sample post-appeal claim file request

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 265-267

A-247 Appendix: Sample Documents Form 15

FORM 15 SAMPLE POST-APPEAL CLAIM FILE REQUEST

Date

CERTIFIED MAIL ( )



INSURER

Re: Client

Claim No.

Policy No.

Policy Holder:

Dear INSURER:

We represent CLIENT in connection with her claim for Long Term Disability



CLIENT is entitled to the opportunity to review the documents considered or

generated by INSURER in denying her claim. Accordingly, pursuant to Section

104(b) of ERISA and 29 C.F.R. 2560.503-1(h)(2)(iii), we hereby request copies

of the following documents:

1) A copy of all documents constituting the Plan, including: (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:

   

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 voca-

tional 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

 

  

determination. See 29 C.F.R. 2560.503-1(h)(2)(iii) and 29 C.F.R.

2560.503-1(m)(8)(ii);