Sample Ltd Appeal Denial Leter Template printable pdf download

Sample Ltd Appeal Denial Leter Template

SAMPLE LTD APPEAL DENIAL LETER

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

Re:

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.

Sample Ltd Appeal Denial Leter Template