Sample Ltd Claim Denial Letter Template printable pdf download

SAMPLE LTD CLAIM DENIAL LETTER

Case Manager

CIGNA Disability Management Solutions

Routing D212

12225 Greenville Avenue

Dallas TX 75243

Telephone 800.352.0611

April 11, 2002

Ext 5643

Facsimile 860.731.3211

RE:

Claimant:

SSN:

Policy Keys:

Account Name:

Company:

Life Insurance Company of North America

Dear Ms.:

This letter is in reference to your Long Term Disability claim. As you know, we have been

investigating your claim for disability benefits and a determination has been reached.

To be eligible for disability benefits, you must satisfy the policy provisions defined as follows:

Disability Definition

“An Insured will be considered Disabled if because of Injury or Sickness, he is unable to perform

all the essential duties of his occupation."

After Monthly Benefits have been payable for 24 months, an Employee will be considered

Disabled only if he cannot actively work in any “substantially gainful occupation” for which he is

qualified or may reasonably become qualified by reason of his education, training or experience.

“Substantial gainful occupation” means one which provides the income required to support the

standard of living reasonably approximating the standard maintained prior to the disability.”

Medical data evaluated

We based our decision to deny your claim for benefits upon policy language and all documents

contained in your claim file, viewed as a whole. According to the information provided by your

physician, you have been released to return to work full-time.

We requested and received medical information from Dr._______. On 02/20/98 your doctor

states that you had gained 10 pounds, still had intermittent diarrhea related to gastrectomy. Your

ENT evaluation was negative with a question of reflux.

Also Dr. _______stated that he saw you on 12/10/98 for an operative procedure. On that date he

states that there is no evidence of persisting ulceration or mass in the esophagus and absolutely no

mucosal abnormalities seen anywhere in the esophagus or in the visualized portion of the

hypopharynx.

Sample Ltd Claim Denial Letter Template