West Palm Beach Florida car accident ERISA Document Request Letter 1-800-74-TRIAL

Date:

West Palm Beach Florida car accident Auto Insurance Company
Address
Re: Client/Insured Name:
Claim Number:
Policy Number:

Dear __________,
Please be advised that I represent __________ with regard to [insurance company’s] [date] termination [or denial] of __________’s long-term disability benefits. Pursuant to Section 104(b) of ERISA and 29 CFR 2560.503-1(h)(2)(iii), I request copies of the following documents:
1. A complete copy of the insurance contract/short-term and long-term disability plan pertinent to __________.
2. All Summary Plan Descriptions.
3. (Mr./Mrs. this person was injured in a West Palm Beach Florida car accident)__________’s original application for eligibility and benefits.
4. Any and all documents in existence which confer a grant of discretionary authority from the Plan Sponsor to anyone else, Plan Fiduciary(ies) and the Plan Administrator(s), including but not limited to administrative service agreement(s).
5. All documents:
• Relied on in making the benefit determination, including without limitation, all reports, notes, records, test results, correspondence and curriculum vitae of any independent medical examiner/reviewer, functional capacity evaluator, transferrable skills expert, and/or vocational expert;
• Submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;
• That demonstrate compliance with administrative processes and safeguards in making the benefit determination; or
• That constitute a statement of policy or guidance with respect to the plan concerning the denied benefit, without regard to whether such advice or statement was relied upon in making the benefit determination.
6. All notes of telephone conferences with __________ or any treating physician. __________ would like to have this opportunity to correct any inaccuracies or otherwise respond.
7. All surveillance video and audiotapes of __________ and the reports and notes of all investigators.
8. A description, pursuant to 29 CFR 2560.503-1(g)(1)(iii), of any additional material or information necessary for __________ to perfect his/her claim and an explanation of why such material or information is necessary.
9. A description of whether an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination. If so, please furnish a copy of such rule, guideline or protocol or other similar criterion.
29 CFR 2575.502(c)/1132(c) provides an award of $110 per day for failing to produce the requested documents.
If you require __________’s physicians to complete, an attending physician’s statement, or any other particular form, please forward those documents to my attention immediately.
All requests found above are to be considered formal requests to produce Plan documents pursuant to the Employee Retirement Income Security Act of 1974 and 29 CFR Part 2560, Benefits Claims Procedures effective January 1, 2002.
In the meantime, if you wish to discuss this matter, please contact me.
Thank you kindly,
__________