Disability Insurance Appeal - Colorado

DISABILITY INSURANCE APPEAL — COLORADO

TABLE OF CONTENTS

1. Cover Letter and Header
2. Threshold ERISA / Non-ERISA Analysis
3. Section A — ERISA Administrative Appeal
4. Section B — Non-ERISA / State-Law Appeal
5. Statement of Facts
6. Statement of Disability
7. Argument
8. Reservation of Rights
9. Demand and Conclusion
10. Document Index
11. Signature Block
12. Colorado DOI Complaint Procedure
13. Practice Notes
14. Sources and References

1. COVER LETTER AND HEADER

SENT VIA CERTIFIED MAIL — RETURN RECEIPT REQUESTED, AND VIA EMAIL/UPLOAD TO CLAIM PORTAL

Date: [__/__/____]

[INSURER / PLAN ADMINISTRATOR NAME]

Attn: Appeals Unit / ERISA Claim Review

[ADDRESS]

Re: Appeal of Adverse Benefit Determination

To Whom It May Concern:

This letter constitutes Claimant's timely [first-level / second-level / final] administrative appeal of the adverse benefit determination dated [__/__/____] denying Claimant's claim for [short-term / long-term / individual] disability benefits. The appeal is submitted within the applicable deadline. Please direct all further communications to undersigned counsel.

2. THRESHOLD ERISA / NON-ERISA ANALYSIS

2.1. The Plan/Policy is governed by:

☐ ERISA — group disability plan provided through Claimant's employment with [EMPLOYER], not satisfying the safe-harbor in 29 C.F.R. § 2510.3-1(j). Proceed under Section A.

☐ State law (non-ERISA) — individually-purchased policy, governmental plan (29 U.S.C. § 1003(b)(1)), church plan (§ 1003(b)(2)), or safe-harbor plan. Proceed under Section B.

2.2. Where the policy was issued or delivered in Colorado, any provision purporting to reserve discretion to the insurer or plan administrator to interpret terms or determine eligibility for benefits is void under C.R.S. § 10-3-1116(4). Review must therefore be de novo, not under an arbitrary-and-capricious standard.

3. SECTION A — ERISA ADMINISTRATIVE APPEAL

3.1. Authority and Standard. This appeal is submitted pursuant to ERISA § 503, 29 U.S.C. § 1133, and the implementing regulations at 29 C.F.R. § 2560.503-1, including the disability-specific protections at § 2560.503-1(h)(4) and § 2560.503-1(o).

3.2. Timeliness. Claimant received the adverse benefit determination on [__/__/____]. This appeal is submitted within 180 days of receipt as required by 29 C.F.R. § 2560.503-1(h)(3)(i)/(4).

3.3. Request for Full and Fair Review. Claimant requests full and fair review under 29 C.F.R. § 2560.503-1(h)(2), including:

• ☐ Reasonable opportunity to submit written comments, documents, records, and other information relating to the claim;
• ☐ Free copies of all documents, records, and other information relevant to the claim, as defined in 29 C.F.R. § 2560.503-1(m)(8);
• ☐ Identity of all medical or vocational experts whose advice was obtained in connection with the adverse determination;
• ☐ A review that takes into account all comments, documents, records, and other information submitted, without regard to whether such information was submitted or considered in the initial benefit determination;
• ☐ Review by an appropriate named fiduciary who is neither the original decision-maker nor a subordinate of that individual;
• ☐ Consultation with a healthcare professional with appropriate training and experience who was not consulted at the initial determination and is not a subordinate of the original consultant;
• ☐ Independence and impartiality of the persons making the appeal decision (29 C.F.R. § 2560.503-1(b)(7)).

3.4. Disability Plan Enhanced Procedural Protections (29 C.F.R. § 2560.503-1(o)). Claimant invokes the enhanced protections applicable to disability claims, including the right to receive any new or additional evidence considered, relied upon, or generated by the plan in advance of the appeal decision and a reasonable opportunity to respond.

3.5. Document Request. Claimant requests, within thirty (30) days, free copies of:

• The complete claim file and administrative record;
• The Plan document, Summary Plan Description, and any insurance policy or contract;
• All policies, procedures, and guidelines relied upon in deciding the claim;
• All medical, vocational, and other expert reports;
• All internal communications regarding the claim;
• Compensation arrangements between the Plan/Insurer and any reviewing experts.

4. SECTION B — NON-ERISA / STATE-LAW APPEAL

4.1. Authority. This appeal is submitted under the appeal procedures of the Policy and pursuant to applicable Colorado law, including C.R.S. § 10-3-1115 (improper denial prohibited), C.R.S. § 10-3-1116 (remedies — two times covered benefit plus reasonable attorney fees and court costs), and C.R.S. § 10-3-1104(1)(h) (Colorado Unfair Claims Settlement Practices).

4.2. Notice of Statutory Remedies. Claimant places Insurer on formal notice that any further unreasonable delay or denial of benefits will be pursued under C.R.S. § 10-3-1116, which entitles a first-party claimant to two (2) times the covered benefit plus reasonable attorney fees and court costs.

4.3. Common-Law Bad Faith. Insurer is further on notice of potential common-law bad-faith liability under Travelers Ins. Co. v. Savio, 706 P.2d 1258 (Colo. 1985), and its progeny, including potential exemplary damages under C.R.S. § 13-21-102.

4.4. Discretionary Clauses Void. To the extent the Policy purports to reserve discretion to Insurer or any administrator, that provision is void under C.R.S. § 10-3-1116(4), and any review is de novo.

5. STATEMENT OF FACTS

5.1. Claimant Background. Claimant is [AGE] years old, resides in [CITY], Colorado, and was employed as a [OCCUPATION / JOB TITLE] by [EMPLOYER] from [__/__/____] until [__/__/____].

5.2. Policy Coverage. The Policy provides [STD / LTD / Individual DI] benefits at a monthly rate of $[AMOUNT] following the [__]-day elimination period, payable for the duration set forth in the Policy.

5.3. Onset of Disability. Claimant became disabled on [__/__/____] due to [DIAGNOSIS / CONDITION]. Symptoms include [describe pain, fatigue, cognitive impairment, range of motion limitations, etc.].

5.4. Claim Submission. Claimant submitted a claim for benefits on [__/__/____], including treating-physician statements, attending-physician forms, and supporting medical records.

5.5. Course of Treatment. Claimant's treating providers include [list of providers, specialties, and treatment dates]. Treatments tried include [medications, surgery, physical therapy, injections] with [results].

5.6. Adverse Determination. On [__/__/____], Insurer/Administrator denied the claim, citing [summarize stated reasons].

5.7. Errors in Initial Determination. The denial is wrong for the reasons set forth in Section 7 below.

6. STATEMENT OF DISABILITY

6.1. Definition of Disability Under the Policy. The Policy defines "Disability" or "Total Disability" as [QUOTE EXACT POLICY DEFINITION].

6.2. "Own Occupation" Period. During the first [__] months of disability, Claimant is disabled if unable to perform the material and substantial duties of his/her own occupation as [OCCUPATION].

6.3. "Any Occupation" Period. After the own-occupation period, Claimant is disabled if unable to perform the duties of any gainful occupation for which Claimant is reasonably suited by education, training, or experience.

6.4. Vocational Profile. Claimant's pre-disability occupation required [describe physical and cognitive demands — lifting, standing, sustained concentration, deadlines, public interaction, etc.].

6.5. Functional Limitations. Supported by the medical evidence and [FCE / IME / treating physician] opinions, Claimant has the following restrictions and limitations: [list — sit/stand/walk tolerances, lifting, postural, mental, off-task percentage, attendance].

6.6. Conclusion. Claimant satisfies the Policy's definition of Disability for the [own occupation / any occupation] period as of [__/__/____].

7. ARGUMENT

7.1. The denial is contrary to the medical evidence. The treating physicians, who have examined and treated Claimant in person over an extended period, all opine that Claimant is unable to perform the material duties of his/her occupation. [Cite specific records — Tab __, p. __]. The Insurer's reviewing physicians performed only paper reviews and did not examine Claimant. Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), permits but does not require deference to treating physicians, but reviewers must address contrary evidence and may not arbitrarily refuse credence to a treating physician's reliable evidence.

7.2. The denial mischaracterizes the occupational duties. Insurer characterized Claimant's job as [denial characterization], but the actual duties — confirmed by employer job description and DOT/ONET classifications — require [describe true demands]. See* Tab __.

7.3. The denial ignores objective evidence. Insurer dismissed objective findings including [MRI/EMG/imaging/lab results]. These findings corroborate the subjective complaints and meet any reasonable standard of objective support.

7.4. The denial relies on a biased file review. The reviewing consultant [NAME] has a documented pattern of [describe pattern — e.g., 80%+ adverse opinion rate, financial dependency on the insurer, lack of relevant specialty]. Bias and conflict of interest are dispositive factors. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008).

7.5. The denial fails the "full and fair review" standard. The denial letter does not adequately specify the reasons for denial, identify the specific Plan provisions on which the denial is based, or explain what additional information would perfect the claim, in violation of 29 C.F.R. § 2560.503-1(g)(1).

7.6. Award of Social Security Disability is corroborative. [If applicable] The Social Security Administration awarded Claimant disability benefits effective [__/__/____], applying a more demanding standard than the Policy's "own occupation" definition. Failure to consider an SSDI award is a recognized abuse of discretion. Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623 (9th Cir. 2009); Glenn, 554 U.S. at 118.

7.7. De novo review applies in Colorado. Even if the Policy purports to grant discretion to Insurer, that provision is void under C.R.S. § 10-3-1116(4), so review is de novo.

8. RESERVATION OF RIGHTS

8.1. Claimant reserves the right to supplement this appeal with additional records, expert opinions, vocational evaluations, and argument prior to the appeal decision.

8.2. Claimant reserves all rights and remedies under ERISA, Colorado common law (including Travelers v. Savio), and Colorado statute (including C.R.S. §§ 10-3-1115, -1116, and -1104), and waives no claim by submission of this appeal.

8.3. Should Insurer fail to render a timely decision in accordance with 29 C.F.R. § 2560.503-1(i), Claimant will treat administrative remedies as deemed exhausted under § 2560.503-1(l) and pursue civil enforcement under 29 U.S.C. § 1132(a).

9. DEMAND AND CONCLUSION

For the foregoing reasons, Claimant respectfully demands that Insurer:

• ☐ Reverse the adverse benefit determination;
• ☐ Pay all back benefits from [__/__/____] to the present, plus interest;
• ☐ Reinstate ongoing benefits under the Policy;
• ☐ Provide written notice of the appeal decision within the timeframes set by 29 C.F.R. § 2560.503-1(i) (45 days, with one 45-day extension for special circumstances) or, for non-ERISA claims, the timeframes under the Policy and Colorado law; and
• ☐ Produce all documents requested in Paragraph 3.5.

If the appeal is denied, please provide a written decision specifying the reasons, the Plan provisions relied upon, the additional information needed to perfect the claim, and a statement of the right to bring civil action.

Failure to act reasonably and in good faith will subject Insurer to liability under ERISA, Travelers v. Savio, and C.R.S. §§ 10-3-1115/-1116, including two (2) times the covered benefit and reasonable attorney fees.

10. DOCUMENT INDEX

The following documents are submitted in support of this appeal and should be incorporated into the administrative record:

11. SIGNATURE BLOCK

Respectfully submitted,

[LAW FIRM NAME]

By: [________________________________]

[ATTORNEY NAME], Atty. Reg. No. [####]

Counsel for Claimant [CLAIMANT NAME]

[STREET ADDRESS]

[CITY, COLORADO ZIP]

Telephone: [NUMBER]

E-mail: [EMAIL]

cc: [CLAIMANT]; [CO DOI — if filing parallel complaint]

12. COLORADO DOI COMPLAINT PROCEDURE

For non-ERISA (or fully-insured) disability claims, Claimant may file a parallel complaint with the Colorado Division of Insurance (DORA):

• Online Consumer Portal: https://doi.colorado.gov/for-consumers/file-a-complaint
• Phone (Denver Metro): 303-894-7499
• Toll-Free (outside Denver): 800-930-3745
• Mail: Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, CO 80202
• Email: [email protected]

A DOI complaint is not a prerequisite to suit but creates documented evidence of insurer conduct and may produce a written response useful in subsequent litigation. ERISA self-funded plans are typically outside DOI jurisdiction.

13. PRACTICE NOTES

• ERISA preemption is THE threshold question. If ERISA governs, the entire universe of remedies collapses to recovery of benefits under 29 U.S.C. § 1132(a)(1)(B), attorney fees under § 1132(g)(1), and prejudgment interest. State-law bad faith and emotional-distress damages are preempted. Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987).
• Closed administrative record. The 10th Circuit follows the closed-record rule: evidence not in the administrative record at the close of the appeal generally cannot be considered in subsequent litigation. Hall v. Unum Life Ins. Co. of America, 300 F.3d 1197 (10th Cir. 2002). Submit everything during the appeal.
• Standard of review. Because C.R.S. § 10-3-1116(4) voids discretionary clauses in policies issued in Colorado, de novo review should apply to most Colorado-issued group disability policies (subject to ERISA preemption analysis on saving-clause grounds for self-funded plans).
• 180-day appeal deadline. ERISA disability appeals must be filed within 180 days of receipt of the adverse determination. 29 C.F.R. § 2560.503-1(h)(3)(i), (4). Calendar carefully.
• Disability plan enhancements (effective April 1, 2018). 29 C.F.R. § 2560.503-1(o) imposes additional protections — independence/impartiality of decision-makers, advance notice of new evidence, broader notice content. Invoke them expressly.
• SSDI offset and award. If the Policy provides for an offset, the SSDI award reduces benefits dollar-for-dollar but does not extinguish the claim. The award itself is corroborative under Glenn.
• Statute of limitations for ERISA suit. ERISA borrows Colorado's most analogous statute (typically 6 years for written contracts, C.R.S. § 13-80-103.5), unless the Plan contains a contractual limitations period. Heimeshoff v. Hartford Life & Acc. Ins. Co., 571 U.S. 99 (2013), upholds reasonable contractual limitations periods.
• Removal to federal court. ERISA cases filed in state court are removable to U.S. District Court for the District of Colorado.

14. SOURCES AND REFERENCES

• 29 U.S.C. § 1132 (ERISA civil enforcement) — https://www.law.cornell.edu/uscode/text/29/1132
• 29 U.S.C. § 1133 (ERISA full and fair review) — https://www.law.cornell.edu/uscode/text/29/1133
• 29 C.F.R. § 2560.503-1 (Claims procedure) — https://www.ecfr.gov/current/title-29/section-2560.503-1
• C.R.S. § 10-3-1115 — https://colorado.public.law/statutes/crs_10-3-1115
• C.R.S. § 10-3-1116 — https://colorado.public.law/statutes/crs_10-3-1116
• C.R.S. § 10-3-1104 — https://colorado.public.law/statutes/crs_10-3-1104
• Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987)
• Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008)
• Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003)
• Heimeshoff v. Hartford Life & Acc. Ins. Co., 571 U.S. 99 (2013)
• Hall v. Unum Life Ins. Co. of America, 300 F.3d 1197 (10th Cir. 2002)
• Travelers Ins. Co. v. Savio, 706 P.2d 1258 (Colo. 1985)
• Colorado Division of Insurance — https://doi.colorado.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Colorado must review and customize this document before submission. Laws, regulations, and court rules change frequently; verify all authorities before use.