PETITION FOR ADMINISTRATIVE REVIEW OF DISABILITY INSURANCE BENEFIT DENIAL
(Florida Administrative Proceeding)
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title
PETITION FOR ADMINISTRATIVE REVIEW OF DISABILITY INSURANCE BENEFIT DENIAL
1.2 Parties
a. Petitioner/Claimant: [CLAIMANT FULL LEGAL NAME], an individual residing at [CLAIMANT ADDRESS] (“Claimant”).
b. Respondent/Insurer: [INSURER LEGAL NAME], a [STATE OF FORMATION] insurance company authorized to transact insurance in the State of Florida, with its principal place of business at [INSURER ADDRESS] (“Insurer”).
1.3 Recitals
WHEREAS, Claimant is the owner and insured under Disability Insurance Policy No. [POLICY NUMBER] issued by Insurer (the “Policy”);
WHEREAS, Claimant submitted a claim for benefits under the Policy on [ORIGINAL CLAIM DATE];
WHEREAS, Insurer issued a written denial of benefits dated [DENIAL DATE] (the “Denial”);
WHEREAS, Claimant seeks administrative review of the Denial pursuant to Fla. Stat. §§ 120.569, 120.57 and all applicable provisions of Florida’s Insurance Code;
NOW, THEREFORE, Claimant files this Petition for Administrative Review (the “Petition”).
1.4 Effective Date and Jurisdiction
This Petition is deemed filed as of the stamp-filed date indicated by the Clerk of the [ADMINISTRATIVE COURT/PANEL NAME] (“Tribunal”) and is governed exclusively by the laws of the State of Florida, including the Florida Administrative Procedure Act and Florida insurance regulations.
[// GUIDANCE: Insert the correct administrative forum (e.g., Division of Administrative Hearings, internal insurer appeal panel, or other designated body) per the Policy’s appeal language. Verify any contractual exhaustion requirements before filing.]
2. DEFINITIONS
The following capitalized terms have the meanings set forth below and apply throughout this Petition:
“Administrative Record” – The complete file maintained by the Insurer concerning Claimant’s disability claim, including but not limited to all communications, medical evidence, vocational assessments, internal notes, and decision-making documentation.
“Benefit Amount” – The maximum monthly and/or lump-sum disability benefit payable under the Policy, capped as stated in Section 7.2.
“Date of Disability” – [DATE] on which Claimant alleges the onset of total or partial disability as defined in the Policy.
“Denial” – The written decision dated [DENIAL DATE] whereby Insurer refused or terminated disability benefits.
“Medical Evidence” – All treating physician records, diagnostic tests, functional capacity evaluations, and independent medical examinations pertaining to Claimant’s disabling condition(s).
“Vocational Factors” – Claimant’s age, education, work experience, transferable skills, and labor-market considerations relevant to employability.
“Tribunal” – The administrative body with jurisdiction over this Petition as identified in Section 1.4.
3. OPERATIVE PROVISIONS
3.1 Relief Requested
Claimant respectfully requests:
a. Reversal of the Denial;
b. Immediate payment of all past-due benefits from [BENEFITS COMMENCEMENT DATE] through the date of judgment;
c. Ongoing monthly disability benefits in accordance with the Policy;
d. Pre-judgment and post-judgment interest; and
e. Such other relief as the Tribunal deems just and proper.
3.2 Grounds for Appeal
a. Erroneous Evaluation of Medical Evidence: Insurer failed to give controlling weight to the opinions of Claimant’s treating physicians and misapplied objective test results.
b. Vocational Misapplication: Insurer disregarded Vocational Factors demonstrating that Claimant cannot engage in “any gainful occupation” as defined by the Policy.
c. Procedural Defects: Insurer did not comply with Fla. Stat. § 627.4265 notice requirements and failed to provide a complete Administrative Record within 30 days of written request.
d. Arbitrary & Capricious Decision-Making: The Denial is unsupported by substantial competent evidence and is contrary to Florida public policy favoring payment of valid disability claims.
3.3 Evidence Submitted
Simultaneously with this Petition, Claimant lodges the following exhibits:
• Exhibit A – Complete Medical Evidence packet (indexed).
• Exhibit B – Vocational Expert Report dated [DATE].
• Exhibit C – Affidavit of Claimant.
• Exhibit D – Policy and all riders.
• Exhibit E – Certified Administrative Record (as produced).
[// GUIDANCE: Tailor the exhibit list. Florida administrative rules generally require exhibits to be consecutively paginated and indexed.]
3.4 Conditions Precedent
Claimant has satisfied all contractual and statutory pre-suit requirements, including:
(i) timely notice of claim;
(ii) exhaustion of any mandatory internal appeals as of [EXHAUSTION DATE]; and
(iii) filing this Petition within the limitation period set forth in Fla. Stat. § 95.11(2)(b) or as modified by the Policy.
4. REPRESENTATIONS & WARRANTIES
4.1 Claimant represents that:
a. All factual assertions herein are true and correct to the best of Claimant’s knowledge, information, and belief;
b. The Medical Evidence is authentic, complete, and unaltered;
c. No other administrative or judicial proceeding concerning the same claim is pending except as disclosed in Schedule 1 attached hereto.
4.2 These representations survive disposition of this Petition.
5. COVENANTS & RESTRICTIONS
5.1 Ongoing Disclosure. Claimant shall promptly provide Insurer and the Tribunal with any newly-available medical or vocational documentation material to the issues herein.
5.2 Cooperation. Claimant agrees to appear for deposition, independent medical examination, or vocational assessment upon reasonable notice and in accordance with Tribunal orders.
5.3 Non-Retaliation. Insurer shall not terminate or modify any other coverage lines issued to Claimant on account of this Petition.
6. DEFAULT & REMEDIES
6.1 Events of Default by Insurer. The following constitute defaults:
a. Failure to produce the Administrative Record within the deadline ordered by the Tribunal;
b. Failure to pay benefits within ten (10) days after a final order requiring payment;
c. Non-attendance at duly-noticed mediation, pre-hearing conferences, or evidentiary hearings.
6.2 Notice & Cure. Claimant shall serve written notice of default; Insurer shall have five (5) business days to cure monetary defaults and ten (10) business days to cure non-monetary defaults, absent Tribunal order to the contrary.
6.3 Remedies. Upon uncured default, Claimant may seek:
a. Entry of default final order;
b. Monetary sanctions, including attorney’s fees and costs under Fla. Stat. § 120.595;
c. Compensatory interest at the statutory rate;
d. Any other relief in equity or law available.
7. RISK ALLOCATION
7.1 Indemnification. Not applicable; no third-party claims are asserted.
7.2 Limitation of Liability. Insurer’s liability shall in no event exceed the Benefit Amount plus statutory interest and reasonable attorney’s fees as allowed by law.
7.3 Insurance. Each party shall bear its own costs of insurance for counsel, experts, and witnesses.
7.4 Force Majeure. Deadlines may be extended for events of force majeure (e.g., natural disasters, declared emergencies) upon motion and Tribunal approval.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Petition and all related proceedings are governed by the laws of the State of Florida, without regard to conflict-of-law principles.
8.2 Forum Selection. Exclusive jurisdiction and venue lie with the [ADMINISTRATIVE COURT/PANEL NAME].
8.3 Arbitration. Not available; statutory administrative remedies control.
8.4 Jury Waiver. The parties acknowledge that matters arising hereunder shall be resolved in an administrative proceeding and that any right to jury trial is hereby waived to the extent permitted by law.
8.5 Injunctive Relief. Claimant reserves the right to seek preliminary or permanent injunctive relief compelling immediate benefit payment where irreparable harm is demonstrated under Fla. R. Civ. P. 1.610, as incorporated by Tribunal rule.
9. GENERAL PROVISIONS
9.1 Amendment. This Petition may be amended once as a matter of right within 30 days of filing; further amendments require Tribunal leave.
9.2 Assignment. Neither party may assign rights or obligations arising from this Petition without prior written consent and Tribunal approval.
9.3 Severability. If any provision is deemed invalid, the remainder shall remain enforceable, and the Tribunal is empowered to modify the offending provision to the minimum extent necessary to render it valid.
9.4 Entire Petition. This document, together with all exhibits and schedules, constitutes the entire Petition and supersedes all prior submissions relating to the Denial.
9.5 Electronic Signatures & Filing. Signatures transmitted via electronic means have the same force and effect as original signatures. Electronic filing through the Tribunal’s e-portal satisfies all service requirements.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the undersigned executes this Petition as of the date set forth below.
CLAIMANT:
[CLAIMANT NAME]
Date: _____
COUNSEL FOR CLAIMANT: [// GUIDANCE: Notarization generally not required for administrative pleadings; verify Tribunal rules.]
[ATTORNEY NAME], Esq.
Florida Bar No. [BAR NUMBER]
[LAW FIRM NAME]
[ADDRESS]
Telephone: [PHONE]
Email: [EMAIL]
RESPONDENT/INSURER (Acknowledgment of Receipt Only):
[AUTHORIZED REPRESENTATIVE NAME]
Title: [POSITION]
Date: _____
Schedule 1 – Other Pending Proceedings
[If none, state “None.”]
[// GUIDANCE:
1. Statutory Citations – Confirm any cited statutes before filing. The template intentionally uses well-established references (e.g., Fla. Stat. §§ 120.569, 120.57).
2. Medical Evidence – Attach treating physician narratives that expressly address work-related functional limitations; Florida adjudicators give significant weight to treating physician opinions.
3. Vocational Factors – Provide a vocational expert report tailored to Florida’s labor market. Highlight transferable skills analysis and regional job availability.
4. Deadlines – Florida’s administrative appeal deadlines are jurisdiction-specific. Verify Policy language, any ERISA preemption issues, and Fla. Stat. § 95.11 contractual limitation periods.
5. Exhaustion – If the Policy is subject to ERISA, ensure internal appeal exhaustion prior to invoking state administrative remedies, or articulate the legal basis for simultaneous pursuit.
6. Formatting – Maintain pleading margins (1-inch), line spacing (double-spaced body text), and 12-point Times New Roman unless Tribunal rules dictate otherwise.
]