ADMINISTRATIVE APPEAL PETITION FOR DISABILITY INSURANCE BENEFITS
(State of Georgia – 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 & Parties
Administrative Appeal Petition (“Petition”) filed by [CLAIMANT FULL LEGAL NAME] (“Claimant”) against [INSURANCE CARRIER / ADMINISTRATIVE AGENCY LEGAL NAME] (“Respondent”) regarding denial of disability insurance benefits under Policy/Plan No. [POLICY NO.] (“Policy”).
1.2 Recitals
A. Claimant is a resident of the State of Georgia who became disabled on [ONSET DATE].
B. Respondent issued a written denial dated [DENIAL LETTER DATE] (“Denial Letter”).
C. Claimant timely seeks administrative review pursuant to OSAH Rules and, where applicable, 20 C.F.R. § 404.900 et seq. (administrative review process).
D. The parties acknowledge that benefits under the Policy constitute valuable consideration for this Petition.
1.3 Effective Date & Jurisdiction
This Petition is effective as of [DATE FILED] and is governed by Georgia disability insurance law and applicable federal regulations. Venue lies in the [NAME OF ADMINISTRATIVE COURT OR OSAH DOCKET NO.].
2. DEFINITIONS
For ease of reference, capitalized terms below have the meanings assigned:
“Administrative Record” – The full file, including pleadings, exhibits, transcripts, and all evidence admitted by the Administrative Law Judge (“ALJ”).
“ALJ” – The duly-appointed Administrative Law Judge presiding over this matter.
“Benefit Amount” – The total monthly and retroactive disability payments asserted, capped as set forth in Section 7.2.
“Date Last Insured” – [MM/DD/YYYY] as established in Respondent’s records.
“Denial Letter” – Respondent’s written determination dated [DATE].
“Medical Evidence” – All records, opinions, and diagnostic studies from treating and examining medical professionals identified in Exhibit A.
“Onset Date” – [MM/DD/YYYY], the claimed date of disability commencement.
“Policy” – The disability insurance policy, certificate, or plan document identified in Section 1.1.
“Vocational Evidence” – Work history, residual functional capacity (“RFC”) evaluations, and labor-market data identified in Exhibit B.
[// GUIDANCE: Add or delete definitions to mirror actual file contents.]
3. OPERATIVE PROVISIONS
3.1 Petition for Review
Claimant hereby appeals the Denial Letter and petitions the ALJ to reverse Respondent’s decision and award all due disability benefits.
3.2 Timeliness
This Petition is filed within [XX] days of receipt of the Denial Letter, satisfying the procedural deadline contained in the Policy and Ga. Comp. R. & Regs. r. [INSERT RULE].
3.3 Standard of Review
The ALJ shall conduct a de novo review unless the Policy expressly confers discretionary authority, in which case review is for abuse of discretion consistent with Georgia law.
3.4 Requested Hearing
Claimant demands an evidentiary hearing at the earliest available session of the administrative docket.
3.5 Exhibits & Evidence
A. Exhibit A – Medical Evidence Index
B. Exhibit B – Vocational Evidence Index
C. Exhibit C – Policy/Plan Documents
D. Exhibit D – Prior Correspondence
3.6 Conditions Precedent
All internal appeal steps under the Policy were exhausted on [DATE]. Proof of exhaustion is attached as Exhibit E.
4. REPRESENTATIONS & WARRANTIES
4.1 Claimant’s Representations
a. Continuous Disability – Claimant has been continuously unable to perform substantial gainful activity from the Onset Date to present.
b. Accuracy of Information – All statements, records, and forms submitted are true, correct, and complete to the best of Claimant’s knowledge.
4.2 Respondent’s Representations
Respondent represented in the Denial Letter that Claimant “retains the capacity to perform [LIGHT/SEDENTARY] work.” Claimant denies the factual basis for that representation.
4.3 Survival
The representations and warranties herein survive final adjudication of this Petition.
5. COVENANTS & RESTRICTIONS
5.1 Claimant’s Covenants
a. Cooperation – Claimant will attend all scheduled medical examinations ordered by the ALJ.
b. Supplemental Evidence – Claimant will promptly furnish newly-acquired medical or vocational evidence.
5.2 Respondent’s Covenants
a. Production – Respondent shall produce the complete administrative claim file within [10] days of service of this Petition.
b. Non-Retaliation – Respondent shall not reduce or terminate any other benefits solely due to this appeal.
5.3 Notice & Cure
Upon any alleged breach of the above covenants, the non-breaching party shall provide written notice and a [5]-business-day opportunity to cure.
6. DEFAULT & REMEDIES
6.1 Events of Default
a. Failure to Produce Administrative File (Section 5.2(a)).
b. Failure to Appear at Scheduled Hearing.
c. Non-Compliance with ALJ Order.
6.2 Remedies
a. Benefit Payment Injunction – Immediate payment of disputed benefits pending final decision.
b. Interest – Statutory pre- and post-judgment interest at the legal rate in Georgia.
c. Fees & Costs – Reasonable attorney fees under O.C.G.A. § 13-6-11 where bad faith is proven.
6.3 Escalating Measures
Should Respondent ignore an ALJ order, Claimant may petition for civil enforcement in the Superior Court of [COUNTY].
7. RISK ALLOCATION
7.1 Indemnification
Not applicable; no indemnity obligation is imposed by or upon either party.
7.2 Limitation of Liability
Respondent’s monetary liability is capped at the total Benefit Amount due under the Policy, together with statutory interest and any fees awarded under Section 6.2(c).
7.3 Force Majeure
Neither party shall be deemed in default for delays caused by acts of God, governmental action, or other events beyond reasonable control; deadlines shall be tolled for the duration of such event.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Petition and all related proceedings are governed by Georgia disability insurance law and, where applicable, 20 C.F.R. Part 404.
8.2 Forum Selection
Exclusive jurisdiction lies with the [FULL NAME OF ADMINISTRATIVE COURT]. Appeals from a final decision shall be taken to the Superior Court of [COUNTY], State of Georgia.
8.3 Arbitration
Not available.
8.4 Jury Waiver
As an administrative proceeding, jury trial is neither available nor requested.
8.5 Injunctive Relief
Nothing herein limits the ALJ’s authority to issue injunctive orders compelling Benefit Payment or other equitable relief.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers
Any amendment or waiver must be in writing, signed by all parties, and approved by the ALJ if material to the proceeding.
9.2 Assignment
Neither party may assign rights or delegate duties under this Petition without written consent of the other party and ALJ approval.
9.3 Severability
If any provision is adjudged invalid, the remaining provisions remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to comply with applicable law.
9.4 Integration
This Petition, together with its exhibits and the administrative record, constitutes the entire agreement of the parties concerning the subject matter and supersedes all prior statements.
9.5 Counterparts & Electronic Signatures
This Petition may be executed in counterparts, including electronically, each of which is deemed an original and all of which together constitute one instrument.
[// GUIDANCE: Georgia recognizes electronic signatures under the Uniform Electronic Transactions Act (O.C.G.A. § 10-12-1 et seq.).]
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the undersigned have executed this Petition as of the Effective Date.
Claimant
[CLAIMANT FULL LEGAL NAME]
Address: [ADDRESS]
Telephone: [PHONE]
Email: [EMAIL]
Counsel for Claimant
[ATTORNEY NAME], Esq.
Georgia Bar No. [BAR NO.]
[LAW FIRM NAME]
[ADDRESS]
Phone: [PHONE] | Email: [EMAIL]
Respondent Representative
[AUTHORIZED SIGNATORY NAME & TITLE]
[RESPONDENT LEGAL NAME]
Address: [ADDRESS]
Telephone: [PHONE]
Email: [EMAIL]
(Notary block or witness lines added if required by OSAH rule or Policy.)
EXHIBIT INDEX
A. Medical Evidence Index
B. Vocational Evidence Index
C. Policy/Plan Documents
D. Correspondence & Denial Letter
E. Proof of Internal Appeal Exhaustion
[// GUIDANCE: Insert separate cover pages and Bates-numbered pagination for each exhibit. Confirm HIPAA compliance before filing medical records.]