Montana Disability Insurance Appeal (ERISA and Non-ERISA)

DISABILITY INSURANCE APPEAL — MONTANA

TABLE OF CONTENTS

1. Letterhead and Delivery Information
2. Plan/Policy and Claimant Identification
3. Threshold Determination — ERISA or Non-ERISA
4. Section A — ERISA Administrative Appeal
5. Section B — Non-ERISA Appeal and Mont. Code Ann. § 33-18-201 Notice
6. Statement of Facts and Disability
7. Medical and Vocational Evidence
8. Refutation of Denial Grounds
9. Demand for Specific Relief
10. Reservation of Rights and Litigation Hold
11. Montana CSI Complaint (Concurrent or Alternative Remedy)
12. Signature and Service
13. Exhibit Index
14. Montana Practice Notes
15. Sources and References

1. LETTERHEAD AND DELIVERY INFORMATION

[LAW FIRM NAME / CLAIMANT NAME]

[STREET ADDRESS]

[CITY, MT ZIP]

Telephone: [NUMBER] | Email: [EMAIL]

Date: [__/__/____]

Delivery Method (select all):

☐ Certified Mail, Return Receipt Requested — Tracking No. [________________________________]

☐ FedEx/UPS Overnight, Signature Required — Tracking No. [________________________________]

☐ Plan-designated electronic appeal portal — Confirmation No. [________________________________]

☐ Hand-delivery — Receipt obtained

Recipient:

[INSURER / PLAN ADMINISTRATOR / CLAIMS FIDUCIARY]

Attn: [APPEALS DEPARTMENT / NAMED FIDUCIARY]

[STREET ADDRESS]

[CITY, STATE ZIP]

2. PLAN/POLICY AND CLAIMANT IDENTIFICATION

3. THRESHOLD DETERMINATION — ERISA OR NON-ERISA

ERISA STATUS DETERMINATION

ERISA, 29 U.S.C. § 1002(1), governs an "employee welfare benefit plan" established or maintained by an employer to provide disability benefits to participants and beneficiaries. The plan at issue [is / is not] ERISA-governed for the following reasons:

• ☐ The plan is sponsored by a private-sector employer for the benefit of its employees;
• ☐ The plan is sponsored by a church and has not elected ERISA coverage (29 U.S.C. § 1003(b)(2)) — NON-ERISA;
• ☐ The plan is a governmental plan (29 U.S.C. § 1003(b)(1)) — NON-ERISA;
• ☐ The policy was purchased individually by the Claimant, not through an employer — NON-ERISA;
• ☐ The plan is a sole-proprietor plan covering only the owner and spouse (29 C.F.R. § 2510.3-3(b)) — NON-ERISA;
• ☐ Other: [________________________________].

Use Section A if ERISA-governed; use Section B if non-ERISA. Do not use both.

4. SECTION A — ERISA ADMINISTRATIVE APPEAL

A.1 Statement of Appeal

Pursuant to 29 U.S.C. § 1133 and 29 C.F.R. § 2560.503-1(h), Claimant hereby appeals the adverse benefit determination dated [__/__/____] denying or terminating disability benefits under the above-referenced Plan. This appeal is timely filed within 180 days of Claimant's receipt of the adverse determination.

A.2 Document Production Request — 29 C.F.R. § 2560.503-1(h)(2)(iii)

Pursuant to 29 C.F.R. § 2560.503-1(h)(2)(iii) and (j)(3), Claimant requests, free of charge, copies of all documents, records, and other information relevant to the claim, including:

• ☐ Complete claim file and administrative record;
• ☐ The Plan document, Summary Plan Description, and any amendments;
• ☐ The group insurance policy or certificate, including riders and endorsements;
• ☐ All internal claim manuals, guidelines, protocols, and standards used in adjudicating the claim;
• ☐ All medical reports, peer reviews, and independent medical examinations;
• ☐ Identification of all medical or vocational experts whose advice was obtained, whether or not relied upon;
• ☐ All vocational analyses, transferable-skills analyses, and labor-market surveys;
• ☐ All correspondence with treating providers and Claimant;
• ☐ All notes, diaries, and internal communications regarding the claim;
• ☐ Any new or additional evidence considered, relied upon, or generated by the plan in connection with the claim, in time for Claimant to respond before a final determination (29 C.F.R. § 2560.503-1(h)(4)(i)).

A.3 Compliance with 29 C.F.R. § 2560.503-1 (2018 Disability Amendments)

The adverse determination fails to comply with the disability-claim regulations because:

• ☐ The denial does not provide a "discussion of the decision," including the basis for disagreeing with treating physicians, agency disability determinations (e.g., SSA), or vocational professionals (29 C.F.R. § 2560.503-1(g)(1)(vii)(A));
• ☐ The denial fails to identify specific internal rules, guidelines, protocols, or other similar criteria relied upon (29 C.F.R. § 2560.503-1(g)(1)(v)(A));
• ☐ The denial fails to provide the explanation of any scientific or clinical judgment (29 C.F.R. § 2560.503-1(g)(1)(v)(B));
• ☐ The plan failed to ensure that the claims and appeals process is conducted in a manner designed to ensure independence and impartiality (29 C.F.R. § 2560.503-1(b)(7));
• ☐ The plan failed to provide notice in a culturally and linguistically appropriate manner (29 C.F.R. § 2560.503-1(o)).

A.4 Procedural Irregularities Warranting Abatie Review

Pursuant to Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006) (en banc), the following procedural irregularities give rise to consideration of evidence outside the administrative record and to heightened scrutiny:

[________________________________]

[________________________________]

A.5 Tolling and Limitations

Pursuant to 29 C.F.R. § 2560.503-1(l)(2)(i), if the plan fails to comply with the regulation, Claimant may be deemed to have exhausted administrative remedies and may proceed directly to civil action under ERISA § 502(a). Any contractual limitations period must comply with Heimeshoff v. Hartford Life & Accident Ins. Co., 571 U.S. 99 (2013).

A.6 Demand for Full and Fair Review

Claimant demands a full and fair review under 29 U.S.C. § 1133 by a different fiduciary than the one who made the initial determination, with no deference to that determination, and with consultation by an independent health-care professional with appropriate training in the relevant medical specialty (29 C.F.R. § 2560.503-1(h)(3)(ii), (iii)).

5. SECTION B — NON-ERISA APPEAL AND MONT. CODE ANN. § 33-18-201 NOTICE

B.1 Statement of Appeal

Pursuant to the appeal procedures of the above-referenced policy and the Montana Insurance Code, Claimant hereby appeals the adverse benefit determination dated [__/__/____] denying or terminating disability benefits.

B.2 Notice of Violations of Mont. Code Ann. § 33-18-201

Defendant's claim handling violates one or more enumerated subsections of Mont. Code Ann. § 33-18-201 supporting a private right of action under Mont. Code Ann. § 33-18-242, including:

• ☐ § 33-18-201(1) — Misrepresenting pertinent facts or policy provisions: [________________________________]
• ☐ § 33-18-201(4) — Refusing to pay claims without a reasonable investigation: [________________________________]
• ☐ § 33-18-201(5) — Failing to affirm or deny coverage within a reasonable time: [________________________________]
• ☐ § 33-18-201(6) — Neglecting to attempt good-faith, prompt, and equitable settlement when liability is reasonably clear: [________________________________]
• ☐ § 33-18-201(13) — Failing to promptly settle one coverage to influence settlement under another: [________________________________]

B.3 Document Production Request

Pursuant to Mont. Admin. R. 6.6.3501 et seq. and the policy's good-faith claim-handling obligations, Claimant requests:

• ☐ Complete claim file;
• ☐ All medical and vocational reports, peer reviews, and IME reports;
• ☐ Identification of all medical and vocational consultants;
• ☐ All internal claim manuals, guidelines, and protocols applied;
• ☐ All correspondence with treating providers;
• ☐ All adjuster notes, diaries, and internal communications.

B.4 Statement of Settlement Posture

Claimant remains willing to resolve this matter without litigation upon payment of the benefits owed and reinstatement of coverage. Failure to pay benefits owed may give rise to a civil action under Mont. Code Ann. § 33-18-242 for actual damages, attorney's fees in equity (see Mountain West Farm Bureau Mut. Ins. Co. v. Brewer, 2003 MT 98, 315 Mont. 231, 69 P.3d 652), and punitive damages under Mont. Code Ann. §§ 27-1-220 and 27-1-221 if actual fraud or actual malice is established by clear and convincing evidence.

6. STATEMENT OF FACTS AND DISABILITY

6.1 Claimant's Background

6.2 Material Duties of the Occupation

[________________________________]

[________________________________]

6.3 Onset and Course of Disability

[________________________________]

[________________________________]

[________________________________]

6.4 Definition of Disability Under the Policy

The Policy defines "Disability" as: "[QUOTE POLICY DEFINITION VERBATIM]."

Claimant satisfies this definition because: [________________________________].

7. MEDICAL AND VOCATIONAL EVIDENCE

7.1 Treating Provider Statements (Exhibits)

7.2 Diagnostic and Objective Findings

[________________________________]

[________________________________]

7.3 Functional Capacity Evaluation / Medical Source Statement

[________________________________]

7.4 Vocational Evidence

[________________________________]

7.5 Social Security Disability Determination (if any)

A favorable SSDI determination dated [__/__/____] is attached as Exhibit [____]. Pursuant to Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666 (9th Cir. 2011), an SSDI determination is significant evidence the plan must address.

7.6 Medications and Side Effects

[________________________________]

8. REFUTATION OF DENIAL GROUNDS

The carrier's stated grounds for denial — [summarize from denial letter] — are without merit:

1. [GROUND 1] — Refutation: [________________________________]

2. [GROUND 2] — Refutation: [________________________________]

3. [GROUND 3] — Refutation: [________________________________]

The denial relies on file-review opinions of consultants who never examined Claimant, contrary to the consistent opinions of treating physicians who have personally evaluated Claimant. Under Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), plans need not afford special weight to treating-physician opinions, but they may not arbitrarily refuse to credit reliable evidence.

9. DEMAND FOR SPECIFIC RELIEF

Claimant demands the following relief:

• ☐ Reversal of the adverse determination and payment of all back benefits from [__/__/____] through the date of payment, with interest;
• ☐ Reinstatement of monthly benefits prospectively for so long as Claimant remains disabled under the Policy;
• ☐ Continuation of any waiver-of-premium, COBRA subsidy, or other ancillary benefits;
• ☐ Written explanation of any continued denial that complies fully with 29 C.F.R. § 2560.503-1(g) (ERISA) or the Policy and Mont. Code Ann. § 33-18-201 (non-ERISA);
• ☐ Production of all documents requested in Section A.2 or B.3.

10. RESERVATION OF RIGHTS AND LITIGATION HOLD

10.1 Reservation of Rights

Claimant expressly reserves all rights and remedies under ERISA, Montana law, and the Policy, including the right to file civil action under 29 U.S.C. § 1132(a)(1)(B) (ERISA) or under Mont. Code Ann. § 33-18-242, breach of contract, and Mont. Code Ann. §§ 27-1-220 and 27-1-221 (non-ERISA). Nothing in this submission constitutes a waiver of any claim or remedy.

10.2 Litigation Hold Notice

You and your agents are hereby instructed to preserve all documents, electronically stored information, and tangible items relating to this claim, including but not limited to:

• ☐ The complete claims file and administrative record;
• ☐ All adjuster notes, diaries, and internal communications;
• ☐ All emails, instant messages, and recorded calls;
• ☐ All medical, vocational, and IME reports;
• ☐ All training materials and claim-handling guidelines;
• ☐ All metadata associated with the foregoing.

Spoliation may give rise to sanctions and adverse-inference instructions.

11. MONTANA CSI COMPLAINT (Concurrent or Alternative Remedy)

Claimant [has filed / reserves the right to file] a consumer complaint with the Montana Commissioner of Securities and Insurance:

12. SIGNATURE AND SERVICE

Respectfully submitted,

[LAW FIRM NAME]

By: [________________________________]

[ATTORNEY NAME]

Montana State Bar No. [________]

Counsel for Claimant

[ADDRESS] | Telephone: [NUMBER] | Email: [EMAIL]

DATED this [____] day of [_______________], 20[____].

13. EXHIBIT INDEX

14. MONTANA PRACTICE NOTES

• ERISA preemption is broad. Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987), and Aetna Health Inc. v. Davila, 542 U.S. 200 (2004), preempt Montana common-law and statutory claims for bad faith, including § 33-18-242, when the dispute concerns the denial of benefits under an ERISA plan. ERISA remedies are limited to plan benefits, prejudgment interest, attorney's fees in the court's discretion (29 U.S.C. § 1132(g)), and (rarely) appropriate equitable relief under § 1132(a)(3).
• Ninth Circuit administrative-record rule. Judicial review of an arbitrary-and-capricious denial is generally limited to the administrative record. Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006) (en banc), permits limited extra-record evidence to evaluate the nature, extent, and effect of any conflict of interest. Build the administrative record exhaustively at the appeal stage.
• Conflict of interest. Where the same entity decides claims and pays benefits, structural conflict of interest is a factor on review. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (2008). Document the conflict and any procedural irregularities.
• 2018 disability regulations. 29 C.F.R. § 2560.503-1 (effective for disability claims filed on or after April 1, 2018) imposes heightened independence/impartiality, disclosure, and explanation requirements. Plan failures support a "deemed exhausted" theory under § 2560.503-1(l)(2)(i).
• Non-ERISA — Montana UTPA. For non-ERISA disability policies, Mont. Code Ann. § 33-18-242 provides a statutory private right of action for violation of subsections (1), (4), (5), (6), (9), or (13) of § 33-18-201. Two-year SOL for insureds; insurer may defeat the claim by establishing a "reasonable basis in law or in fact" for contesting the claim (§ 33-18-242(6)).
• No common-law tort of bad faith. Section 33-18-242(3) confines insured remedies to (a) breach of contract, (b) fraud, and (c) the statutory UTPA action. Do NOT plead a separate "common-law bad faith" tort for an insured plaintiff.
• Punitive damages (non-ERISA). Available under Mont. Code Ann. § 27-1-220(2)(b) for UTPA violations, on clear-and-convincing proof of actual fraud or actual malice (§ 27-1-221), capped at the lesser of $10,000,000 or 3% of net worth.
• Attorney's fees against insurer. Mountain West Farm Bureau Mut. Ins. Co. v. Brewer, 2003 MT 98, 315 Mont. 231, 69 P.3d 652, allows an insured forced to litigate to obtain the benefit of the policy to recover attorney's fees as compensatory damages, independent of any fee-shifting statute (non-ERISA only).
• Statutes of limitations.
• ERISA: per the plan's contractual limitations period if reasonable (Heimeshoff); otherwise the most analogous state period (typically 8-year written-contract under § 27-2-202(1)).
• Non-ERISA contract: 3 years (§ 27-2-202(2)) or 8 years (§ 27-2-202(1)) depending on policy form.
• Non-ERISA UTPA (insured): 2 years (§ 33-18-242(8)).
• CSI jurisdiction. The Commissioner of Securities and Insurance can investigate non-ERISA disability disputes and state-regulated aspects of insured ERISA group plans (licensure, marketing, producer conduct). It cannot order payment of benefits in an ERISA dispute.
• SSDI and SSA decisions. Salomaa v. Honda, 642 F.3d 666 (9th Cir. 2011), holds that a plan's failure to address a contrary SSA disability determination is a strong indicator of arbitrary and capricious decision-making. Always submit and discuss the SSA determination if available.
• Preserve "build the record." Treating-physician statements, FCEs, vocational reports, and witness declarations should be obtained and submitted at the administrative-appeal stage. Late-developed evidence usually cannot be considered on judicial review.

15. 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/subtitle-B/chapter-XXV/subchapter-G/part-2560/section-2560.503-1
• Federal Register — Claims Procedure for Plans Providing Disability Benefits — https://www.federalregister.gov/documents/2016/12/19/2016-30070/claims-procedure-for-plans-providing-disability-benefits
• Mont. Code Ann. § 33-18-201 — https://mca.legmt.gov/bills/mca/title_0330/chapter_0180/part_0020/section_0010/0330-0180-0020-0010.html
• Mont. Code Ann. § 33-18-242 — https://mca.legmt.gov/bills/mca/title_0330/chapter_0180/part_0020/section_0420/0330-0180-0020-0420.html
• Mont. Code Ann. § 27-1-220 — https://mca.legmt.gov/bills/mca/title_0270/chapter_0010/part_0020/section_0200/0270-0010-0020-0200.html
• Mont. Code Ann. § 27-1-221 — https://mca.legmt.gov/bills/mca/title_0270/chapter_0010/part_0020/section_0210/0270-0010-0020-0210.html
• Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987)
• Aetna Health Inc. v. Davila, 542 U.S. 200 (2004)
• Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008)
• Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003)
• Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006) (en banc)
• Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666 (9th Cir. 2011)
• Heimeshoff v. Hartford Life & Accident Ins. Co., 571 U.S. 99 (2013)
• Brewington v. Employers Fire Ins. Co., 1999 MT 312, 297 Mont. 243, 992 P.2d 237
• Mountain West Farm Bureau Mut. Ins. Co. v. Brewer, 2003 MT 98, 315 Mont. 231, 69 P.3d 652
• Montana Commissioner of Securities and Insurance — https://csimt.gov/
• Montana CSI File a Complaint — https://csimt.gov/file-a-complaint/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. ERISA disability appeals carry strict pre-suit exhaustion and limitations rules; the administrative record may be the only evidence considered on judicial review. A Montana-licensed attorney with ERISA experience must review and customize this document before submission.