Ohio Disability Insurance Appeal (ERISA and Non-ERISA)

DISABILITY INSURANCE APPEAL — OHIO

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 Bad-Faith Demand
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. Ohio DOI Complaint (Concurrent or Alternative Remedy)
12. Signature and Service
13. Exhibit Index
14. Ohio Practice Notes
15. Sources and References

1. LETTERHEAD AND DELIVERY INFORMATION

[LAW FIRM NAME / CLAIMANT NAME]

[STREET ADDRESS]

[CITY, OH ZIP]

Telephone: [NUMBER] | Email: [EMAIL]

Date: [__/__/____]

Delivery Method (select all):

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

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

☐ Email to designated appeals address: [________________________________]

☐ Plan portal upload — Confirmation No. [________________________________]

☐ Hand delivery

To:

[INSURER / PLAN ADMINISTRATOR NAME]

Attn: Appeals Department

[STREET ADDRESS]

[CITY, STATE ZIP]

2. PLAN/POLICY AND CLAIMANT IDENTIFICATION

3. THRESHOLD DETERMINATION — ERISA OR NON-ERISA

Check the applicable box and complete only the corresponding section:

☐ ERISA-governed plan. Coverage was provided through an employer-sponsored welfare benefit plan within the meaning of 29 U.S.C. § 1002(1). Use Section A below. State-law bad-faith, consequential, and emotional-distress claims are preempted under Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987), and Aetna Health Inc. v. Davila, 542 U.S. 200 (2004).

☐ Non-ERISA plan. Coverage is an individually-purchased policy, a church plan (29 U.S.C. § 1003(b)(2)), a governmental plan (29 U.S.C. § 1003(b)(1)), or otherwise outside ERISA. Use Section B below. Ohio common-law bad-faith remedies under Hoskins/Zoppo are available.

☐ Status disputed / unclear. Preserve both theories. State the plan's status as alleged by the claimant; reserve the right to amend if discovery reveals a different status.

4. SECTION A — ERISA ADMINISTRATIVE APPEAL

RE: Formal Appeal of Adverse Benefit Determination Pursuant to 29 U.S.C. § 1133 and 29 C.F.R. § 2560.503-1

Dear Appeals Committee:

This letter constitutes Claimant's formal administrative appeal of the adverse benefit determination dated [__/__/____] ("Denial Letter," Exhibit 1) under the Plan, pursuant to 29 U.S.C. § 1133 and 29 C.F.R. § 2560.503-1(h). This appeal is timely filed within 180 days of receipt of the Denial Letter.

4.1. Document Production Demand (29 C.F.R. § 2560.503-1(h)(2)(iii), (m)(8))

Pursuant to 29 C.F.R. § 2560.503-1(h)(2)(iii) and (m)(8), Claimant demands production of the entire claim file and all "relevant" documents, including:

☐ The complete claim file and administrative record;

☐ All Plan documents, summary plan descriptions (SPDs), summary of material modifications (SMMs), and amendments in effect during the relevant period;

☐ The insurance policy, group contract, and any administrative-services agreement;

☐ All documents submitted to or generated by the Plan in connection with the claim;

☐ All medical, vocational, and other expert reports, including peer reviews, IMEs, and FCEs, and the names, qualifications, and reports of all reviewers;

☐ All internal claim notes, diary entries, and electronic claim-system entries;

☐ All guidelines, protocols, criteria, and clinical or administrative checklists relied upon;

☐ The administrative record on which the denial was based;

☐ Any documents generated after the denial that the Plan may rely upon, which must be disclosed in advance under 29 C.F.R. § 2560.503-1(h)(4)(i)–(ii) (2018 disability amendments).

4.2. Standard of Review — Preserved Objection to Discretion

Claimant disputes that the Plan validly grants the administrator discretionary authority sufficient to trigger arbitrary-and-capricious review under Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989). To the extent any discretion exists, it is undermined by structural conflict of interest under Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008), because the same entity both decides claims and pays benefits.

4.3. Full and Fair Review Demand

Pursuant to 29 C.F.R. § 2560.503-1(h)(3) and (h)(4), Claimant demands:

• (a) Review by a person who did not participate in the initial denial and is not the subordinate of any such person;
• (b) Consultation with an independent medical professional with appropriate training and experience for any denial based on medical judgment, who was not involved in the initial determination;
• (c) Identification of any medical or vocational expert whose advice was obtained, regardless of reliance;
• (d) Advance disclosure of any new or additional evidence or rationale, with a reasonable opportunity to respond before the appeal decision is issued (29 C.F.R. § 2560.503-1(h)(4)(i)–(ii));
• (e) A written decision within 45 days, extendable once for 45 additional days only on written notice and only for matters beyond the Plan's control (29 C.F.R. § 2560.503-1(i)(3)(i)).

4.4. Preservation of Federal Remedies

If this appeal is denied, Claimant intends to file a civil action under 29 U.S.C. § 1132(a)(1)(B) for recovery of benefits, declaratory and injunctive relief, attorney's fees and costs under § 1132(g), and pre-judgment interest, in the appropriate United States District Court (likely the Northern or Southern District of Ohio).

5. SECTION B — NON-ERISA APPEAL AND BAD-FAITH DEMAND

RE: Formal Appeal and Notice of Common-Law Bad-Faith Claim Under Ohio Law

Dear Claims Manager:

This letter constitutes Claimant's formal appeal of the denial dated [__/__/____] under non-ERISA disability policy no. [POLICY NUMBER], and serves as notice that continued refusal to pay benefits without reasonable justification will subject Insurer to liability under Ohio common-law bad faith. Hoskins v. Aetna Life Ins. Co., 6 Ohio St. 3d 272 (1983); Zoppo v. Homestead Ins. Co., 71 Ohio St. 3d 552 (1994).

5.1. Statement of Bad-Faith Standard

Under Zoppo, "An insurer fails to exercise good faith in the processing of a claim of its insured where its refusal to pay the claim is not predicated upon circumstances that furnish reasonable justification therefor." Insurer's denial is not so predicated, for the reasons set forth in Sections 6–8 below.

5.2. Available Remedies

If Insurer maintains its denial, Claimant will pursue:

• (a) Contract benefits, plus pre-judgment interest under R.C. § 1343.03;
• (b) Consequential and emotional-distress damages flowing from the bad-faith breach;
• (c) Punitive damages on proof of actual malice, fraud, or insult, capped under R.C. § 2315.21(D);
• (d) Reasonable attorney's fees as compensatory damages following a punitive award (Zoppo, 71 Ohio St. 3d at 558).

5.3. Statute of Limitations Notice

The contract limitations period is six years (R.C. § 2305.06); the bad-faith tort limitations period is four years (R.C. § 2305.09(D)). Claimant reserves the right to file suit at any time consistent with these periods.

6. STATEMENT OF FACTS AND DISABILITY

6.1. Personal background. Claimant, age [____], was employed by [EMPLOYER] as a [OCCUPATION] from [__/__/____] through [__/__/____], earning $[________] per year.

6.2. Onset of disability. On [__/__/____], Claimant became unable to perform the material and substantial duties of [his/her/their] occupation due to [diagnosis]. Symptoms include [symptoms].

6.3. Treatment course. Claimant has been treated by [providers] and has undergone [treatments]. Continued treatment is documented in Exhibits [__]–[__].

6.4. Functional limitations. Claimant cannot [describe restrictions: sit/stand/walk for X hours; lift > X lbs; concentrate for sustained periods; tolerate cognitive load; etc.], supported by treating-provider opinions and any FCE.

6.5. SSDI status. Claimant [has applied / has been approved / has been denied] Social Security Disability benefits as of [__/__/____]. Approval is highly probative; the Sixth Circuit treats SSA awards as significant evidence the plan must address. Calvert v. Firstar Fin., Inc., 409 F.3d 286, 294–95 (6th Cir. 2005).

7. MEDICAL AND VOCATIONAL EVIDENCE

8. REFUTATION OF DENIAL GROUNDS

8.1. Insurer's stated grounds. The Denial Letter relies on: [summarize each ground — e.g., "no objective evidence," "able to perform sedentary work," "self-reported symptoms," "surveillance," "video review," "policy exclusion," "elimination period not met"].

8.2. Refutation by ground.

• (a) "No objective evidence." [Identify objective findings ignored — MRI, EMG, lab, imaging, neuropsych testing.] A plan administrator may not require "objective evidence" of conditions that are inherently subjective. Smith v. Bayer Corp. Long Term Disability Plan, 444 F. App'x 791 (6th Cir. 2011).
• (b) "Able to perform sedentary work." Sedentary capacity is not coextensive with the claimant's "regular occupation"; the plan must address actual job duties. Calvert, 409 F.3d at 296.
• (c) "Self-reported symptoms." Self-reports are valid evidence and may not be discounted without an articulated basis. Cooper v. Life Ins. Co. of N. Am., 486 F.3d 157 (6th Cir. 2007).
• (d) Surveillance / activities of daily living. Surveillance snippets do not refute disability where the activities shown are consistent with intermittent functional capacity. Bennett v. Kemper Nat'l Servs., Inc., 514 F.3d 547 (6th Cir. 2008).
• (e) Paper review by non-examining physician. A pure paper review, particularly when conflicting with treating-physician opinions and an in-person evaluation, is suspect. Smith, 444 F. App'x at 798.
• (f) Elimination period / waiting period. [Explain how elimination period is satisfied with date-by-date documentation.]

8.3. Conflict of interest. Insurer both decides the claim and pays benefits — a structural conflict that must weigh against the denial under Glenn, 554 U.S. at 117.

9. DEMAND FOR SPECIFIC RELIEF

Claimant demands:

• A. Reversal of the adverse determination and reinstatement of benefits, retroactive to [__/__/____], in the amount of $[________] per month;
• B. Payment of all past-due benefits with interest;
• C. Continuing payment of monthly benefits during ongoing disability, subject only to the Plan/Policy's lawful conditions;
• D. Reimbursement of any out-of-pocket COBRA, premium-waiver, or related amounts;
• E. Reasonable attorney's fees and costs (under 29 U.S.C. § 1132(g) for ERISA matters; under Zoppo upon punitive award for non-ERISA matters);
• F. All other relief available under applicable law.

Response deadline: Pursuant to 29 C.F.R. § 2560.503-1(i)(3) (ERISA) or [__] days from delivery of this letter (non-ERISA), whichever applies.

10. RESERVATION OF RIGHTS AND LITIGATION HOLD

Claimant reserves all legal and equitable rights, including the right to file suit under 29 U.S.C. § 1132 (ERISA) or in Ohio state court (non-ERISA).

Litigation Hold. Insurer / Plan Administrator must immediately preserve all documents and electronically stored information related to the claim, including but not limited to:

☐ Complete claim file and administrative record

☐ Underwriting file

☐ All policy and plan documents and amendments

☐ All claim-system entries, diaries, and audit trails

☐ All emails, instant messages, and text messages relating to the claim

☐ All medical, vocational, and surveillance reports

☐ All recorded statements and call recordings

☐ Personnel records of decision-makers and reviewers

☐ Performance metrics, bonuses, and incentive structures tied to denial rates

☐ Backup tapes and archived ESI

Confirm the hold in writing within ten (10) days.

11. OHIO DOI COMPLAINT (CONCURRENT OR ALTERNATIVE REMEDY)

Claimant may file a parallel complaint with the Ohio Department of Insurance, Office of Consumer Services:

• Online: https://gateway.insurance.ohio.gov/UI/ODI.CS.Public.UI/Complaint.mvc/DisplayConsumerComplaintForm
• Phone: 1-800-686-1526 (in-state) or 614-644-2673
• Mail: Ohio Department of Insurance, Office of Consumer Services, 50 W. Town St., Third Floor, Suite 300, Columbus, OH 43215

The Ohio DOI typically acknowledges the complaint within two weeks and assigns an analyst. The DOI cannot award damages but may impose administrative penalties under R.C. § 3901.22 and may pressure compliance with claims-handling rules in OAC 3901-1-07.

12. SIGNATURE AND SERVICE

Respectfully submitted,

[LAW FIRM NAME]

By: [________________________________]

[ATTORNEY NAME] (0[####])

Counsel for Claimant

[STREET ADDRESS]

[CITY, OH ZIP]

Telephone: [NUMBER]

Email: [EMAIL]

Service: A copy of this appeal has been served on:

• [INSURER / PLAN ADMINISTRATOR] by the delivery method(s) checked in Section 1 above.

[________________________________]

[ATTORNEY NAME]

13. EXHIBIT INDEX

14. OHIO PRACTICE NOTES

• ERISA preemption is broad. Pilot Life and Davila eliminate state common-law bad faith, punitive damages, jury trial, and emotional-distress remedies for ERISA-governed claims. The exclusive remedies are recovery of benefits, equitable relief, and attorney's fees under § 1132(a) and (g). Plead carefully — pleading state-law tort claims in an ERISA case invites complete-preemption removal followed by 12(b)(6) dismissal.
• Non-ERISA disability is a Hoskins/Zoppo case. Ohio common-law bad faith provides robust remedies: contract benefits, consequential and emotional-distress damages, punitive damages on actual malice, and attorney's fees as compensatory damages. R.C. § 3901.21 and OAC 3901-1-07 are not stand-alone causes of action (Strack v. Westfield Cos.) but support a Hoskins/Zoppo count.
• Sixth Circuit "build the record" rule. Wilkins v. Baptist Healthcare Sys., 150 F.3d 609 (6th Cir. 1998), restricts judicial review under arbitrary-and-capricious standard to the administrative record. Submit ALL evidence at the appeal stage; supplementation in district court is generally unavailable.
• Limitations. ERISA contractual limitations clauses are enforceable per Heimeshoff v. Hartford Life & Acc. Ins. Co., 571 U.S. 99 (2013); confirm and calendar the plan-specified deadline. Non-ERISA: six years on contract (R.C. § 2305.06); four years on bad-faith tort (R.C. § 2305.09(D)).
• Venue for ERISA suits. 29 U.S.C. § 1132(e)(2) authorizes suit where the plan is administered, where the breach took place, or where a defendant resides or may be found. Ohio claimants typically file in the Northern or Southern District of Ohio.
• SSA awards matter. Calvert v. Firstar Fin., Inc., 409 F.3d 286 (6th Cir. 2005), and progeny require the plan to address an SSA award seriously. Always include the SSA decision in the appeal record.
• Conflict-of-interest review. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008), requires courts to weigh structural conflict in arbitrary-and-capricious review. Document the conflict and any history of denials by the Insurer or its IME vendors.
• Self-funded vs. insured plans. Self-funded ERISA plans are exempt from Ohio insurance regulation under the deemer clause, 29 U.S.C. § 1144(b)(2)(B); insured ERISA plans remain subject to state insurance law under the savings clause, § 1144(b)(2)(A). This affects DOI complaint utility and certain state-law claim theories.
• Develop the record like trial. Treat the administrative appeal as the only chance to put on the case. Include treating-physician narratives addressing each denial ground point-by-point, FCE, vocational expert testimony tied to the policy's "regular occupation" or "any occupation" definition, and a personal narrative.

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 (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
• DOL Benefit Claims Procedure Regulation FAQs — https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/benefit-claims-procedure-regulation
• Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987)
• Aetna Health Inc. v. Davila, 542 U.S. 200 (2004)
• Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989)
• Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008)
• Heimeshoff v. Hartford Life & Acc. Ins. Co., 571 U.S. 99 (2013)
• Wilkins v. Baptist Healthcare Sys., 150 F.3d 609 (6th Cir. 1998)
• Calvert v. Firstar Fin., Inc., 409 F.3d 286 (6th Cir. 2005)
• Hoskins v. Aetna Life Ins. Co., 6 Ohio St. 3d 272 (1983)
• Zoppo v. Homestead Ins. Co., 71 Ohio St. 3d 552 (1994)
• Strack v. Westfield Cos., 33 Ohio App. 3d 336 (9th Dist. 1986)
• Ohio Rev. Code § 3901.21 — https://codes.ohio.gov/ohio-revised-code/section-3901.21
• Ohio Rev. Code § 2305.06 (six-year written-contract limitations) — https://codes.ohio.gov/ohio-revised-code/section-2305.06
• Ohio Rev. Code § 2315.21 (punitive damages cap) — https://codes.ohio.gov/ohio-revised-code/section-2315.21
• Ohio Admin. Code 3901-1-07 (Unfair life and health claims settlement practices) — https://codes.ohio.gov/ohio-administrative-code/rule-3901-1-07
• Ohio Department of Insurance, Office of Consumer Services — https://insurance.ohio.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Ohio with ERISA experience must review and customize this document before submission. Verify all citations and procedural deadlines.