DISABILITY INSURANCE ADMINISTRATIVE APPEAL PETITION

(Commonwealth of Pennsylvania)

[// GUIDANCE: This template is designed for use in appealing a denial or termination of disability insurance benefits before a Pennsylvania administrative tribunal or other adjudicative body designated by the governing policy or statute. It is intentionally broad so it can be adapted to private, employer-sponsored, or state-run disability benefit plans. Practitioners should tailor all bracketed placeholders, confirm venue and procedural rules, and attach all supporting evidence.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
   3.1 Statement of Appeal
   3.2 Jurisdiction & Timeliness
   3.3 Grounds for Appeal
   3.4 Relief Requested
   3.5 Evidence Submitted
   3.6 Hearing Demand
4. Representations & Warranties
5. Covenants & Continuing Obligations
6. Default & Administrative Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block
11. Certificate of Service

1. DOCUMENT HEADER

Petitioner/Appellant: [APPELLANT LEGAL NAME], an individual domiciled in the Commonwealth of Pennsylvania, with principal address at [ADDRESS] (“Appellant”).

Respondent: [INSURER / PLAN ADMINISTRATOR LEGAL NAME], a [STATE] [corporation/other entity] authorized to transact insurance business in Pennsylvania, with principal claims office at [ADDRESS] (“Respondent”).

Effective Date of Petition: [DATE] (“Effective Date”).

Recitals

A. Appellant is/was an insured participant under Disability Insurance Policy No. [POLICY #] issued by Respondent (the “Policy”).
B. On [DENIAL DATE] Respondent issued a written determination denying, terminating, or reducing Appellant’s claim for disability benefits (the “Denial Notice”).
C. Pennsylvania law and the Policy afford Appellant a right to an administrative appeal of the Denial Notice.
D. Appellant timely brings this Petition to secure payment of benefits and any ancillary relief available under applicable law.

NOW, THEREFORE, Appellant hereby petitions the appropriate administrative tribunal for the relief set forth below.

2. DEFINITIONS

Unless the context clearly requires otherwise, the following capitalized terms shall have the meanings assigned below:

“Administrative Court” means the [NAME OF TRIBUNAL OR AGENCY] having jurisdiction over this appeal pursuant to state disability law and/or the Policy.

“Appeal Record” means the complete file of medical, vocational, and administrative materials required to be considered on appeal.

“Benefit Amount” means the total monetary benefits due under the Policy, inclusive of accrued past-due benefits, statutory interest, and any cost-of-living adjustments, not to exceed the maximum policy limits.

“Disability” means Appellant’s inability to perform [his/her/their] own occupation—or any gainful occupation, as applicable under the Policy—by reason of medically determinable physical or mental impairment(s).

“Medical Evidence” means treating source records, objective diagnostic testing, treating physician opinions, independent medical examinations, and any other competent evidence concerning Appellant’s impairment(s).

“Vocational Factors” means Appellant’s age, education, work history, transferable skills, and labor-market data relevant to employability, as recognized under Pennsylvania disability adjudicatory standards.

Other capitalized terms used but not defined herein shall have the meanings ascribed to them in the Policy or applicable statutes.

3. OPERATIVE PROVISIONS

3.1 Statement of Appeal

Appellant hereby appeals the Denial Notice in its entirety and seeks de novo review of all factual and legal issues.

3.2 Jurisdiction & Timeliness

a. This Petition is filed within [APPEAL PERIOD] days of the Denial Notice, satisfying all contractual and statutory deadlines.
b. Venue is proper before the Administrative Court under state disability law and the forum-selection provisions of the Policy.

3.3 Grounds for Appeal

a. Erroneous Medical Findings: Respondent failed to give controlling weight to substantial Medical Evidence demonstrating ongoing Disability.
b. Vocational Misapplication: Respondent improperly concluded that Appellant can perform alternative occupations without considering Vocational Factors mandated by Pennsylvania administrative precedent.
c. Procedural Irregularities: Respondent’s claims process violated fundamental fairness and notice requirements, prejudicing Appellant’s substantive rights.

3.4 Relief Requested

Appellant respectfully requests:
1. Reversal of the Denial Notice;
2. Immediate reinstatement or commencement of Disability benefits retroactive to [ONSET DATE];
3. Payment of the Benefit Amount, subject to policy limits;
4. Ongoing future benefits so long as Disability persists;
5. Such other equitable or declaratory relief as the Administrative Court deems just.

3.5 Evidence Submitted

a. Medical Evidence: See Exhibit A (complete treating-source records), Exhibit B (functional capacity evaluations), Exhibit C (specialist narrative reports).
b. Vocational Evidence: See Exhibit D (vocational expert report), Exhibit E (labor-market survey), Exhibit F (educational transcripts).
c. Procedural Documentation: See Exhibit G (Policy), Exhibit H (Denial Notice), Exhibit I (prior correspondence).

[// GUIDANCE: Ensure each exhibit is Bates-stamped and indexed for ease of reference by the administrative judge.]

3.6 Hearing Demand

Pursuant to governing regulations, Appellant demands a full evidentiary hearing, including the right to:
a. Present testimonial and documentary evidence;
b. Cross-examine Respondent’s witnesses;
c. Submit post-hearing briefs.

4. REPRESENTATIONS & WARRANTIES

4.1 Appellant affirms that all statements herein and in the accompanying Appeal Record are true, complete, and made in good faith.

4.2 Appellant has disclosed all material Medical Evidence and Vocational Factors known at this time.

4.3 Appellant warrants having exhausted all mandatory internal review procedures prior to filing this Petition.

4.4 These representations survive the conclusion of the administrative proceedings.

5. COVENANTS & CONTINUING OBLIGATIONS

5.1 Duty to Supplement: Appellant shall promptly submit any newly-acquired Medical Evidence material to the claim.

5.2 Cooperation: Appellant agrees to attend independent medical or vocational examinations reasonably requested by the Administrative Court, provided such examinations comply with Pennsylvania law.

5.3 Notice of Change: Appellant shall notify the Administrative Court and Respondent of any change in residence, employment, or medical condition that may affect Disability status within ten (10) calendar days of such change.

6. DEFAULT & ADMINISTRATIVE REMEDIES

6.1 Failure of either party to comply with a lawful order of the Administrative Court shall constitute default and may result in sanctions, including adverse inference, exclusion of evidence, or dismissal of the Petition.

6.2 Attorney’s Fees and Costs: If authorized by statute or policy, the prevailing party may seek reasonable attorney’s fees, filing fees, and costs incurred in connection with this Appeal.

7. RISK ALLOCATION

7.1 Limitation of Liability: Consistent with the Policy and applicable law, Respondent’s aggregate liability is capped at the Benefit Amount together with any statutory interest.

7.2 Force Majeure: Neither party shall be deemed in default for delay caused by events beyond reasonable control (e.g., natural disasters, acts of God); provided, however, that the affected party gives prompt written notice and resumes performance as soon as practicable.

8. DISPUTE RESOLUTION

8.1 Governing Law: This Petition and all related matters shall be governed by the laws of the Commonwealth of Pennsylvania without regard to conflicts-of-law principles.

8.2 Forum Selection: Exclusive jurisdiction lies with the Administrative Court identified above.

8.3 Arbitration: Not available for this matter per Policy and state disability regulations.

8.4 Jury Waiver: The proceedings are administrative; jury trial rights are inapplicable.

8.5 Injunctive Relief Preservation: Nothing herein limits the Administrative Court’s inherent authority to order immediate benefit payment or other equitable relief.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver: This Petition may be amended only by written motion granted by the Administrative Court. No waiver of any provision shall be effective unless in writing and entered on the record.

9.2 Assignment: Appellant may not assign rights or delegate obligations arising under this Appeal without prior written consent of the Administrative Court, except to legally appointed representatives.

9.3 Severability: If any provision is held unenforceable, the remaining provisions shall remain in full force to the maximum extent permissible.

9.4 Integration: This Petition, together with its Exhibits, constitutes the entire submission for purposes of initiating the Appeal and supersedes all prior written or oral statements regarding matters addressed herein.

9.5 Electronic Signatures: Signatures transmitted by electronic means shall be deemed originals for all purposes permitted under Pennsylvania law.

10. EXECUTION BLOCK

IN WITNESS WHEREOF, the undersigned have executed this Petition as of the Effective Date.

[// GUIDANCE: Notarization is generally not required for administrative appeals in PA; confirm tribunal-specific rules. Add witness lines if mandated.]

11. CERTIFICATE OF SERVICE

I, [ATTORNEY NAME], hereby certify that on this ___ day of [MONTH], [YEAR], a true and correct copy of the foregoing Petition, together with all Exhibits, was served upon the following via [METHOD OF SERVICE] in accordance with governing regulations:

1. [NAME], Claims Appeal Representative
   [INSURER NAME]
   [ADDRESS]

2. [OFFICE/CLERK OF ADMINISTRATIVE COURT]
   [ADDRESS]

Signature: _____
Date: _____

[// GUIDANCE: File the original Petition and Certificate of Service with the tribunal clerk, keep a conformed copy, and calendar all response and hearing deadlines immediately upon acceptance for filing.]