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Dear Ms. Stahl:
Thank you for sending us your letter dated October 24, 2014. You indicated the letter is your “notice of intent to appeal” the decision to deny further benefits on your Long Term Disability claim. You also requested an extension of the appeal deadline.
The decision letter dated September 12, 2014, outlined the process required to request an appeal. You will need to submit a written letter of appeal outlining the basis of your disagreement. Please include any additional information you would like considered with your letter of appeal. The timeframe for requesting an appeal is 180 days from the date you received the decision letter.
We cannot extend the 180-day appeal timeframe, as this is mandated by ERISA. We must receive your formal written appeal and supporting documentation by March 11, 2014. This is 180 days from the September 12, 2014 decision letter.
The Benefits Center will respond to your other inquiries and requests for information from your claim file.
If you have any questions…
Lead Appeals Specialist
Dear Ms. Stahl:
I am writing in response to your letter dated October 24, 2014. I understand the Appeals area has responded to your request for an extension. I would like to respond to your other questions and requests mentioned in your letter.
Please refer to our letters of June 16, 2014, July 24, 2014, and September 12, 2014. We previously informed you that we needed the following information, which was not provided:
* Disability Status Update form -Please give the Attending Physician section of this form to your physician to complete. The information your physician provides will assist us in the continued evaluation of your claim.
* Estimated Functional Abilities form – Please give this form to your physician to complete. This form asks for information concerning what you are able to physically do each day, which will assist us in the continued evaluation of your claim.
* Medical Records – Please ask your physician to also include all office visit notes, diagnostic tests, and any other medical information relevant to your claim for benefits, along with a list of your physical restrictions and limitations. Please understand that a note from your physician saying you cannot return to work will not be acceptable without the supporting medical data listed above.
The submission of forms alone does not mean your claim will be paid. Whether proof of loss has been provided will depend on our assessment of the information you submit.
We also informed you in our letters of June 16, 2014, and July 24, 2014, that you are not under the care of a physician as required under the policy. You may be treated by any licensed physician qualified to assess your conditions of Temporomandibular Joint pain, chronic pain, and fibromaylagia. (Misspelled in letter.)
We would regard physicians qualified in any of the following areas to be appropriate to assess and treat any conditions you claim are disabling: Family Practice, Internal Medicine, Rheumatology, Physical Medicine and Rehabilitation, Orthopedics, or any other physician who is trained to address the conditions which you state are the basis of your disability.
A nurse practitioner is not qualified to have a medical license in New Mexico; a physician’s assistant may provide services only under the direct supervision of a physician.
A copy of your claim file will be provided to you under separate cover, with the exception of any materials to which Unum is claiming legal privilege. We will also send you a copy of the Claims Manual in effect as of the date of the adverse benefit determination made on your claim, September 12, 2014. The remaining documents you requested, many of which do not exist, will not be provided.
We are unable to accommodate your request to communicate by e-mail. We will continue to send correspondence to you at your address of record by U.S. Mail.
We must decline your request to “hire and pay an independent agency to undertake a market evaluation to determine if ‘Unum’ is in violation of state laws or engages in unfair claim practices.” As previously communicated to you, we take exception to your characterization of the handling of your claim as inappropriate in any way.
Please refer to the adverse decision letter for information on the Appeal process, including the timeframes in which you must submit your request for an appeal.
Ms. Stahl, if you have any questions…
Lead Disability Benefits Specialist
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