TEXAS STATE OFFICE OF ADMINISTRATIVE HEARINGS

_________

In the Matter of:

[CLAIMANT FULL LEGAL NAME],

Claimant,

v.

[INSURANCE COMPANY LEGAL NAME],

Respondent.

PETITION AND REQUEST FOR ADMINISTRATIVE APPEAL

(Disability Insurance Benefits)

Effective Date of Filing: [DATE]
Agency Tracking/Claim No.: [NUMBER]

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
3.1 Statement of Jurisdiction and Governing Law
3.2 Timeliness and Exhaustion of Internal Remedies
3.3 Issues Presented for Review
3.4 Summary of Medical Evidence
3.5 Summary of Vocational Evidence
3.6 Requested Relief
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1.1 Parties
 a. Claimant: [CLAIMANT FULL LEGAL NAME], an individual residing at [ADDRESS].
 b. Respondent: [INSURANCE COMPANY LEGAL NAME], a [STATE OF INCORPORATION] insurance company duly licensed to transact disability insurance in Texas, principal office at [ADDRESS].

1.2 Recitals
 A. On [ORIGINAL POLICY EFFECTIVE DATE], Respondent issued Disability Insurance Policy No. [POLICY NUMBER] (the “Policy”).
 B. Claimant became disabled on [DATE OF DISABILITY] within the meaning of the Policy and Texas disability-insurance law.
 C. Respondent denied or terminated Claimant’s benefits by written notice dated [DATE OF DENIAL] (the “Adverse Determination”).
 D. Claimant timely exhausted all mandatory internal appeal procedures as confirmed by Respondent’s final denial dated [DATE OF FINAL DENIAL].
 E. Claimant now petitions this Administrative Court for de novo review of the Adverse Determination pursuant to applicable Texas state disability-insurance statutes and regulations.

1.3 Purpose
 This Petition seeks (i) reversal of the Adverse Determination, (ii) reinstatement and payment of all past-due benefits together with statutory interest, and (iii) any further relief the Administrative Court deems just and equitable.

II. DEFINITIONS

“Administrative Court” means the Texas State Office of Administrative Hearings (“SOAH”) or other designated tribunal with subject-matter jurisdiction over this appeal.

“Adverse Determination” has the meaning set forth in Recital C.

“Benefits” means the monthly disability income payments, cost-of-living adjustments, and ancillary benefits available under the Policy.

“Medical Evidence” means all treating and consulting physician records, diagnostic imaging, laboratory results, hospital records, and expert opinions submitted with or incorporated by reference into this Petition.

“Policy” has the meaning set forth in Recital A.

“Vocational Factors” means Claimant’s age, education, work experience, transferable skills, and the functional limitations established by the Medical Evidence.

[// GUIDANCE: Expand or modify definitions as needed. Ensure every capitalized term is used consistently.]

III. OPERATIVE PROVISIONS

3.1 Statement of Jurisdiction and Governing Law

This Administrative Court has jurisdiction under Tex. Ins. Code Title 8 and 28 TAC § [SECTION], and all matters herein are governed by Texas law (“state_disability_law”) unless superseded by controlling federal law.

3.2 Timeliness and Exhaustion of Internal Remedies

Claimant filed this Petition within [●] days of receipt of the Adverse Determination, satisfying the 30-day statutory filing window. All contractual and statutory prerequisites to external appeal have been met.

3.3 Issues Presented for Review

1. Whether Claimant meets the Policy’s definition of “Total Disability.”
2. Whether Respondent’s reliance on [SPECIFIC REASON FOR DENIAL] lacked substantial evidence.
3. Whether Respondent failed to give proper weight to vocational considerations as required under Texas law.

3.4 Summary of Medical Evidence

• Treating Physician: [NAME, SPECIALTY] — Narrative report dated [DATE] confirming permanent work restrictions of [DETAILS].
• Diagnostic Imaging: MRI ( [DATE] ) showing [KEY FINDINGS].
• Independent Medical Evaluation: [NAME] on [DATE] confirming inability to perform any occupation for which Claimant is reasonably qualified.

[// GUIDANCE: Attach full medical records as Exhibit A. Provide citation to page/paragraph for each key finding.]

3.5 Summary of Vocational Evidence

• Vocational Expert Report of [NAME] dated [DATE] concluding that, considering Claimant’s age ([AGE]), education ([EDUCATION LEVEL]), and functional limitations, no gainful employment exists in the regional economy.
• Labor Market Survey dated [DATE] corroborating absence of suitable positions.

[// GUIDANCE: Attach vocational file as Exhibit B. Demonstrate integration of medical restrictions with vocational factors.]

3.6 Requested Relief

a. Reversal of the Adverse Determination;
b. Immediate reinstatement of monthly Benefits retroactive to [DATE];
c. Lump-sum payment of past-due Benefits plus statutory interest;
d. Continuing Benefits for so long as Claimant remains disabled under the Policy;
e. Attorney’s fees and costs as authorized by Tex. Ins. Code § 542.060;
f. Any other relief in equity or law deemed appropriate.

IV. REPRESENTATIONS & WARRANTIES

4.1 Claimant represents that all factual statements herein are true and correct to the best of Claimant’s knowledge and belief and are supported by the attached Exhibits.

4.2 Claimant warrants that no material fact relevant to eligibility for Benefits has been concealed or misrepresented.

4.3 These representations and warranties survive the Administrative Court’s final disposition of this matter.

V. COVENANTS & RESTRICTIONS

5.1 Supplementation of Record
 Claimant covenants to supplement the record with additional medical or vocational evidence that becomes available prior to final hearing.

5.2 Cooperation
 Claimant agrees to submit to reasonable, statutorily-authorized medical examinations upon order of this Administrative Court.

5.3 Notice Obligations
 Each party shall provide prompt written notice of any change in address, representation, or legal status that could affect these proceedings.

VI. DEFAULT & REMEDIES

6.1 Events of Default by Respondent
 a. Failure to timely file an Answer within [20] days of service;
 b. Failure to produce the complete administrative claim file within [30] days of receipt of this Petition;
 c. Failure to comply with discovery orders of this Administrative Court.

6.2 Remedies
 Upon any uncured default, Claimant may request:
  i. Entry of default judgment awarding Benefits;
  ii. Monetary sanctions, including attorney’s fees;
  iii. Evidentiary presumptions adverse to Respondent.

VII. RISK ALLOCATION

7.1 Limitation of Liability
 Respondent’s liability is strictly limited to the aggregate Benefit amount payable under the Policy, together with any statutory penalties expressly provided by Texas law.

7.2 Indemnification
 Not applicable pursuant to the parties’ relationship and the metadata directive.

VIII. DISPUTE RESOLUTION

8.1 Governing Law
 This appeal shall be decided under “state_disability_law,” specifically the Texas Insurance Code and related administrative regulations.

8.2 Forum Selection
 All proceedings shall be held before SOAH (or other designated Administrative Court) sitting in [COUNTY], Texas.

8.3 Arbitration
 Arbitration is not available for this matter under Texas law.

8.4 Jury Waiver
 Because this is an administrative proceeding, trial by jury is neither available nor requested.

8.5 Injunctive Relief
 The Administrative Court is expressly empowered to order immediate payment of Benefits as provisional or final relief.

IX. GENERAL PROVISIONS

9.1 Amendment
 This Petition may be amended once as a matter of right within seven (7) days of filing and thereafter only upon leave of the Administrative Court.

9.2 Assignment
 Neither this Petition nor any Benefits hereunder may be assigned without prior written consent of Respondent, except as permitted by law (e.g., for child-support enforcement).

9.3 Severability
 If any provision herein is held invalid, the remaining provisions shall remain in full force and effect.

9.4 Integration
 This document, together with attached Exhibits, constitutes the complete petition for appeal and supersedes all prior submissions in this matter.

9.5 Electronic Signatures
 Electronic or facsimile signatures shall be given the same legal effect as original signatures, consistent with Tex. Bus. & Com. Code § 322.007.

X. EXECUTION BLOCK

Executed this ___ day of _, 20.

CLAIMANT

[CLAIMANT FULL LEGAL NAME]
[Phone] | [Email]

COUNSEL FOR CLAIMANT (if any)

[ATTORNEY NAME], State Bar No. [NUMBER]
[LAW FIRM NAME]
[ADDRESS]
Tel: [PHONE] | Email: [EMAIL]

[// GUIDANCE: Insert Notary block if the Administrative Court requires verification. Check SOAH or agency-specific rules.]

CERTIFICATE OF SERVICE

I certify that on this ___ day of _, 20, a true and correct copy of this Petition and all Exhibits was served on Respondent by [CERTIFIED MAIL / EMAIL / ELECTRONIC FILING SYSTEM] to:

[NAME], Authorized Representative
[INSURANCE COMPANY]
[ADDRESS]

[NAME], Counsel for Claimant

[// GUIDANCE:

1. Appeal Procedures – Sections 3.1–3.3 track Texas administrative-appeal prerequisites and preserve timeliness arguments.
2. Medical Evidence Requirements – Section 3.4 provides a structured checklist; attach full medical file as Exhibit A.
3. Vocational Factors – Section 3.5 ensures ERISA-style “own-occupation/any-occupation” analyses are documented, a frequent insurer deficiency.
4. Customization – Replace all bracketed placeholders. Verify agency-specific rules (TDI vs. SOAH) for filing deadlines, page limits, and verification language.
5. Risk Management – Section 7.1 caps potential insurer arguments that extra-contractual damages exceed policy limits, aligning with metadata “liability_amount.”
6. Statutory References – Only foundational Texas provisions are cited in compliance with the Citation Policy. Practitioners should add pinpoint cites as needed.
   ]