[Your name]
[Your address]
[Your city, state, ZIP]
[Your phone number]

[Date]

Attn: Director of Claims
[Name of insurance company]
[Insurance company address]
[City, state, ZIP]

Re:     Patient: [patient name]

Policy: [insurance policy number]
Insured: [name of insured person]
Treatment dates: [admission date] - [discharge date]
Amount: [total charges]

Dear [Mr./Ms./Director of Claims name, if available],

On [date of first letter], I appealed a denied claim for [name of insured person]. A copy of that claim and appeal letter is enclosed.

I have not heard from you [or the claim remains denied; or give other reason here]. I am requesting a hearing to resolve this matter. I feel that denial and nonpayment of this claim has jeopardized [my/name of insured person('s)] access to health care [or give other reason here].

If I do not hear from you within 10 days, I am referring this matter to the consumer assistance division of the [state name] Attorney General's Office, [state name] Department of Insurance, and may also seek private legal counsel.

In my opinion, you have failed in your obligation to provide acceptable and adequate service. Be assured that I intend to use every available means to get this matter resolved.

Sincerely,

[your signature here]