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[Your name]


[Your address]

[Your city, state, ZIP]

[Your phone number]




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.




[your signature here]

author image
Michelle Megna


Michelle, the former editorial director, insurance, at QuinStreet, is a writer, editor and expert on car insurance and personal finance. Prior to joining QuinStreet, she reported and edited articles on technology, lifestyle, education and government for magazines, websites and major newspapers, including the New York Daily News.