Free Health Insurance Grievance Letter [Sample]

Health Insurance Grievance Letter sample

Name of Policy Holder
Address of Policy Holder
City, State, Zip Code

DATE

Director of Claims
Name of Insurance Company
Address of Insurance Company
City, State, Zip Code

RE: Policy Number NUMBER appeal for claim denied. Claim number NUMBER

Dear Name of Claims Director,

You denied payment for a procedure that was prescribed by my doctor NAME OF DOCTOR for me after an automobile accident on DATE. The denial stated that the procedure was not medically necessary.

The denial of this claim was not justified and I am appealing it. The explanation you gave for denying the claim was not adequate, since it didn’t include any report of a medical review of my situation, nor did it include the names and credentials of the insurance representative who did review my claim. 

I would like copies of any medical opinion that caused the denial of my claim, so I can have the proper medical experts respond with the applicability of this treatment for my condition. Without the physiotherapy treatment, I will not have full use of my legs. 

Please review my claim again. Enclosed is a new claim application with the information about the appropriate diagnosis and treatment. I have also enclosed a letter and notes from my physician. 

I would like you to cover all the treatment I need to completely recover from the injuries I sustained in the accident. 

If you need any further information, I can be reached at 555-123-4567 or at Name@email.com. I hope to get a favorable reply from you within 10 days.

Thank you for your attention to this matter. 

Sincerely,

Signature of Policy Holder
Name of Policy Holder Printed
List of Enclosures