Hardship Letter Insurance Network

{Your Name}
{Your Address}
{Your Phone #}
{Your Account #}

{Date}

To Whom It May Concern:

My name is {Name} and I have a {plan type} insurance policy with your company under the account number {number}. I am writing to request leniency with regards to my {visit/operation/etc.} on {date} due to financial hardship.

On {date}, I had a {doctor visit/operation/surgery/etc.} at {location} in {City, State}. The total bill was {amount} but I was told by {hospital/clinic} that {doctor/surgeon} was in my insurance's network and that I would only pay {amount} of the total cost. However, on {date} I received a bill for the full amount and was told that the {doctor/surgeon} was not covered by my plan.

This unforeseen amount will completely deplete the savings that I have, savings that I need to pay for {food/rent/schooling/etc.}. If I have to pay the full amount, I will be forced to {foreclose/declare bankruptcy/drop out of school/etc.}. I don't know if a miscommunication occurred or if I was simply misinformed, but I respectfully ask for leniency regarding this debt.

Thank you for your consideration. Attached are my financial statements, payment stubs, loan records, and medical bills, along with a copy of my insurance policy and network coverage.

Thank you,

{Sender Name}

Index of Hardship Letter Examples