Medical Benefit Dependent Denial

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

{Date}

Dear {Insurance Representative}:

I am writing with regards to a claim filed by {Provider} on {date} for {Patient}. The claim number is {number} and the total amount billed was {amount}. The claim has been denied in its entirety on the basis that the patient is no longer covered by the health plan as of {date}.

I respectfully contest the decision reached concerning {Patient}'s dependent status. {He/she} is my {daughter/son} and did turn 26 years old on {date}, as the rejection states. However, {he/she} is still completely financially dependent on me because {he/she is disabled, a student, etc.}. Enclosed is {student registration, disability status papers, etc.} that prove the nature of {his/her} current condition.

Therefore, I request reconsideration of this claim, and I ask that {Patient} be allowed to remain on my health plan until {projected date}. Thank you very much for your time and consideration.

Sincerely,

{Sender Name}

Index of Hardship Letter Examples