Medical Benefit Extension

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

{Date}

Dear {Insurance Representative}:

I am writing with regards to the benefits offered by my health plan, {plan and policy number}. My health plan currently only allows {maximum number} therapy sessions for {condition}, and I would like to request an extension of these benefits.

On {date}, I had {an accident/major surgery/injury}. The result was that {I can no longer work/I'm unable to move/I have to walk with a cane, etc.}. Aside from these restrictions, I also {list of debilitating or painful symptoms}. My doctor has recommended {number} {therapy type} sessions to rehabilitate and heal. It is {his/her} professional opinion that with this therapy, I could {positive projected result}. Enclosed is {his/her} statement.

Unfortunately, my health plan only covers {number} therapy sessions, meaning that I will be forced to pay {amount} out of pocket. Enclosed are my bank statements and income stubs to prove that I will be unable to meet these expenses, and therefore unable to continue therapy. If that is the case, I will be forced to {file for bankruptcy, go on disability, quit my job, etc.}. I am trying to avoid such extreme circumstances, and as such I am requesting an extension of my benefits to {benefits required}.

I hope that we can reach an agreement, as this therapy is medically necessary for me to continue as a functioning member of society. Thank you for your time and consideration.

Sincerely,

{Sender Name}

Index of Hardship Letter Examples