Medical Benefit Not Covered

{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}. 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 on the basis that {benefit} is not one of the benefits covered by {health plan}.

I am not contesting the fact that it is not covered but, due to the medical necessity of {benefit}, I am requesting an exception. Enclosed is a statement from my doctor about the justification for this {procedure/diagnosis/prescription}. Without it, {result}. As such, I hope that perhaps I can exchange {benefit} for {other, less used benefit covered by plan}.

Without coverage of {benefit} by {health plan}, I will not be able to make my medical payments, and I will be forced to {drop plan/file for bankruptcy/etc.}. I hope that we can work together to find a solution in this matter. Thank you for your time.

Sincerely,

{Sender Name}

Index of Hardship Letter Examples