{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 have been informed that my disability claim was denied, and therefore all coverage of {claim one} and {claim two} have been denied as well.
The coverage rejection sent to me on {date} indicated that my disability claim was denied due to {reason}. I would like to ask you to reconsider, as I believe that my situation is more severe than you realize. Attached is a physician's statement affirming that my {condition} makes me unable to {work, stand, etc.}. As I am currently unable to work, I have no means of paying my medical bills, making rent, and buying food.
{Brief description of condition and validity of claim}.
If you are unwilling or unable to reconsider this claim, please send me the name and contact information for the representative who rejected my request, as I require further information on the process involved.
Sincerely,
{Sender Name}
Download this hardship letter — free!
Formatted and ready to use with Microsoft Word, Google Docs, or any other word processor that can open the .DOC file format.
Index of Hardship Letter Examples