Free Legal Forms
| Denial of Medical Insurance Claim, Response |
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Name Insurance Coverage In: Plan #: Family Name Covered Under Plan: Individual Covered & Subject to This Letter: Social Security Number of Individual: Their Case Number, if one is assigned: Dear Sir or Madam: On ______________ (Date), a claim was filed with you regarding _________________. We received notice, see Exhibit 1 attached, that the claim was denied. This claim should not have been denied for the following reasons: Additional documentation is also attached; see Exhibit 2, supporting our claim. Please review the new materials submitted in order to reconsider your denial of the claim. Please call me after you have reviewed the information I have submitted. Please call us in the next few days so we can both take care of this promptly. With best regards, _______________ Writer _______________ Family Member Under Whose Name the Plan is listed Enclosures: Exhibit 1 & 2. |
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