Insurance Appeal Letter Template: A Structure That Works

Writing an effective insurance appeal letter is harder than it looks. You need to present your case clearly, organize evidence effectively, and sound professional without being legalistic. This template provides a structure proven to work for insurance appeals.

Use this template as your guide. Customize it for your situation, but keep the basic structure.

The Complete Appeal Letter Template

[Your Header]

[Your Name] [Your Address] [Your City, State ZIP Code] [Your Phone Number] [Your Email]

Date: [Today's Date]

[Insurance Company Header]

[Insurance Company Name] Appeals Department [Their Address from denial letter]

Re: APPEAL OF CLAIM DENIAL Policy Number: [Your Policy Number] Claim Number: [Your Claim Number] Date of Service: [When you received service] Date of Denial: [When insurance denied it] Claimed Amount: [What you're claiming]

[Opening Paragraph]

I am writing to formally appeal the denial of my claim dated [denial date]. I believe [Insurance Company] made an error in denying my claim for [brief description of what you claimed], and I request that the company reverse this decision and approve my claim.

[Your Situation - Section 2]

[Describe your medical situation, injury, or event briefly. This section explains context.]

On [date], I [experienced the event/received treatment for the diagnosis]. Specifically:

• I have been diagnosed with [diagnosis]
• I experienced [specific symptoms]
• I [received treatment from Doctor X]
• My condition required [type of treatment claimed]

This situation is covered under my policy, which [reference relevant coverage].

[Insurance's Stated Reason for Denial - Section 3]

[Quote or summarize exactly what insurance said was the reason for denial.]

In their denial letter dated [date], [Insurance Company] stated my claim was denied because: "[exact quote from denial letter]"

[Why Insurance's Reason Is Wrong - Section 4]

[This is your core argument. Address directly why their stated reason is incorrect.]

I respectfully disagree with this determination for the following reasons:

Reason 1: [Primary reason insurance is wrong]

[Explain specifically why this reason doesn't apply to your claim]

Example: "Insurance states the claim is for a non-covered service. However, my policy explicitly covers [service]. The policy states on page 15: '[exact quote].' This language clearly covers my situation."

Reason 2: [Secondary reason if applicable]

[Explain your second strongest argument]

Example: "Insurance also states that pre-authorization was required. However, my condition was emergent, requiring immediate treatment. My policy states on page 8 that emergency treatment 'does not require pre-authorization.' My treatment was clearly emergent due to [specific facts]."

Reason 3: [Third reason if applicable]

[Your third strongest point, if you have one]

Example: "Additionally, my physician has documented that treatment was medically necessary. The attached letter from [Doctor Name] specifically addresses Insurance's concern and explains why treatment was necessary for my condition."

[Supporting Evidence - Section 5]

[List all documents you're attaching, numbered clearly. Makes it easy for insurance to track everything.]

I am enclosing the following documentation to support my appeal:

1. [Document 1 - e.g., "My complete policy document, pages 1-50"]
2. [Document 2 - e.g., "Denial letter dated [date]"]
3. [Document 3 - e.g., "Medical records from [Doctor], dated [dates]"]
4. [Document 4 - e.g., "Physician letter from [Doctor] dated [date]"]
5. [Document 5 - e.g., "Operative report from [Hospital], dated [date]"]
6. [Document 6 - e.g., "My claim submission, dated [date]"]
7. [Document 7 - e.g., "Insurance's previous correspondence"] [etc.]

All attached documents are clearly numbered and correspond to references in this letter.

[Specific Request - Section 6]

[Be absolutely clear about what you want insurance to do.]

Based on the above, I request that [Insurance Company]:

1. Reverse the denial of my claim for [service/treatment]
2. Approve the claim in the amount of $[amount]
3. Process payment to [me / the provider]

If [Insurance Company] has additional questions or requires additional information, I am available at [phone number] or [email]. Please contact me directly rather than delaying resolution.

[Timeline Reference - Section 7]

[Note your urgency and timeline if applicable. Insurance responds faster when they understand the time-sensitive nature.]

[Optional: "This matter is time-sensitive because [reason: ongoing medical need, surgical appointment scheduled, etc.]. I appreciate your prompt attention to this appeal."]

[Closing]

Thank you for your careful review of this appeal. I look forward to [Insurance Company]'s reconsideration and reversal of this claim denial.

Sincerely,

[Your Signature] [Your Typed Name]

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[Enclosures: Numbered list of documents you're attaching]

Key Principles for Your Appeal Letter

Keep It Concise

Your letter should be no more than 2-3 pages. Insurance reviewers are busy. Make your points clearly and move on.

Be Professional and Respectful

Avoid:

• Angry language ("This is outrageous!")
• Accusations ("You're being dishonest")
• Emotional appeals ("I'm suffering terribly")

Use:

• Professional tone
• Respectful language
• Factual, clinical descriptions
• Logical arguments

Focus on Policy Language

Always reference your actual policy. Quote the relevant sections. Show that coverage is promised in the policy language itself.

Example: "My policy clearly states on page 15: '[quote].' This language covers my situation."

Address Insurance's Specific Stated Reason

Don't argue generally about your condition. Directly address what insurance said. If they said treatment wasn't medically necessary, show why it was. If they said it's not covered, show where the policy covers it.

Organize Clearly

Use numbered sections and bullets. Make your argument easy to follow. Insurance reviewers may be reading dozens of appeals daily—make yours clear and easy to understand.

Include All Supporting Evidence

Attach everything that supports your position. Number it clearly. Reference it in your letter by number.

Don't Include Irrelevant Information

Keep focus on the denial reason. If insurance said treatment wasn't medically necessary, include medical evidence. Don't include irrelevant personal information.

Common Mistakes to Avoid

Mistake 1: Rambling Narrative

Don't write: "I was having these symptoms for weeks and it was really frustrating. I went to the doctor and they said..."

Do write: "I was diagnosed with [condition] on [date]. My physician recommended [treatment] because [medical reason]."

Mistake 2: Forgetting to Cite Your Policy

Don't: Argue about medical necessity without showing the policy covers the treatment.

Do: Quote the policy language that covers your situation, then explain why you meet that coverage requirement.

Mistake 3: Missing Crucial Documents

Don't: Mention a physician letter but forget to attach it.

Do: Include a numbered list of every document attached. Ensure each one is actually attached.

Mistake 4: Being Unclear About What You Want

Don't: Close with "I hope you'll reconsider."

Do: "I request that [Insurance] reverse the denial and approve payment of $[amount]."

Mistake 5: Using Emotional Language

Don't: "I'm devastated by this denial" or "This is clearly unfair."

Do: "Insurance's denial appears to misapply the policy coverage, as detailed above."

Mistake 6: Insulting the Insurance Company

Don't: "Your company is being dishonest" or "Your reviewers are incompetent."

Do: "Insurance may have inadvertently misinterpreted the policy language" or "This determination appears to conflict with the policy terms."

Customizing the Template for Different Claim Types

For Medical Claims

Emphasize medical necessity. Include medical documentation. Quote your physician.

For Dental Claims

Emphasize medical purpose vs. cosmetic. Include objective findings (measurements, X-rays, clinical notes).

For Disability Claims

Emphasize functional impairment. Include objective evidence of inability to work.

For Life Insurance Claims

Focus on policy language about coverage. Include death certificate and medical cause of death documentation.

For Travel Claims

Provide timeline evidence. Include receipts. Show you couldn't travel due to covered event.

Tone Guidelines

Your appeal letter should be:

Empathetic: Show that you understand insurance needs to manage claims fairly.

"I understand that insurance companies must carefully review claims for medical necessity and policy compliance."

Respectful: Assume insurance made an honest error, not a malicious one.

"I believe Insurance may have inadvertently..."

Clear: Be direct and easy to understand.

"My policy covers hospitalization for cancer. I was hospitalized for cancer. Insurance should cover this claim."

Professional: Sound educated and organized.

Not: "Y'all ain't paying this claim fairly."

Yes: "Insurance's denial appears to misapply the policy terms."

After You Send Your Appeal

• Keep a copy for your records
• Note the date you sent it
• Request confirmation of receipt if sending by mail (certified/registered mail with return receipt)
• Set a calendar reminder to follow up if you don't hear back in 30 days
• Don't send the exact same letter twice—add new information if needed

Getting Help Writing Your Appeal Letter

Writing an effective appeal letter requires balancing multiple elements: legal policy language, medical facts, emotional situation, and persuasive argument. Getting it right matters enormously—one weak letter means your denial stands.

ClaimBack's AI can take your situation, your policy, your denial, and your supporting evidence, and draft a complete appeal letter using this proven structure. You review, customize, and submit it yourself—maintaining full control while ensuring your letter is as effective as possible.

Get help drafting your appeal letter →

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Disclaimer: ClaimBack provides AI-generated appeal assistance for informational purposes only. ClaimBack is not a law firm and does not provide legal advice. Always review your appeal letter before sending and consider professional advice for complex or high-value claims.

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