Dependent Withdrew Appeal Letter Free Download

Dependent Withdrew

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Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Dependent Denial

Your name and address


Address of Claims review department

RE: Name of Insured:
Plan ID #:
Claim #:

Dear Claims Review Department:

I am writing to you in regards to a claim submitted by [Medical Provider] for [patient]. The charges were rendered on [Date] and totaled [Claim dollar total]. [Health Plan] has denied payment for this claim stating that [patient name] was not eligible under this plan and therefore no benefits were payable.

I have received a statement from [health plan] indicating that I was not a full time student at the time of my treatment [son or daughter] and I therefore have no coverage under this plan. As a result of this decision, this claim is denied.

Choose Most Appropriate Wording. I am a full time student at [name college], but due to a severe illness, I had to withdraw from my courses to attend to my health. I have every intention of returning back to school to complete my studies. This is the very reason I have obtained this insurance to cover any illness that I may have received. Please reconsider my benefit eligibility and consider this claim for payment.

The situation I find myself in is a true exception and should be taken as such in re-instating my coverage. The actions that occurred were truly out of my control and appeal to you to grant me an exception.

Based on this information, this claim was denied in error and I respectfully request that you take this into consideration and reprocess and pay this claim in full.

Thank you for your time and consideration.


[Insured’s Name]