Dependent Denial Appeal Letter Free Download

Dependent Denial

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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.

We have received a statement from [health plan] indicating that my [son or daughter] exceeds the age of a covered dependent and therefore has no coverage under this plan. As a result of this decision, this claim is denied.

Choose Most Appropriate Options. I have been advised by [my agent, my human resources director, or a health plan representative] that if my [son or daughter] attends college on a full time basis that the acceptable age of dependent coverage can exceed 21 [enter age]. My [son or daughter] is currently attending [name college] on a full time basis, and I have included a copy of his/her registered units. In addition, my [son or daughter] is financially dependent upon me and as such, can be exempt from your policies restricting coverage. He/she is unable to purchase health insurance on his/her own and my agent/human resources director has indicated that denial of coverage could be waived for this reason.

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]