Disability Appeal Letter Free Download


Disability

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Health Symphony Appeal Letter

Second Level Appeal

Your name and address

Date

Address of Claims review department

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

Dear Claims Review Department:

On [date of denial], I was denied additional disability payment of my claim. However, I believe this was in error as I am still under the care of my physician for [indicate illness or injury] and benefits should still be payable.

The reason for the denial of my claim is unclear as it was not adequately described as to why my claim has ended. In order to properly evaluate your decision, please provide me with the name and credentials of the insurance representative who made the decision to not pay for my claim and an outline of the records reviewed and any other information used to support your decision.

I am prepared to provide you with supporting documentation from my attending physician who will support my request to continue the approval of my claim. I look forward to your response to this letter and I am requesting your full reconsideration of my claim.

Sincerely,

[Insured Name]

Enclosures:
A statement of medical necessity from your medical provider
A copy of your original appeal letter
Any additional information to justify your position