Insurance Claim Appeal Letter

Insurance Claim Appeal Letter

[Your name, or your business's legal name]
[Mailing address]
[Phone] | [Email]

[Date of this letter]

Sent by [certified mail, return receipt requested, or email to the claims address in the denial letter] [Keep proof of the date you sent it.]

[Adjuster's name], [Adjuster's title]
[Insurance company name]
[Claims department mailing address]

Re: Request for reconsideration of denied claim

• Named insured: [Name exactly as it appears on the declarations page]
• Policy number: [Policy number]
• Claim number: [Claim number]
• Date of loss: [Date of loss]
• Insured property or vehicle: [Property address, or vehicle year, make, model and VIN]
• Denial letter: [Date of the denial letter, and whether it denies all or part of the claim]

Dear [Adjuster's name]:

I am writing to ask [Insurance company name] to reconsider its decision, in your letter dated [date of denial letter], to deny [all / part] of the claim above. The policy covers this loss for the reasons set out below, and I ask you to reverse the denial and pay the claim.

1. What happened

[Two to four sentences of plain fact: what was damaged, when and how it happened, when you found it, and what you did to prevent further damage.]

I reported the loss on [date reported] by [phone / online / to your agent, name]. [Name of adjuster or inspector] inspected on [date of inspection].

2. The reason given for the denial

Your letter gives this reason for the denial:

"[Quote the denial reason exactly, word for word, and note the page or paragraph of the letter.]"

The letter relies on [the policy form number, section, and name of the exclusion, condition, or limitation the insurer cited].

[If the letter gives more than one reason, list each one here and answer each in section 4. The Denial Reason Map sheet lines them up side by side.]

3. The policy language that supports coverage

Coverage grant. The policy states: "[Quote the insuring agreement or coverage section that covers this kind of loss.]" ([Form number], page [page], section [section])

The provision the denial relies on. The full wording is: "[Quote the entire exclusion, condition, or limitation the insurer cited, not only the part in the denial letter.]" ([Form number], page [page])

Why it does not apply here. [Explain in plain terms why the facts of this loss fall outside that provision, and point to the evidence. Example: the exclusion is for damage that happened slowly over time, and the plumber's report says the pipe burst on one day.]

Other policy terms that matter. [Any exception to the exclusion, additional coverage, or endorsement listed on the declarations page that changes the result. Delete this paragraph if there is none.]

4. Response to each denial reason

Reason 1: [Short name for the reason]

• What the denial says: "[Quote]"
• Why it does not apply: [Your answer, tied to the policy wording above]
• Evidence: Exhibit [letter]

Reason 2: [Short name for the reason] [Delete if the letter gives only one reason.]

• What the denial says: "[Quote]"
• Why it does not apply: [Your answer]
• Evidence: Exhibit [letter]

5. Evidence enclosed

• Exhibit A: Denial letter dated [date]
• Exhibit B: Declarations page and the policy pages quoted above ([form numbers])
• Exhibit C: [Number] photos of the damage, taken on [dates]
• Exhibit D: [Report or estimate from a contractor, mechanic, engineer, or other professional], dated [date]
• Exhibit E: [Invoices, receipts, police or fire report, weather report, or repair records]
• Exhibit F: Log of calls, emails, and inspections on this claim

[Send copies and keep the originals. Number every page so the adjuster can cite it.]

6. What I am asking for

1. Reverse the denial and accept coverage for [the loss / the specific items denied].
2. Pay [$ amount] based on [Exhibit D], less the [$ deductible] deductible. [Or, if the amount is not yet known: resume adjusting the claim and send a written estimate.]
3. If you uphold any part of the denial, explain in writing the specific policy provisions and facts you rely on for each part, and send copies of any reports, estimates, photos, or statements the decision is based on.
4. If you need anything else to decide, tell me in writing exactly what it is.

7. Response requested

Please respond in writing by [response date]. [Choose a date that fits your state's claim handling time limits and any appeal deadline stated in the denial letter. These rules vary by state.]

I also ask that [Insurance company name] handle this request within the time limits set by [state] law. [Cite a specific statute or regulation only after you have checked it.]

Please send all communication about this claim to [email or mailing address].

Nothing in this letter waives any of my rights under the policy or the law.

Sincerely,

[Signature]
[Printed name]
[Title, if writing for a business]
[Business name, if any]

Enclosures: Exhibits A to [last exhibit letter]
cc: [Your insurance agent or broker, if any]

Notes for you, delete before sending:

• Check the policy's "Suit Against Us" or "Legal Action Against Us" condition for a time limit to sue. Asking for reconsideration may not pause it.
• If the insurer upholds the denial or does not answer, other options include a complaint to your state insurance department, a licensed public adjuster, or a lawyer. Each has different costs and limits. This template does not recommend one.
• This template is a drafting aid, not legal advice.