Question 1

What kinds of denials can this letter handle?

Accepted Answer

Health insurance denials of all kinds — denied claims, denied prior authorization, denied medical necessity, denied as experimental or investigational, out-of-network denials, formulary or step-therapy denials — as well as denied or undervalued auto and homeowners property claims. The structure of an internal appeal is the same: address the insurer's stated reason, cite the policy, attach the evidence, ask for the specific outcome.

Question 2

What is the difference between an internal appeal and an external review?

Accepted Answer

An internal appeal is a request to your insurer to reconsider its own decision through its internal appeals unit. Under the Affordable Care Act, most non-grandfathered health plans must offer this and decide within 30 days for pre-service claims (72 hours if urgent) and 60 days for post-service claims. An external review is the next step if the internal appeal is denied: an independent reviewer with no relationship to your insurer takes a fresh look, and their decision is binding on the insurer. This tool helps you write the internal appeal — the first formal step.

Question 3

How long is the appeal deadline?

Accepted Answer

For ACA-governed health plans and most ERISA employer plans, you have 180 days from the date of the denial notice to file an internal appeal. Auto and homeowners deadlines are set by state law and by the policy itself, and typically range from 30 to 90 days. Check the denial notice — insurers are required to print the deadline on it.

Question 4

Do I need a letter from my doctor?

Accepted Answer

For health insurance denials based on medical necessity, a letter of medical necessity from your treating provider is the single highest-value attachment you can include. It does not have to be long — it needs to address the insurer's specific denial reason with clinical detail. Ask your provider's office; many doctors' offices write these regularly. Your appeal letter then references it.

Question 5

Should I threaten to sue or to complain to the state?

Accepted Answer

No. A clear, factual appeal that argues the policy and the facts gets read on the merits. Legal threats tend to get the letter routed to the insurer's legal department, where it sits in a queue. If your internal appeal is denied, an external review (binding) or a complaint to your state's department of insurance are the next channels — and at that point, it is reasonable to consult an attorney.

Question 6

What if my plan is self-funded by my employer?

Accepted Answer

Self-funded employer health plans are governed by ERISA, which gives you the right to request the complete administrative record of documents the insurer used to deny your claim. Submitting that request before or alongside your appeal is a strong move. If the appeal is denied, ERISA litigation has specific rules and short timelines — at that stage, consult a licensed ERISA attorney.

Question 7

Is this legal advice?

Accepted Answer

No. This tool helps you draft a clear letter to your insurer's appeals department using the facts and policy language you provide. It does not interpret the law, evaluate the merits of your case, or guarantee any outcome. For complex denials, suspected bad-faith handling, large dollar losses, or ERISA litigation, consult a licensed attorney or your state's department of insurance.

Question 8

How much does this cost?

Accepted Answer

$29, one time. No subscription, no hidden fees. You get PDF, Word, and clipboard formats, plus inline editing and unlimited re-downloads.

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