ERISA claim file request + appeal letter

Template

{{MEMBER_NAME}}
{{MEMBER_ADDRESS}}
{{MEMBER_PHONE}}
Member ID: {{MEMBER_ID}}
Claim / Reference #: {{CLAIM_NUMBER}}
Date of Service: {{DATE_OF_SERVICE}}
Date of Denial Notice: {{DENIAL_DATE}}

{{INSURER_NAME}}
Appeals and Grievances Department
{{INSURER_APPEAL_ADDRESS}}

Re: Formal Internal Appeal — {{CLAIM_NUMBER}}

Pursuant to 29 CFR 2560.503-1(h)(2)(iii), I request, at no cost, all documents, records, and other information relevant to my claim, including:
  1. The complete claim file;
  2. All internal rules, guidelines, protocols, medical necessity criteria (MCG/InterQual/proprietary), or similar criteria applied;
  3. The identity and credentials of medical or vocational experts consulted;
  4. Any expert reports;
  5. Notes and communications considered in making the determination.

I also formally appeal the denial. My grounds are: {{APPEAL_GROUNDS_SUMMARY}}. Detailed supporting records are enclosed.

Please treat this letter as (a) a document request under 29 CFR 2560.503-1(h)(2)(iii) and (b) a written appeal preserving all rights and remedies under ERISA, including future civil action under 29 USC 1132(a).

Sincerely,
{{MEMBER_NAME}}

Key points before you send it

• You have a legal right to the full claim file at no cost.
• Do not miss the 180-day deadline while waiting on documents.