Insurance Curator A denied claim is stressful, but most denials can be resolved if you respond quickly, document carefully, and follow a clear appeal strategy. This guide gives practical steps, ready-to-use templates, and escalation criteria so you know when to negotiate, hire experts, or file a regulator complaint.
Quick overview — what this guide covers
- Common denial reasons and the best immediate responses
- Evidence checklist to support appeals
- Appeal templates (initial appeal and demand letter) you can copy and customize
- When to escalate to an independent adjuster, attorney, or your state Department of Insurance
- Links to deeper resources in the Best Insurance content pillar for continued reading
Common reasons claims are denied (and what to do first)
| Denial reason | Why it happens | First-step fix |
|---|---|---|
| Coverage exclusion | Policy fine print excludes the loss type | Review policy; ask insurer to cite specific policy provision |
| Late filing or missed deadline | FNOL (First Notice of Loss) or proof submitted late | Provide proof of timely notice (emails, calls); request deadline exception |
| Lack of coverage/eligibility | Claim falls outside policy period or named insured | Confirm policy period, endorsements, and named insureds |
| Insufficient documentation | Missing receipts, photos, medical records | Submit a complete packet (see checklist below) |
| Pre-existing condition | Carrier claims condition predated coverage | Provide prior medical or maintenance records showing change/new cause |
| Fraud or misrepresentation allegation | Carrier alleges wrong statements on application/claim | Request specifics and show evidence that statements were accurate |
| Policy cancellation/non-payment | Premium lapse or cancellation | Provide proof of payment or request reinstatement evidence |
Immediate steps after a denial
- Read the denial letter carefully — note the denial code, date, and appeal deadline.
- Contact the adjuster and request a written explanation if not provided.
- Assemble the documentation checklist below before filing an appeal.
- Consider the appropriate escalation path based on complexity and dollar amount.
For detailed timelines and what to expect, see: How Long Do Claims Take? Typical Timelines for Auto, Home, Health, and Disability Claims.
Documentation checklist (must-have items for any appeal)
| Category | Examples of documents |
|---|---|
| Proof of loss | Claim form, FNOL confirmation, policy number |
| Evidence of damages | Photos, videos, repair estimates, appraisal reports |
| Financial records | Receipts, invoices, bank statements, pay stubs (for income loss) |
| Medical records | ER notes, treatment summaries, diagnostic tests, provider bills |
| Communication log | Dates, times, names, and summaries of calls/emails/texts with insurer |
| Policy documents | Full declaration page, endorsements, prior correspondence |
| Third-party evidence | Police reports, witness statements, independent adjuster report |
Also review the step-by-step claims checklist for best practices: Step-by-Step Best Insurance Claims Checklist: From First Notice of Loss to Final Settlement.
Appeal templates you can copy and customize
Use clear, factual language. Include policy number, claim number, denial reference, and attach supporting documents.
1) Short initial appeal letter (for straightforward denials)
[Date]
Claim Number: [claim number]
Policy Number: [policy number]
Insurer: [insurer name]
Adjuster: [adjuster name]
To Whom It May Concern,
I am appealing the denial dated [denial date] for the above-referenced claim. The denial states: “[quote denial reason].” I disagree because [brief factual reason — e.g., “the policy’s water damage endorsement covers sudden burst pipes; the damage was caused by a burst pipe on [date].”]
Enclosed are the following supporting documents:
- Proof of loss / FNOL confirmation
- Photos showing the burst pipe and water damage
- Repair estimate from [contractor name]
- Relevant pages of the policy (declarations and endorsements)
Please reopen and re-evaluate the claim. I request written confirmation of receipt and an expected timeline for your reconsideration.
Sincerely,
[Your name, contact info]
2) Demand letter for underpayment or wrongful denial (stronger tone)
[Date]
Claim Number: [claim number]
Policy Number: [policy number]
To [Claims Manager / Appeals Unit]:
This letter is a formal demand for payment for the above-referenced claim. On [date], my claim was denied/underpaid for the following stated reason: [quote]. The denial is incorrect for these reasons:
1) [Legal/policy argument — e.g., specific clause entitles coverage]
2) [Evidence summary — e.g., independent estimate, medical records]
Attached: itemized estimate, independent adjuster report, medical bills, communications log.
If the insurer does not provide a full, written reversal or payment of $[amount] within 30 days, I will escalate by: filing a complaint with the [State Department of Insurance], sharing documentation on policyholder review sites, and seeking independent appraisal or legal remedies.
Sincerely,
[Name, address, phone, email]
For more negotiation templates and when to hire an independent adjuster, see: Claims Negotiation Templates: Demand Letters, Repair Estimates, and When to Hire an Independent Adjuster.
When to hire experts (independent adjuster or attorney)
Consider hiring an independent adjuster or attorney if:
- The claim involves large losses (total loss, major structural damage, long-term disability). See tips: Best Insurance for Complex Claims: Expert Tips for Total Loss, Liability, and Long-Term Disability Cases.
- The insurer refuses to engage or provides vague technical reasons.
- You suspect bad faith (deliberate delay or misrepresentation).
- The insurer's valuation differs significantly from independent estimates.
Independent adjusters provide an objective damage assessment; attorneys specialize in bad faith and complex policy interpretation.
When to escalate to regulators — an escalation playbook
If internal appeals fail, escalate to your state regulator. Use this checklist before filing:
- Confirm final denial in writing and keep the appeal denial reference.
- Compile a complete appeal packet (denial letters, communications log, all evidence).
- Include a concise summary page with key dates, amounts, and why you believe the denial is incorrect.
- Note your requested remedy (payment amount, re-opening claim, appraisal).
File a complaint with your state Department of Insurance if:
- The insurer missed statutory deadlines, or
- The insurer engaged in deceptive practices, or
- You believe the insurer acted in bad faith and you have a complete record.
Follow the official steps in: Escalation Playbook: When to File a Complaint with Your State Department of Insurance and How to Prepare.
Practical tips to avoid denials and speed resolution
- Know your insurer’s claims reputation and payout speed before an event — research rankings and payout times: Best Insurance for Claims Handling: Insurer Rankings, Average Payout Times, and How to File a Fast Claim.
- Keep a claims folder (digital + paper) with policy, contacts, photos, and receipts.
- Use trust signals when selecting insurers — AM Best ratings, privacy practices, transparency scores: Best Insurance Trust Signals: Financial Strength (AM Best), Privacy Practices, and Transparency Metrics.
- Monitor customer service metrics and reviews to choose an insurer that handles claims well: Best Insurance Customer Service: JD Power Scores, Call Center Metrics, and Real Policyholder Reviews.
Final checks & next steps
- Act fast: appeal deadlines are critical.
- Keep communications recorded and courteous but firm.
- Escalate strategically — appraisal, independent adjuster, attorney, regulator — based on the claim's value and complexity. For staged guidance on selecting insurers and comparing complaint ratios, see: How to Choose an Insurer With the Best Claims Reputation: Complaint Ratios, Social Proof, and Case Studies.
If you need a tailored appeal letter or a checklist review for your specific denial, provide the denial letter text and key dates and I’ll draft a customized appeal you can send.