INSURANCE CLAIM DENIAL APPEAL & DEMAND FOR RECONSIDERATION
(California – Comprehensive Template)
[// GUIDANCE: This template is drafted as a formal, court-ready demand/appeal letter addressed to an insurer that has issued a written denial. It is intentionally more robust than a simple correspondence so that it can (1) satisfy all statutory “written notice” prerequisites, (2) preserve bad-faith claims, and (3) become an exhibit in any subsequent litigation or arbitration. Delete or tailor bracketed language as appropriate.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title. Insurance Claim Denial Appeal & Demand for Reconsideration (the “Appeal”).
1.2 Parties.
(a) Claimant/Insured: [INSURED LEGAL NAME], a [STATE] [Entity Type / Individual], policyholder under Policy No. [POLICY NO.] (the “Policy”).
(b) Insurer: [INSURER LEGAL NAME], NAIC No. [_] (the “Insurer”).
1.3 Effective Date. This Appeal is effective as of [DATE] (the “Effective Date”).
1.4 Jurisdiction & Governing Law. This Appeal and any ensuing dispute are governed by the laws of the State of California, including but not limited to the California Insurance Code and the Fair Claims Settlement Practices Regulations, 10 Cal. Code Regs. §§ 2695.1 et seq.
1.5 Recitals.
A. On [DATE OF LOSS], the Claimant sustained a loss described herein.
B. The Claimant timely submitted Claim No. [CLAIM NO.] (the “Claim”) to the Insurer.
C. On [DATE OF DENIAL LETTER], the Insurer issued a written denial (the “Denial Letter”).
D. Pursuant to California law and the Policy, the Claimant hereby appeals the Insurer’s decision and demands full, prompt payment.
2. DEFINITIONS
For ease of reference, capitalized terms have the meanings set forth below. Terms used in the singular include the plural and vice-versa.
“Appeal Window” – The period within which this Appeal must be filed, typically not less than sixty (60) days from receipt of the Denial Letter unless the Policy specifies otherwise.
“Bad Faith” – Any act or omission by the Insurer that constitutes a breach of the implied covenant of good faith and fair dealing under California common law, or that violates Cal. Ins. Code § 790.03(h).
“Business Day” – Any day other than a Saturday, Sunday, or California-recognized legal holiday.
“Claim File” – The complete file maintained by the Insurer with respect to the Claim, as required by 10 Cal. Code Regs. § 2695.3.
“Covered Loss” – The direct physical, financial, or other loss that is insured under the Policy.
“Demand Amount” – The total amount sought herein, inclusive of policy benefits, interest, statutory penalties, and attorneys’ fees, currently estimated at $[AMOUNT] and subject to revision.
“Denial Letter” – The Insurer’s written correspondence dated [DATE] denying the Claim.
“Policy Limits” – The maximum liability of the Insurer for the Covered Loss, being $[LIMITS], subject to all applicable endorsements.
3. OPERATIVE PROVISIONS
3.1 Timeliness. This Appeal is submitted within the Appeal Window and therefore is timely under California law and the Policy.
3.2 Bases for Appeal.
(a) Errors of Fact. The Denial Letter relies on inaccurate or incomplete facts, including [BRIEF SUMMARY].
(b) Errors of Policy Interpretation. The Insurer misconstrues Policy provisions [CITE POLICY SECTIONS].
(c) Statutory Non-Compliance. The Insurer failed to (i) fully investigate all bases of the Claim, (ii) respond within the 40-day period mandated by 10 Cal. Code Regs. § 2695.7(b)(1), and/or (iii) provide a detailed factual and legal basis for denial as required by 10 Cal. Code Regs. § 2695.7(b)(1)(B).
(d) Bad Faith Conduct. The foregoing acts and omissions constitute Bad Faith.
3.3 Demand for Action. The Claimant hereby demands that the Insurer:
(i) set aside the Denial Letter;
(ii) accept coverage for the Claim; and
(iii) remit the Demand Amount within ten (10) Business Days of receipt of this Appeal.
3.4 Supporting Documentation. Attached hereto as Exhibit A is a true and correct copy of the Denial Letter. Additional proof of loss, invoices, expert reports, and photographs are attached as Exhibits B-F.
[// GUIDANCE: Add or remove exhibits as needed, label sequentially, and cross-reference correctly.]
3.5 Conditions Precedent. Upon the Insurer’s written acknowledgment of coverage, the Claimant shall cooperate in any further reasonable investigation, including an examination under oath (“EUO”) if required under the Policy.
4. REPRESENTATIONS & WARRANTIES
4.1 Representations of Claimant. The Claimant represents and warrants that:
(a) all statements herein are true and correct to the best of their knowledge;
(b) the Claimant has complied with all material post-loss obligations under the Policy; and
(c) no part of the Claim is fraudulent or overstated.
4.2 Survival. The foregoing representations and warranties shall survive any payment or settlement.
5. COVENANTS & RESTRICTIONS
5.1 Claimant Covenants. The Claimant covenants to:
(a) supplement information reasonably requested by the Insurer within ten (10) Business Days of request;
(b) preserve all relevant evidence; and
(c) refrain from any act that would impair subrogation rights until the Claim is resolved.
5.2 Insurer Covenants (Demanded). The Insurer is hereby demanded to:
(a) comply with all investigative obligations under 10 Cal. Code Regs. § 2695.7;
(b) maintain and produce the Claim File upon written request; and
(c) communicate all coverage positions in writing with specificity.
6. DEFAULT & REMEDIES
6.1 Events of Default. Any of the following shall constitute a default by the Insurer:
(a) failure to respond in writing within fifteen (15) calendar days of receipt of this Appeal, contrary to 10 Cal. Code Regs. § 2695.5(d);
(b) failure to pay the undisputed portion of the Claim within the time allowed by California law;
(c) continuation of any Bad Faith conduct.
6.2 Notice & Cure. Upon default, the Claimant may provide written notice affording the Insurer five (5) Business Days to cure. Failure to cure shall trigger the remedies in Section 6.3.
6.3 Remedies. Without limitation, the Claimant may:
(i) commence litigation in the Superior Court of California;
(ii) seek consequential, emotional distress, and punitive damages for Bad Faith;
(iii) pursue statutory interest and attorneys’ fees; and
(iv) request injunctive relief compelling claim payment.
6.4 Attorneys’ Fees & Costs. If litigation or arbitration is initiated, the prevailing party shall be entitled to recover reasonable attorneys’ fees and costs, consistent with Cal. Civ. Code § 1717 when applicable.
7. RISK ALLOCATION
7.1 Indemnification. Not applicable; no third-party indemnification is required under the Policy or this Appeal.
7.2 Limitation of Liability. The Claimant seeks recovery up to, but not exceeding, the Policy Limits, together with permissible extracontractual damages arising from Bad Faith.
7.3 Force Majeure. Force majeure does not excuse or delay the Insurer’s statutory duties to promptly investigate, evaluate, and pay covered claims.
8. DISPUTE RESOLUTION
8.1 Governing Law. California law controls all aspects of this dispute.
8.2 Forum Selection. Any action shall be filed exclusively in the Superior Court of the State of California, [COUNTY] County, subject to Ins. Code §§ 10160-10169 where applicable.
8.3 Optional Arbitration. At the Claimant’s sole election, the parties may submit the dispute to binding arbitration before a single retired California judge under JAMS Rules. Arbitration costs shall be advanced by the Insurer but subject to reallocation by the arbitrator. Nothing herein shall impair the Claimant’s right to file suit.
8.4 Jury Trial Preservation. Nothing in this Appeal constitutes a waiver of the Claimant’s constitutional right to a jury trial.
8.5 Injunctive Relief. The Claimant expressly reserves the right to seek provisional or permanent injunctive relief compelling claim payment.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver. This Appeal may be amended only by a written instrument executed by the Claimant. No waiver of rights is implied by any delay or partial exercise.
9.2 Assignment. The Claimant may assign benefits under the Policy to repair vendors or medical providers as permitted by law.
9.3 Severability. If any provision herein is held invalid, the remainder shall remain in full force.
9.4 Entire Appeal. This document, together with its Exhibits, constitutes the Claimant’s complete appeal and demand.
9.5 Counterparts & Electronic Signatures. This Appeal may be executed in counterparts and delivered via electronic transmission, each of which shall be deemed an original.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Claimant hereby executes this Appeal as of the Effective Date.
[INSURED NAME]
[Title / Capacity, if applicable]
Date: _____
Address for Correspondence:
[STREET ADDRESS]
[CITY, STATE ZIP]
Telephone: [_]
Email: [_]
cc: Claims Department, [INSURER NAME]
via Certified Mail, Return Receipt Requested # [TRACKING NO.]
[// GUIDANCE:
1. Preserve proof of mailing; statutory deadlines often run from the Insurer’s receipt.
2. Calendar 40 days from Insurer’s receipt for follow-up under 10 Cal. Code Regs. § 2695.7(b).
3. If the claim involves health insurance, incorporate the additional internal/external review timelines in Cal. Health & Safety Code § 1368 and 45 C.F.R. § 147.136.
4. Consider sending a parallel Cal. Ins. Code § 790.03(h) notice to the Department of Insurance when Bad Faith is egregious.]