INSURANCE CLAIM DENIAL APPEAL & DEMAND FOR COVERAGE
(Commonwealth of Massachusetts)
[// GUIDANCE: This template is drafted for use by Massachusetts–licensed counsel when appealing an insurer’s denial of coverage or benefits under any first-party policy (e.g., health, disability, property & casualty, life). It is structured as a comprehensive, stand-alone instrument that (i) satisfies Massachusetts statutory deadlines, (ii) preserves all common-law and statutory bad-faith remedies, and (iii) is litigation-ready should the insurer refuse to reverse its denial. Bracketed fields MUST be customized before issuance. Remove all guidance comments prior to filing or service.]
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
FORMAL APPEAL OF INSURANCE CLAIM DENIAL AND DEMAND FOR PAYMENT
1.2 Parties
Claimant/Insured: [LEGAL NAME], a resident of the Commonwealth of Massachusetts, mailing address [ADDRESS], phone [PHONE], e-mail [EMAIL].
Insurer: [INSURER LEGAL NAME], a [STATE] insurance company, NAIC No. [NO.], principal place of business [ADDRESS].
1.3 Effective Date
This Appeal is deemed received on the date on which it is delivered to the Insurer pursuant to Section 5.2 (the “Effective Date”).
1.4 Governing Law
This Appeal is governed by Massachusetts insurance law, including without limitation Mass. Gen. Laws ch. 175, ch. 176D § 3(9), and ch. 93A (collectively, “Massachusetts Insurance Law”).
1.5 Recitals
A. Claimant is the holder of Policy No. [POLICY NUMBER] issued by Insurer (the “Policy”) with limits of liability of USD [POLICY LIMITS].
B. On [DATE OF LOSS], Claimant suffered a covered loss as defined in the Policy (the “Loss”).
C. Claimant timely submitted Claim No. [CLAIM NO.] together with all proofs of loss required.
D. By correspondence dated [DATE OF DENIAL LETTER] (the “Denial Letter”), Insurer denied, in whole or in part, the Claim.
E. Claimant now lodges this formal Appeal in accordance with Massachusetts Insurance Law, the Policy, and any applicable internal appeals procedure.
2. DEFINITIONS
The following terms, when capitalized, have the meanings set out below; other capitalized terms have the meanings given elsewhere in this Appeal.
“Appeal” means this Insurance Claim Denial Appeal & Demand for Coverage, including all Exhibits and supplements.
“Business Day” means any day other than Saturday, Sunday, or a Massachusetts state holiday.
“Claim” means the request for benefits or coverage identified in Recital C.
“Denial Letter” has the meaning given in Recital D and is attached as Exhibit A.
“Good-Faith Review Period” means the thirty-(30)-day period commencing on the Effective Date, subject to extension under Section 3.4.
“Policy” has the meaning given in Recital A.
“Policy Limits” means the maximum amount payable under the Policy, as restated in Section 7.2.
3. OPERATIVE PROVISIONS
3.1 Filing of Appeal
a. Claimant hereby appeals the Denial Letter in its entirety and demands full payment of all amounts due under the Policy.
b. This Appeal is filed within the earlier of:
(i) the time frame set forth in the Denial Letter; or
(ii) one-hundred-eighty (180) days after Claimant’s receipt of the Denial Letter, consistent with 211 C.M.R. 52.15(3)(b) for health plans or analogous policy provisions for other lines.
[// GUIDANCE: For non-health policies, confirm the contractually required appeal period—commonly 60 days for property & casualty.]
3.2 Grounds for Appeal
Insurer’s denial is erroneous because:
a. The Loss is a covered peril/event under Section [__] of the Policy;
b. All conditions precedent have been satisfied;
c. Insurer’s stated exclusions are inapplicable or void under Massachusetts Insurance Law; and
d. Insurer’s investigation was incomplete and/or in violation of Mass. Gen. Laws ch. 176D § 3(9)(d)–(f).
3.3 Supplemental Evidence
Concurrently with this Appeal, Claimant submits the following supporting materials:
(i) Sworn Proof of Loss (Exhibit B);
(ii) Independent Expert Report(s) (Exhibit C);
(iii) Photographs/Records (Exhibit D); and
(iv) Any additional documents referenced in Section 5.1.
3.4 Insurer’s Good-Faith Review
a. Within the Good-Faith Review Period, Insurer shall:
(1) Reopen the Claim;
(2) Conduct a complete, fair, and prompt investigation; and
(3) Issue a written determination with detailed factual and legal support.
b. If extraordinary circumstances require additional time, Insurer may extend the Good-Faith Review Period once, not to exceed fifteen (15) Business Days, by written notice stating specific reasons for the extension.
3.5 Payment Obligation Upon Reversal
If Insurer overturns any portion of the Denial Letter, Insurer shall:
a. Pay all undisputed amounts within five (5) Business Days; and
b. Pay any remaining disputed amounts within ten (10) Business Days after final resolution, together with pre-judgment interest at the statutory rate under Mass. Gen. Laws ch. 231 § 6C.
3.6 Conditions Precedent
Claimant’s obligations under this Appeal are expressly conditioned on Insurer’s compliance with Section 3.4.
4. REPRESENTATIONS & WARRANTIES
4.1 By Claimant
a. Authority. Claimant is the named insured or lawful assignee under the Policy.
b. Accuracy. All statements and documents provided are true, complete, and not misleading.
c. Timeliness. This Appeal is filed within all contractual and statutory deadlines.
4.2 By Insurer
Insurer represents that it is duly licensed in Massachusetts and subject to Massachusetts Insurance Law.
4.3 Survival
The representations and warranties in this Section 4 survive any resolution of the Appeal and any payment of the Claim.
5. COVENANTS & RESTRICTIONS
5.1 Claimant’s Continuing Cooperation
Claimant shall promptly furnish any additional non-privileged information reasonably requested by Insurer that is material to adjudication of the Claim.
5.2 Service of Notices
All notices must be in writing and delivered (a) by certified U.S. mail, return receipt requested; (b) by nationally-recognized overnight courier; or (c) by hand delivery, to the addresses listed in Section 1.2, or as later updated in writing. Notice is effective on delivery.
5.3 Confidentiality
To the extent permitted by law, the parties shall maintain the confidentiality of medical records, proprietary information, and policy data exchanged under this Appeal.
6. DEFAULT & REMEDIES
6.1 Events of Default
Insurer is in default if it:
a. Fails to comply with Section 3.4 within the prescribed time;
b. Refuses to reverse the Denial Letter without substantial justification; or
c. Engages in any act constituting an unfair claim-settlement practice under Mass. Gen. Laws ch. 176D § 3(9).
6.2 Notice & Cure
Claimant shall provide written notice of default, granting Insurer five (5) Business Days to cure.
6.3 Graduated Remedies
If default is not cured, Claimant may, cumulatively and without limitation:
a. File suit in any Massachusetts state court of competent jurisdiction for breach of contract and violations of ch. 93A;
b. Seek prejudgment attachment or injunctive relief compelling payment of the Claim;
c. Demand statutory treble damages and attorneys’ fees under ch. 93A § 9; and
d. Commence an external review or arbitration in accordance with Section 8.2.
6.4 Attorneys’ Fees
Pursuant to ch. 93A § 9(4), Claimant is entitled to recover reasonable attorneys’ fees and costs incurred in enforcing this Appeal.
7. RISK ALLOCATION
7.1 Indemnification
Not applicable—see metadata.
7.2 Limitation of Liability
Insurer’s liability shall not exceed the Policy Limits of USD [POLICY LIMITS] plus any statutory interest, multipliers, or attorneys’ fees recoverable under Massachusetts Insurance Law.
7.3 Force Majeure
Neither party shall be liable for delay due to events beyond its reasonable control (e.g., natural disasters, governmental orders); provided, however, that this Section does not excuse Insurer’s payment obligations once liability is established.
8. DISPUTE RESOLUTION
8.1 Governing Law & Forum Selection
This Appeal and any related dispute are governed by the substantive laws of the Commonwealth of Massachusetts. Exclusive venue lies in the state courts sitting in [COUNTY], Massachusetts.
8.2 Optional Arbitration
At Claimant’s sole election, any dispute arising from the Denial Letter may be submitted to binding arbitration administered by the American Arbitration Association under its Commercial Arbitration Rules. The arbitration clause is expressly optional and does not waive Claimant’s right to a judicial forum.
8.3 Jury Waiver
Nothing herein shall be construed as a waiver of Claimant’s constitutional right to trial by jury.
8.4 Injunctive Relief
Claimant may seek provisional or permanent injunctive relief compelling claim payment or preserving policy benefits without posting bond, to the fullest extent permitted by law.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers
No amendment or waiver is effective unless in writing and signed by Claimant. No waiver constitutes a continuing waiver unless expressly stated.
9.2 Assignment
Claimant may assign rights under the Policy and this Appeal to healthcare providers, contractors, or mortgagees as permitted by the Policy. Insurer may not assign its obligations without Claimant’s written consent.
9.3 Severability
If any provision of this Appeal is held invalid or unenforceable, the remaining provisions remain in full force and effect, and the invalid provision shall be reformed to the minimum extent necessary to render it valid.
9.4 Integration
This Appeal, together with all Exhibits, constitutes the entire agreement between the parties concerning the subject matter and supersedes all prior communications regarding the Denial Letter.
9.5 Counterparts & Electronic Signatures
This Appeal may be executed in counterparts, each of which is deemed an original, and signatures transmitted via PDF or electronic signature technology (e.g., DocuSign®) are binding.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, Claimant executes this Appeal as of the Effective Date.
| CLAIMANT / INSURED | |
| Signature: _____ | |
| Name: [PRINT NAME] | |
| Date: [DATE] |
ACKNOWLEDGED AS RECEIVED:
| INSURER | |
| By: _______ | |
| Name: [AUTHORIZED REPRESENTATIVE] | |
| Title: [CORPORATE TITLE] | |
| Date: [DATE] |
[// GUIDANCE: Insurer’s signature is optional but strongly recommended. If the insurer refuses to countersign, attach certified-mail proof of service.]