INSURANCE CLAIM DENIAL APPEAL
(Formal Appeal & Stand-Still Agreement)
New York Jurisdiction
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 and Stand-Still Agreement (this “Appeal”).
1.2 Parties.
(a) “[POLICYHOLDER LEGAL NAME],” an individual/entity having a principal address at [ADDRESS] (“Appellant”); and
(b) “[INSURER LEGAL NAME],” an insurance company organized under the laws of [STATE] with its principal place of business at [ADDRESS] (“Insurer”).
1.3 Recitals.
A. Appellant is the named insured under Policy No. [POLICY NUMBER] issued by Insurer, with effective dates from [START DATE] through [END DATE] (the “Policy”).
B. Appellant submitted a claim dated [DATE] (the “Claim”) for [BRIEF DESCRIPTION OF LOSS].
C. By correspondence dated [DENIAL DATE] (the “Denial Letter”), Insurer denied the Claim.
D. Pursuant to applicable New York Insurance Law and the Policy, Appellant timely seeks internal reconsideration and preservation of rights for judicial review.
E. The Parties desire to set forth the procedures, time limits, and mutual obligations governing this Appeal.
1.4 Effective Date; Governing Law. This Appeal is effective as of [EFFECTIVE DATE] (the “Effective Date”) and shall be governed by the laws of the State of New York, without regard to conflict-of-laws principles.
2. DEFINITIONS
For ease of reference, the following capitalized terms are used herein:
“Appeal Record” – Collectively, the Claim, Denial Letter, supporting evidence, expert reports, correspondence, and any materials submitted or relied upon in connection with this Appeal.
“Bad Faith” – Any refusal by Insurer to honor its contractual obligations without a reasonable basis and with knowledge of, or reckless disregard for, the lack of a reasonable basis, as interpreted under New York law.
“Business Day” – Any day other than Saturday, Sunday, or a New York State or federal holiday.
“Claim Payment” – The monetary amount due under the Policy for the Claim, including interest as required by law.
“Final Determination” – Written notice from Insurer that (i) reverses, upholds, or modifies the Denial Letter and (ii) exhausts all internal appeal levels.
“Stand-Still Period” – The time commencing on the Effective Date and terminating upon the earliest of: (a) issuance of a Final Determination; (b) expiration of the Cure Period under Section 6.2; or (c) mutual written agreement of the Parties.
3. OPERATIVE PROVISIONS
3.1 Initiation of Appeal. Appellant hereby lodges a formal appeal of the Denial Letter and demands reconsideration pursuant to New York Insurance Law and Section [POLICY APPEAL CLAUSE] of the Policy.
3.2 Submission of Appeal Record.
(a) Within five (5) Business Days after the Effective Date, Appellant shall transmit to Insurer the complete Appeal Record.
(b) Insurer shall acknowledge receipt in writing within two (2) Business Days.
3.3 Review Standard; Examiner. Insurer shall conduct a de novo review employing qualified, impartial claims personnel or an independent reviewer not involved in the original denial.
3.4 Time Limits.
(a) Insurer must issue its Final Determination within thirty (30) calendar days after receipt of the Appeal Record (the “Determination Period”).
(b) For good cause shown, Insurer may extend the Determination Period once, for up to fifteen (15) additional calendar days, by written notice stating the specific reasons for extension.
3.5 Additional Information Requests. Any request by Insurer for supplementary information must be made at least ten (10) calendar days before the expiration of the Determination Period and shall toll such period only for the number of days Appellant reasonably requires to produce the requested materials.
3.6 Preservation of Legal Rights. During the Stand-Still Period, all limitations periods applicable to judicial proceedings (including but not limited to C.P.L.R. § 213) are tolled.
3.7 No Waiver of Coverage. By entering into this Appeal, neither Party waives any rights, defenses, or obligations under the Policy, except as expressly set forth herein.
4. REPRESENTATIONS & WARRANTIES
4.1 Appellant’s Representations.
(a) Accuracy. All information contained in the Appeal Record is true, correct, and complete to the best of Appellant’s knowledge.
(b) Timeliness. This Appeal is filed within the deadlines prescribed by applicable law and the Policy.
4.2 Insurer’s Representations.
(a) Authority. Insurer has full authority under the Policy and applicable law to reconsider the Claim.
(b) Good Faith Review. Insurer shall act in good faith and comply with New York’s Bad Faith standards throughout the appeal process.
4.3 Survival. The representations and warranties set forth in this Section 4 shall survive the Final Determination.
5. COVENANTS & RESTRICTIONS
5.1 Cooperation. Each Party shall reasonably cooperate in providing documents, access, and information necessary for a complete review.
5.2 Confidentiality. Except as required by law or to enforce rights hereunder, neither Party shall disclose non-public elements of the Appeal Record to third parties without the other Party’s prior written consent.
5.3 Notice Obligations. Any notice required under this Appeal must be in writing and delivered by certified mail, reputable overnight courier, or email with confirmation, addressed to the respective Party at the address set forth in Section 1.2, or as later designated in writing.
6. DEFAULT & REMEDIES
6.1 Events of Default.
(a) Failure of Insurer to issue a Final Determination within the Determination Period.
(b) Failure of Insurer to comply with the good-faith obligations in Section 4.2(b).
6.2 Cure Period. Upon an Event of Default, Insurer shall have ten (10) Business Days to cure after receipt of written notice from Appellant.
6.3 Appellant’s Remedies. If the default is not cured within the Cure Period, Appellant may:
(i) Commence litigation in a New York State court of competent jurisdiction;
(ii) Seek injunctive relief compelling Claim Payment; and
(iii) Recover reasonable attorneys’ fees and costs incurred in enforcing rights hereunder.
6.4 Insurer’s Remedies. If Appellant materially breaches Section 5.1 or 5.2, Insurer may suspend the Determination Period until the breach is cured.
7. RISK ALLOCATION
7.1 Indemnification. Not applicable per Section 7 of the metadata; each Party bears its own losses except as expressly provided herein.
7.2 Limitation of Liability. The liability of Insurer to Appellant arising out of or related to the Claim shall not exceed the Policy limits, together with any statutory interest, except that this cap shall not apply to (i) Insurer’s Bad Faith or (ii) Insurer’s willful misconduct.
7.3 Force Majeure. Neither Party shall be liable for delay or failure in performance caused by events beyond its reasonable control, provided that the affected Party gives prompt notice and resumes performance as soon as reasonably practicable.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Appeal is governed by the laws of the State of New York (see Section 1.4).
8.2 Forum Selection. The state courts of New York located in [COUNTY] shall have exclusive jurisdiction over any judicial proceeding arising from this Appeal or the Claim.
8.3 Optional Arbitration. By mutual written agreement executed after the Effective Date, the Parties may submit any dispute to binding arbitration administered by [AAA/JAMS] under its Commercial Arbitration Rules.
8.4 Jury Waiver. To the fullest extent permitted by law, each Party knowingly and voluntarily waives its constitutional right to a trial by jury with respect to any litigation arising out of this Appeal or the Claim.
8.5 Injunctive Relief Reserved. Nothing herein shall prevent Appellant from seeking equitable relief, including an order compelling Claim Payment.
9. GENERAL PROVISIONS
9.1 Amendments; Waivers. No modification or waiver is effective unless in a writing signed by both Parties.
9.2 Assignment. Neither Party may assign its rights or delegate its duties under this Appeal without the prior written consent of the other Party, except that Appellant may assign receivables to a financing entity.
9.3 Successors & Assigns. This Appeal is binding on and inures to the benefit of the Parties and their respective successors and permitted assigns.
9.4 Severability. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to make it enforceable.
9.5 Integration. This Appeal, together with the Appeal Record, constitutes the entire agreement between the Parties regarding the subject matter and supersedes all prior discussions.
9.6 Counterparts; Electronic Signatures. This Appeal may be executed in counterparts, each of which is deemed an original, and signatures transmitted electronically (e.g., PDF, DocuSign) are deemed originals for all purposes.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties have executed this Appeal as of the Effective Date.
| [POLICYHOLDER LEGAL NAME] | [INSURER LEGAL NAME] |
| By: _________ | By: ______ |
| Name: _______ | Name: ____ |
| Title: ________ | Title: _________ |
| Date: ________ | Date: ____ |
[NOTARY BLOCKS or WITNESS ATTESTATION, if required under NY law]
[// GUIDANCE:
1. Insert policy provisions governing internal appeals to ensure consistency.
2. Verify applicable statutes of limitation and update “Stand-Still Period” language if litigating a health-insurance denial subject to Article 49 external appeal rights (60-day filing window).
3. For health claims, include HIPAA authorization if needed to share medical records.
4. For ERISA-governed plans, add federal pre-emption language and adjust forum selection accordingly.
5. Always attach the Denial Letter and any expert opinions as exhibits to create a complete Appeal Record.
]