FORMAL INSURANCE CLAIM DENIAL APPEAL AND DEMAND FOR COVERAGE
(Pennsylvania)
[// GUIDANCE: This template is drafted for use by policyholders or their counsel when appealing a denied insurance claim under Pennsylvania law. Customize all bracketed placeholders and tailor sections to the specific policy language, claim facts, and procedural posture.]
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 Insurance Claim Denial Appeal and Demand for Coverage
1.2 Parties
This Appeal (“Appeal”) is submitted by [INSURED NAME], [individual/corporate] policyholder (“Appellant” or “Insured”) to [INSURANCE COMPANY NAME], a [STATE OF INCORPORATION] insurance company (“Insurer”).
1.3 Recitals
A. Insurer issued Policy No. [POLICY_NUMBER] (“Policy”) to Insured, effective [POLICY_EFFECTIVE_DATE]–[POLICY_EXPIRATION_DATE].
B. Insured timely submitted Claim No. [CLAIM_NUMBER] (“Claim”) on [CLAIM_SUBMISSION_DATE] for [brief loss description].
C. By letter dated [DENIAL_DATE] (“Denial Letter”), Insurer denied coverage.
D. Pursuant to the Policy, Pennsylvania insurance regulations, and controlling law, Insured hereby appeals the Denial Letter within the applicable time limits.
1.4 Effective Date
This Appeal is effective as of [DATE_OF_APPEAL] (“Effective Date”).
1.5 Governing Law & Jurisdiction
This Appeal is governed by Pennsylvania insurance law (“Governing Law”) and any applicable federal statutes.
2. DEFINITIONS
“Bad Faith” means any frivolous or unfounded refusal to pay proceeds of a policy (see 42 Pa. Cons. Stat. § 8371).
“Business Day” means any day other than Saturday, Sunday, or a Pennsylvania-recognized legal holiday.
“Claim File” means the entire record, including all adjuster notes and correspondence, relating to the Claim.
“Policy Limits” means the maximum monetary coverage as stated in the Policy Declarations.
3. OPERATIVE PROVISIONS
3.1 Timeliness of Appeal
Insured files this Appeal within [NUMBER] days of the Denial Letter, satisfying any contractual or statutory deadline, including but not limited to 40 P.S. § 1171.5(a)(10) [// GUIDANCE: Cross-check policy—some policies shorten or extend statutory periods].
3.2 Basis for Appeal
a. Coverage Triggered: The [CAUSE OF LOSS] constitutes a covered peril under Section [SECTION_REFERENCE] of the Policy.
b. Conditions Precedent Satisfied: Insured provided all proofs of loss, examinations, and documentation required under Sections [XYZ] of the Policy.
c. Erroneous Denial: The Denial Letter misapplies [specific policy exclusion] and disregards controlling Pennsylvania law interpreting similar exclusions.
3.3 Relief Requested
a. Immediate payment of covered damages in the amount of $[AMOUNT], plus applicable interest from [DATE].
b. Reimbursement of reasonable attorney fees, costs, and statutory damages for Bad Faith under 42 Pa.C.S. § 8371, if Insurer fails to reverse the denial within the Cure Period (defined below).
c. Preservation of all rights to seek injunctive relief compelling claim payment.
3.4 Supporting Exhibits
Attached hereto and incorporated by reference:
Exhibit A Copy of Policy
Exhibit B Proofs of Loss and Supporting Documentation
Exhibit C Denial Letter
Exhibit D Damage Estimates and Expert Reports
4. REPRESENTATIONS & WARRANTIES
4.1 Insured’s Representations
a. Authority: Insured (or undersigned counsel) is duly authorized to submit this Appeal.
b. Truthfulness: All statements herein and in the Exhibits are true and correct to the best of Insured’s knowledge, information, and belief.
4.2 Insurer’s Implied Warranties
a. Good-Faith Handling: Insurer is obligated to evaluate the Appeal fairly and promptly under Pennsylvania’s Unfair Insurance Practices Act.
b. Regulatory Compliance: Insurer will comply with 31 Pa. Code Ch. 146 claim-handling standards.
4.3 Survival
The representations and warranties herein survive determination of this Appeal and any subsequent litigation.
5. COVENANTS & RESTRICTIONS
5.1 Insured’s Covenants
a. Additional Information: Insured shall furnish any further documentation reasonably requested by Insurer within ten (10) Business Days of receipt of such request.
b. Cooperation: Insured will make all reasonable efforts to facilitate prompt inspection or appraisal of the insured property.
5.2 Insurer’s Covenants
a. Response Deadline: Insurer shall provide a written determination on this Appeal within fifteen (15) Business Days (“Response Deadline”) after receipt.
b. Disclosure of Claim File: Within five (5) Business Days of this Appeal, Insurer shall produce the Claim File to Insured.
5.3 Restrictions
Neither party shall release claim-related information to third parties except as required by law, court order, or written consent of the other party.
6. DEFAULT & REMEDIES
6.1 Events of Default
a. Insurer Default: Failure to (i) meet the Response Deadline, (ii) act in good faith, or (iii) tender undisputed amounts constitutes default.
b. Insured Default: Failure to supply requested additional information within required timeframes.
6.2 Notice & Cure
The non-defaulting party shall provide written notice (“Default Notice”) specifying the nature of the default. The defaulting party shall have ten (10) Business Days (“Cure Period”) to cure.
6.3 Remedies
a. Insured Remedies: Upon Insurer Default, Insured may pursue (i) statutory bad-faith damages under 42 Pa.C.S. § 8371, (ii) injunctive relief compelling coverage, and (iii) litigation costs.
b. Insurer Remedies: Upon Insured Default, Insurer may suspend appeal review until cured; policy defenses remain reserved.
c. Attorney Fees & Costs: The prevailing party in any enforcement action shall be entitled to reasonable attorney fees and costs.
7. RISK ALLOCATION
7.1 Liability Cap
Insurer’s monetary liability shall not exceed Policy Limits except as augmented by statutory bad-faith damages, interest, costs, and attorney fees authorized under Pennsylvania law.
7.2 Indemnification
Not applicable.
7.3 Force Majeure
Neither party shall be liable for delays caused by acts of God, war, or other events beyond their reasonable control; however, monetary obligations remain unaffected.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Appeal, and any dispute arising hereunder, shall be governed by Pennsylvania law without regard to conflict-of-law principles.
8.2 Forum Selection
Exclusive venue shall lie in the Court of Common Pleas of [COUNTY], Pennsylvania or, if applicable, the United States District Court for the [DISTRICT] of Pennsylvania.
8.3 Optional Arbitration
At Insured’s election, disputes may be submitted to binding arbitration under the [ARBITRATION_RULES_REFERENCE], seated in [CITY], Pennsylvania. The arbitrator shall have authority to award all statutory and contractual remedies available under Pennsylvania law.
8.4 Jury Trial
Nothing herein constitutes a waiver of the parties’ constitutional right to a jury trial.
8.5 Injunctive Relief
The parties acknowledge that failure to timely pay covered benefits may cause irreparable harm; Insured may seek emergent injunctive relief compelling claim payment without posting bond to the extent permitted by law.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver
No amendment or waiver of any provision herein shall be effective unless in writing and signed by both parties. No waiver of any breach constitutes waiver of any other or subsequent breach.
9.2 Assignment
Neither party may assign rights or delegate duties under this Appeal without prior written consent of the other, except to successors by operation of law.
9.3 Entire Agreement
This Appeal and its Exhibits constitute the entire submission concerning the Denial Letter and supersede all prior oral or written communications regarding the Claim.
9.4 Severability
If any provision is held invalid, the remainder shall remain enforceable, and the invalid provision shall be re-formed to the minimum extent necessary to effect its original intent.
9.5 Counterparts & Electronic Signatures
This Appeal may be executed in counterparts, each of which is deemed an original, and may be delivered by electronic means (e.g., PDF or e-signature) with the same force and effect as an original.
10. EXECUTION BLOCK
Executed as of the Effective Date.
INSURED / APPELLANT
[INSURED NAME]
By: _____
Name: [PRINTED_NAME]
Title: [IF APPLICABLE]
Date: ____
[// GUIDANCE: If represented, add attorney signature block and Pennsylvania Rule of Professional Conduct certification.]
COUNSEL FOR INSURED (if applicable)
[LAW FIRM NAME]
By: _____
[ATTORNEY NAME], Esquire
PA Attorney I.D. No. [BAR_NUMBER]
Date: ____
CERTIFICATE OF SERVICE
I, [NAME], certify that on this ___ day of ____ 20__, I served the foregoing Appeal, with all Exhibits, via [CERTIFIED MAIL / EMAIL / FACSIMILE] upon:
[INSURANCE COMPANY NAME]
Attn: [CLAIMS MANAGER NAME]
[ADDRESS]
Signature
[NOTARY BLOCK – add if required by policy or for evidentiary purposes]
[// GUIDANCE:
1. Verify policy language for any bespoke appeal procedures and deadlines.
2. Attach comprehensive supporting documentation to bolster factual and legal grounds.
3. Calendar all response and cure periods immediately upon mailing/filing.
4. Consider parallel complaint to Pennsylvania Insurance Department for leverage.
5. Preserve electronic metadata of all correspondence for potential litigation discovery.]