INSURANCE CLAIM DENIAL APPEAL
(Texas Jurisdiction – Comprehensive Template)
[// GUIDANCE: This template is designed for use when appealing a Texas-governed insurance claim denial (e.g., property, auto, health, or life). It blends formal letter-style advocacy with contract-style enforceability provisions so that counsel may (1) submit it directly to the carrier and, if necessary, (2) rely on the same document as a cornerstone exhibit in subsequent litigation or administrative complaint proceedings.]
TABLE OF CONTENTS
- Document Header
- Recitals
- Definitions
- Operative Provisions
4.1 Statement of Facts
4.2 Grounds for Appeal
4.3 Requested Relief
4.4 Conditions Precedent & Subsequent - Representations & Warranties
- Covenants
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
Insurance Claim Denial Appeal
Effective Date: [DATE]
Appealing Party (the “Policyholder”): [LEGAL NAME], policy no. [POLICY #]
Responding Party (the “Insurer”): [INSURANCE COMPANY LEGAL NAME]
Claim Reference No.: [CLAIM #]
Jurisdiction & Governing Law: State of Texas
2. RECITALS
A. On [DATE OF LOSS], the Policyholder sustained a Loss covered under the Policy.
B. The Policyholder timely submitted a Claim in compliance with all notice provisions.
C. On [DATE OF DENIAL LETTER], the Insurer issued its written Notice of Denial.
D. The Policyholder now files this Appeal pursuant to:
(i) the Appeals Procedure set forth in Section [ ___ ] of the Policy;
(ii) Tex. Ins. Code Ann. §§ 541.060 & 542.056 (West 2023); and
(iii) all other applicable law.
E. The parties desire to memorialize the terms and conditions governing this Appeal and any further handling of the Claim.
NOW, THEREFORE, in consideration of the mutual promises herein, the parties agree as follows.
3. DEFINITIONS
For purposes of this Appeal, the following capitalized terms shall have the meanings set forth below. Any term used but not defined herein shall have the meaning ascribed in the Policy.
“Appeal” means this formal, written demand that the Insurer reconsider the Denial and pay the Claim.
“Bad Faith” means any violation of Tex. Ins. Code Ann. Chs. 541 or 542, or the common-law duty of good faith and fair dealing, including but not limited to unfounded refusal to pay, failure to conduct a reasonable investigation, or delay in payment after liability is reasonably clear.
“Business Day” means any day other than a Saturday, Sunday, or Texas-recognized legal holiday.
“Claim” means the insurance claim identified in the Recitals, inclusive of all coverages, supplemental claims, and amendments.
“Denial” or “Notice of Denial” means the Insurer’s written correspondence dated [DATE] rejecting coverage in whole or in part.
“Policy” means insurance policy number [POLICY #], including all endorsements.
“Prompt Payment Statute” means Tex. Ins. Code Ann. Ch. 542, Subch. B.
4. OPERATIVE PROVISIONS
4.1 Statement of Facts
- Date of Loss: [DATE].
- Nature of Loss: [DESCRIPTION].
- Claim Submission Date: [DATE].
- Denial Basis Cited by Insurer: [POLICY EXCLUSION / OTHER].
4.2 Grounds for Appeal
- Coverage Interpretation: The alleged exclusion does not apply because [LEGAL ARGUMENT].
- Factual Error: The investigation omitted critical evidence, specifically [DESCRIBE].
- Texas Prompt Payment Violations: The Insurer failed to (i) acknowledge receipt of the Claim within 15 calendar days and/or (ii) pay or deny within 60 days as required by Tex. Ins. Code Ann. § 542.056.
- Bad Faith: The Insurer lacked a reasonable basis to deny the Claim and acted with knowledge or reckless disregard of that fact, contrary to Tex. Ins. Code Ann. § 541.060(a)(2)(A).
4.3 Requested Relief
- Reversal of Denial and payment of covered benefits in the amount of $[AMOUNT], plus any applicable interest under § 542.060.
- Attorneys’ Fees & Costs incurred in preparing and prosecuting this Appeal.
- Statutory Penalties of 18% per annum on the amount of the Claim pursuant to § 542.060.
- Injunctive Relief ordering immediate Claim payment (reserving all equitable remedies).
4.4 Conditions Precedent & Subsequent
- The Policyholder has satisfied all policy-based and statutory prerequisites to appeal.
- Should the Insurer fail to overturn the Denial within [__] Business Days of receipt of this Appeal, the Policyholder reserves the right to:
a. Commence litigation in a court of competent jurisdiction;
b. File a complaint with the Texas Department of Insurance; and/or
c. Invoke any Dispute Resolution mechanism set forth herein.
5. REPRESENTATIONS & WARRANTIES
5.1 Policyholder represents and warrants that:
a. All information herein is true, correct, and complete to the best of its knowledge;
b. The Appeal is timely under both the Policy and Texas law; and
c. It has not assigned or otherwise transferred its rights under the Policy.
5.2 Insurer represents and warrants that:
a. It is duly licensed to transact insurance in Texas;
b. The individual signing below possesses full authority to bind the Insurer; and
c. It will handle this Appeal in good faith and in compliance with all applicable statutes.
[// GUIDANCE: Insurers often refuse to sign; however, requesting acknowledgment locks them into representations useful in later litigation.]
5.3 Survival. All representations and warranties survive the resolution of this Appeal and any payment of the Claim.
6. COVENANTS
6.1 Policyholder Covenants:
a. To cooperate with any reasonable, promptly-scheduled re-inspection or interview.
b. To furnish additional documentation within [__] Business Days of a written request.
6.2 Insurer Covenants:
a. To conduct any supplemental investigation within [15] Business Days of this Appeal.
b. To issue a written determination overturning or affirming the Denial within [30] Calendar Days of receipt of this Appeal.
c. To maintain a complete claim file per Tex. Ins. Code Ann. § 542.005.
7. DEFAULT & REMEDIES
7.1 Event of Default. Failure by the Insurer to comply with Section 6.2 constitutes an “Event of Default.”
7.2 Notice & Cure. Upon Default, Policyholder shall provide written Notice of Default. The Insurer shall have 5 Business Days to cure.
7.3 Remedies. If Default is uncured, Policyholder may pursue:
a. Civil action for breach of contract and Bad Faith;
b. Recovery of statutory interest, costs, and attorneys’ fees under Tex. Ins. Code Ann. § 542.060;
c. All other remedies at law or in equity, including injunctive relief compelling claim payment.
8. RISK ALLOCATION
8.1 Limitation of Liability. The Insurer’s liability shall not exceed the Policy Limits except for:
a. Statutory interest and penalties;
b. Extra-contractual damages available under Chs. 541 & 542.
8.2 Indemnification. Not applicable (per metadata).
8.3 Force Majeure. Neither party shall be liable for delay or failure to perform caused by events beyond reasonable control, excluding financial inability and lack of diligence.
9. DISPUTE RESOLUTION
9.1 Governing Law. This Appeal and any ensuing dispute shall be governed by the laws of the State of Texas, without regard to conflict-of-law principles.
9.2 Forum Selection. Exclusive venue shall lie in the state courts of [COUNTY], Texas.
9.3 Arbitration (Optional). If both parties consent in writing, any dispute may be submitted to binding arbitration administered by [ARBITRATION BODY] under its rules.
9.4 Jury Waiver. Nothing herein shall constitute a waiver of the Policyholder’s constitutional right to trial by jury.
9.5 Injunctive Relief. The Policyholder retains the right to seek temporary, preliminary, or permanent injunctive relief compelling claim payment or preserving coverage.
10. GENERAL PROVISIONS
10.1 Amendment & Waiver. No amendment or waiver is effective unless in a writing signed by both parties.
10.2 Assignment. Neither party may assign this Appeal without prior written consent, except that the Policyholder may assign post-loss rights to a contractor or mortgagee as allowed by law.
10.3 Successors & Assigns. This Appeal binds and benefits the parties and their respective successors and permitted assigns.
10.4 Severability. If any provision is held invalid, the remainder shall remain enforceable, and the invalid provision reformed to the minimum extent necessary.
10.5 Integration. This document, together with the Policy and the Claim file, constitutes the entire agreement regarding the Appeal.
10.6 Counterparts; Electronic Signatures. This document may be executed in multiple counterparts (including PDF or electronic signatures), each of which is an original and all of which together constitute one instrument.
11. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties have executed this Insurance Claim Denial Appeal as of the Effective Date.
POLICYHOLDER
Legal Name: [_____]
Signature: ____
Printed Name: ___
Title (if applicable): __
Date: _____
INSURER (acknowledgment of receipt and good-faith handling)
Legal Name: [_____]
Signature: ____
Printed Name: ___
Title: _____
Date: _________
[// GUIDANCE: If the Insurer refuses to sign, email or certified-mail proof of delivery is sufficient to start statutory clocks under the Prompt Payment Statute.]
APPENDIX A – EXHIBITS (check all that apply)
☐ Exhibit 1 – Copy of Policy
☐ Exhibit 2 – Proof of Loss & Supporting Documents
☐ Exhibit 3 – Photographs / Expert Reports
☐ Exhibit 4 – Notice of Denial Letter
☐ Exhibit 5 – Prior Correspondence
[// GUIDANCE: Always attach the Denial Letter as an exhibit; its date triggers critical statutory deadlines.]
END OF DOCUMENT