INSURANCE CLAIM DENIAL APPEAL

(Washington State – Comprehensive Template)

[// GUIDANCE: This template is designed for Washington-law governed first-party or third-party insurance claim appeals (property, casualty, health, disability, life, etc.). It is drafted to be sufficiently formal for submission either (a) to the insurer’s internal appeals unit, or (b) as the written notice of appeal/IFCA* 20-day notice preparatory to litigation. Practitioners should tailor the substance, tone, and exhibits to the particular policy form, line of coverage, and factual record. Replace all bracketed items with client-specific information and delete this guidance block prior to filing or service.]

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1. Title. FORMAL APPEAL OF INSURANCE CLAIM DENIAL (“Appeal”).
2. Claimant. [Full Legal Name of Insured/Claimant], a [State] [Entity Type / Individual], with principal address at [Address] (“Claimant”).
3. Insurer. [Full Legal Name of Insurance Company], a [State of Incorporation] insurance company, NAIC No. [●], with claims office at [Address] (“Insurer”).
4. Policy. Policy No. [●] issued effective [Policy Effective Date] through [Expiration Date] (the “Policy”).
5. Effective Date of Appeal. [Date] (the “Effective Date”).
6. Recitals.
   6.1 Claimant submitted a claim (“Claim”) on [Date of Loss] for [Brief Description of Loss/Occurrence].
   6.2 Insurer issued its written denial dated [Denial Letter Date] (the “Denial Letter”).
   6.3 Claimant timely invokes all contractual, statutory, and regulatory rights to appeal such denial under Washington law, including but not limited to internal appeal procedures, the Washington Insurance Fair Conduct Act (“IFCA”), and Washington’s unfair claims-handling standards.
   6.4 The parties desire to set forth herein the grounds for appeal and requested relief.

II. DEFINITIONS

For ease of reference, the following capitalized terms have the meanings set forth below and shall apply throughout this Appeal:

“Administrative Review” – Any internal review or reconsideration process established by the Insurer or mandated by statute or regulation.

“Bad Faith” – Conduct by Insurer in handling the Claim that is unreasonable, frivolous, unfounded, or in reckless disregard of Claimant’s rights under Washington law.

“Business Day” – Any day other than Saturday, Sunday, or a Washington State or federal holiday.

“Coverage Determination” – Any position, whether formal or informal, taken by Insurer regarding coverage, liability, or payment obligations under the Policy.

“Supplemental Documentation” – All exhibits, estimates, medical bills, photographs, expert reports, or affidavits supplied in support of this Appeal.

[// GUIDANCE: Insert additional defined terms (e.g., “Loss,” “Service Provider,” “UIM Benefits”) as required by the specific claim.]

III. OPERATIVE PROVISIONS

3.1 Notice of Appeal. Pursuant to the Policy, applicable Washington insurance regulations, and any federal or state external review rights, Claimant hereby lodges this Appeal and demands full reconsideration of the Denial Letter.

3.2 Timeliness. This Appeal is filed within (a) the deadline specified in the Denial Letter (□ days) and (b) any statutory or regulatory period (e.g., 180-day internal appeal for certain health claims). Claimant reserves all tolling arguments should Insurer dispute timeliness.

3.3 Grounds for Appeal.
(a) Factual Errors – [List concise factual inaccuracies in Denial Letter].
(b) Policy Interpretation – [Identify misapplied policy terms, exclusions, limitations].
(c) Bad Faith Indicators – [Enumerate unreasonable investigative delays, failure to conduct reasonable investigation, misrepresentation of pertinent facts/policy provisions].
(d) Legal Authority – [Cite Washington-specific standards without statutory numbers unless certain; e.g., “Washington’s IFCA” and “unfair claims-handling regulations”].

3.4 Relief Requested. Claimant seeks:
(i) Immediate reversal of the Denial Letter;
(ii) Payment in the amount of $[●] within ten (10) Business Days of receipt of this Appeal, plus applicable interest;
(iii) Confirmation of any continuing benefits and coverage; and
(iv) Reimbursement of reasonable attorney fees, costs, and expert expenses incurred in connection with this Appeal.

3.5 Performance Standards & Deadlines.
(a) Insurer shall acknowledge receipt of this Appeal in writing within three (3) Business Days.
(b) Insurer shall issue a substantive written response within [15/30] Business Days, consistent with Washington claims-handling regulations.
(c) Failure to meet these deadlines constitutes a separate violation and triggers the remedies in Article VI below.

3.6 Conditions Precedent. Claimant’s obligation to commence litigation or arbitration is conditioned upon (a) completion of the Administrative Review process, unless futile, and (b) expiration of any mandatory pre-suit notice period.

IV. REPRESENTATIONS & WARRANTIES

4.1 Claimant hereby represents and warrants that:
(a) The statements of fact contained herein and in the Supplemental Documentation are true and correct to the best of Claimant’s knowledge, information, and belief;
(b) The loss or injury forming the basis of the Claim is covered under the Policy;
(c) This Appeal is timely and procedurally proper;
(d) All material relevant to the Claim that is currently in Claimant’s possession has been or will be provided promptly upon request.

4.2 Survival. The representations and warranties in this Article IV shall survive any resolution, settlement, or payment of the Claim.

V. COVENANTS & RESTRICTIONS

5.1 Cooperation. Claimant covenants to cooperate in any reasonable requests for additional information, examinations under oath, or inspections, provided such requests comply with Washington law and the Policy.

5.2 Confidentiality. All non-public medical or financial data furnished as Supplemental Documentation shall be used solely for adjudication of this Appeal and related proceedings.

5.3 Duty of Good Faith and Fair Dealing. Both parties shall discharge their respective obligations under this Appeal consistent with the covenant of good faith and fair dealing implied in every insurance contract under Washington law.

VI. DEFAULT & REMEDIES

6.1 Events of Default. The following constitute defaults by Insurer:
(a) Failure to acknowledge or respond within the timeframes in § 3.5;
(b) Failure to conduct a reasonable investigation;
(c) Failure to overturn the Denial Letter when warranted;
(d) Any act of Bad Faith.

6.2 Notice and Cure. Claimant shall provide written notice of default; Insurer shall have five (5) Business Days to cure, unless such default is not capable of cure through diligent action within that period.

6.3 Graduated Remedies. Upon uncured default, Claimant may, without limitation:
(i) File a complaint with the Washington State Office of the Insurance Commissioner;
(ii) Issue IFCA pre-suit notice and commence civil action seeking treble damages, attorney fees, and costs;
(iii) Seek declaratory and injunctive relief compelling coverage and payment;
(iv) Initiate arbitration if elected under § VIII.3.

6.4 Attorneys’ Fees and Costs. In any action to enforce this Appeal or to recover under the Policy, Claimant shall be entitled to reasonable attorney fees and costs as permitted under Washington law and the Policy.

VII. RISK ALLOCATION

7.1 Indemnification. Not applicable per Parties’ metadata; all rights reserved under existing policy terms and Washington law.

7.2 Limitation of Liability. Absent Bad Faith or statutory penalty enhancements, Insurer’s liability for contractual benefits shall not exceed applicable Policy Limits. This clause does not limit statutory remedies (e.g., treble damages) available for Bad Faith.

7.3 Insurance Requirements. Each party maintains its respective existing insurance programs; no additional insurance is allocated by this Appeal.

7.4 Force Majeure. Neither party shall be liable for delay caused by events beyond reasonable control; however, Insurer’s payment obligations for a covered loss are not excused absent a Policy provision expressly providing otherwise.

VIII. DISPUTE RESOLUTION

8.1 Governing Law. This Appeal, and any dispute arising from the underlying Claim, shall be governed by and construed under the laws of the State of Washington, without regard to conflict-of-laws principles.

8.2 Forum Selection. Exclusive venue shall lie in the state courts of [County], Washington, unless federal jurisdiction is invoked, in which case the U.S. District Court for the Western/Eastern District of Washington shall apply.

8.3 Arbitration (Optional). At Claimant’s sole election, any dispute may be submitted to binding arbitration administered by [AAA / JAMS] under its Insurance Claims Rules. The Insurer shall bear filing fees and administrative costs.

8.4 Jury Waiver. Claimant does not waive any constitutional right to trial by jury; any waiver must be mutual and expressly executed in writing.

8.5 Injunctive Relief. Claimant reserves the right to seek temporary, preliminary, and permanent injunctive relief compelling coverage, claim payment, or other equitable remedies notwithstanding any election to arbitrate.

IX. GENERAL PROVISIONS

9.1 Amendment and Waiver. No amendment to this Appeal shall be effective unless in writing signed by the party against whom enforcement is sought. No waiver of any right shall be deemed a waiver of any subsequent, similar right.

9.2 Assignment. Claimant may assign benefits or causes of action to medical providers, contractors, or subrogees as permitted by the Policy and Washington law. Insurer may not assign its obligations without Claimant’s prior written consent.

9.3 Successors and Assigns. This Appeal shall bind and inure to the benefit of the parties and their respective successors, assigns, trustees, receivers, and legal representatives.

9.4 Severability. If any provision of this Appeal is held invalid or unenforceable, such provision shall be reformed to the minimum extent necessary, and the remaining provisions shall remain in full force and effect.

9.5 Integration. This Appeal, together with all referenced exhibits and Supplemental Documentation, constitutes the entire statement of grounds for reversal of the Denial Letter and supersedes any prior oral or written communications on the subject.

9.6 Counterparts; Electronic Signatures. This Appeal may be executed in counterparts, each of which shall be deemed an original. Signatures transmitted electronically or by facsimile shall be deemed original for all purposes.

X. EXECUTION BLOCK

IN WITNESS WHEREOF, the undersigned have executed this Appeal as of the Effective Date.

CLAIMANT:

[Name]
[Title / Capacity, if entity]
Date: ___

INSURER ACKNOWLEDGMENT (receipt only):

[Authorized Claims Representative]
[Title]
Date: ___

[// GUIDANCE: Add notarization block if required for specific filings (e.g., sworn statement of insured), or verification pursuant to Washington court rules when used as a pleading.]

*IFCA – Insurance Fair Conduct Act, codifying enhanced remedies for unreasonable or bad-faith claim denials in Washington.