Month Date, Year 

Name of State Insurance Commission
Name of Insurance Company
Street Address
City, State ZIP code 

Dear Insurance Commissioner: 

I have filed the attached insurance claim with Name of Insurance Company on Date of Claim. My physician has deemed this therapy medically necessary for my Epidermolysis Bullosa; however, in spite of this my insurance company has denied me access to Name of Treatment. EB-Epidermolysis Bullosa, is a genetic disease where the skin's fragility causes serious wounds all over the body, and there is no cure. Although EB reveals itself on the skin, there is also a significant negative effect on daily functioning associated with this disease. EB patients have esophageal problems, hands web and contract and infection is on-going concern. Epidermolysis Bullosa is a lethal condition, especially with poor treatment of wounds. Without proper treatment, EB is physically and emotionally devastating, preventing the carrying out of most normal activities, diminishing life expectancy. 


I have had the following specific problem(s) with this insurance company: 

1. Example: Name of Insurance Co. has refused to cover my physician prescribed, medically necessary therapy. 

2. Example: My claim has been neither paid nor denied. 

3. Example: Name of Insurance Co. has not acknowledged my request for a copy of their policy regarding the therapy my physician has prescribed me. 

4. Example: In violation of my policy, Name of Insurance Co. has denied my claim. 

Please accept this letter as a formal written complaint against Name of Insurance Co. 

Sincerely,
Patient Name
Patient Address and Phone #