Dental Insurance Denied Your Claim? California Demand Letter for Dental Plan Disputes

DEMAND FOR COVERAGE - DENTAL PLAN DISPUTE [Your Name] [Your Address] [City, CA ZIP] [Phone] [Email] [Date] VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED [Dental Plan Name] Appeals and Grievances Department [Plan Address] [City, State ZIP] Re: Formal Demand for Coverage - Wrongful Denial Member Name: [Your Name] Member ID: [Your Member ID] Claim Number: [Claim Number] Date of Service: [Date of Dental Procedure] Denied Procedure: [Procedure Name and CDT Code if known] Treating Dentist: [Dentist Name, DDS] Dear Claims Administrator: I am writing to formally demand coverage for dental services that were wrongfully denied by [Dental Plan Name]. Your denial dated [Denial Date] violates my policy terms and California law. FACTS: 1. I am a member of [Dental Plan Name] under policy/group number [Policy Number]. 2. On [Date], my dentist, [Dentist Name, DDS], determined that I require [Procedure Name - e.g., "a porcelain crown on tooth #14"] due to [Clinical Reason - e.g., "extensive decay that has compromised the structural integrity of the tooth, making a filling clinically inappropriate"]. 3. On [Date], I received your denial letter stating the procedure was denied because: [Quote the exact denial reason from the letter]. 4. I filed an internal appeal on [Date], which was denied on [Date]. WHY THE DENIAL IS WRONG: Your denial is improper for the following reasons: [Select and customize applicable reasons:] Medical Necessity: My treating dentist has determined this procedure is medically necessary based on clinical examination, x-rays, and professional judgment. I have attached Dr. [Dentist Name]'s letter of medical necessity explaining why [the recommended procedure] is the only clinically appropriate treatment for my condition. Policy Violation: My policy provides coverage for [procedure type] under [cite specific policy provision]. Your denial contradicts the plain language of my coverage. Improper Downgrade: Your "alternate benefit" determination paying only for [lesser procedure] ignores my dentist's professional judgment that [recommended procedure] is the only appropriate treatment. California law requires coverage decisions to be based on clinical appropriateness, not cost savings. CALIFORNIA LAW: [For Dental HMOs:] Under California Health & Safety Code Section 1371-1371.4, your plan must provide or arrange for the provision of medically necessary dental care. Denying coverage for a procedure my dentist has determined is medically necessary violates your obligations under the Knox-Keene Act. [For Dental PPOs:] Under California Insurance Code Section 10144.5, your company must process claims in good faith and cannot deny coverage that is provided under my policy terms. DEMAND: I hereby demand that you: 1. Immediately reverse the denial and authorize coverage for [Procedure Name]; 2. Pay the covered amount of $[Amount] to [Dentist/Provider Name]; 3. Reimburse me $[Amount] for any amounts I have already paid out-of-pocket for this procedure; 4. Provide written confirmation of this reversal within fifteen (15) days. If I do not receive a satisfactory response within 15 days, I will: - File a complaint with [DMHC/CDI - use appropriate agency] - Request Independent Medical Review [if DMHC-regulated plan] - Pursue all available legal remedies, including claims for bad faith denial of benefits SUPPORTING DOCUMENTATION ENCLOSED: 1. Copy of denial letter dated [Date] 2. Letter of medical necessity from [Dentist Name, DDS] 3. Treatment plan and clinical notes 4. Relevant x-rays and diagnostic images 5. Copy of my policy/certificate of coverage (relevant sections) 6. Prior appeal correspondence Please contact me at [Phone/Email] to resolve this matter. Sincerely, _______________________________ [Your Signature] [Your Printed Name] cc: [DMHC or CDI - appropriate regulator] [Your Dentist] [Your Employer's Benefits Department, if applicable]