If your health coverage comes through a private employer, it is usually governed by ERISA, and you have strong rights to see exactly why your claim was denied. Under the “full and fair review” rules, you can request — free of charge — the complete claim file, the specific plan provisions the plan relied on, any internal rules, guidelines, or clinical protocols it applied, and any expert or medical reviewer’s report it used. You can also request plan documents such as the Summary Plan Description (SPD). Getting these documents before you appeal lets you answer the plan’s actual reasoning instead of guessing. The mailing address for the plan administrator is on your denial letter, SPD, or benefits portal.
Before you write
Have these on hand so the request is specific:
- The denial letter or EOB with the denial reason and code.
- Your member ID, group number, and claim number.
- The date(s) of service and the date of the denial.
- The name and address of your plan administrator (often the employer or a third-party administrator listed in the SPD).
The letter
[Your full name]
[Your address]
[City, State ZIP]
[Phone] | [Email]
[Date]
[Plan administrator / Insurer - Appeals or Plan Documents]
[Address from your denial letter or SPD]
Re: Request for claim file and plan documents
Member: [Name] Member ID: [number] Group #: [number]
Claim number: [number] Date(s) of service: [dates]
Denial date: [date] Denial reason/code: [as stated on the EOB]
To the Plan Administrator:
In connection with the denial identified above, I am requesting, free of
charge, all documents relevant to the claim so that I can prepare a full and
fair appeal. Specifically, I request:
1. The complete claim file for this claim.
2. The specific plan provisions on which the denial was based.
3. Any internal rules, guidelines, protocols, or clinical criteria the plan
applied or relied on in denying the claim.
4. Any report from a medical or other expert whose advice was obtained on
behalf of the plan in connection with the denial, whether or not the
advice was relied upon.
5. The name of any medical or vocational expert whose advice was obtained.
6. The Summary Plan Description (SPD) and the governing plan document.
Please provide these documents promptly. I understand that the plan is required
to furnish relevant documents free of charge, and that plan documents are
generally due within 30 days of this request.
If any requested item is withheld, please identify it and state the basis for
withholding it.
Thank you for your attention. Please send the documents to the address above.
Sincerely,
[Your signature]
[Your printed name]
How to send it
Send by certified mail with return receipt requested to the plan administrator (and to the insurer’s appeals address if different), or use the plan’s official document-request channel. Keep a dated copy and your receipt, because the timing of your request can matter for penalties if the plan fails to respond. If you are also appealing, you can send this alongside your internal appeal letter so you have the file before your deadline runs.
Notes. For employer-sponsored ERISA plans, the full-and-fair-review regulation (29 CFR 2560.503-1) entitles you to request, free of charge, the claim file plus the specific plan provisions, internal rules, guidelines, or protocols, and any expert report the plan relied on. Separately, ERISA section 104(b)(4) requires the plan administrator to furnish plan documents (such as the SPD) on written request, generally within 30 days, with possible statutory penalties for failure to comply. These ERISA rights do not apply to government, church, or individual-market (non-employer) plans; if your plan is non-ERISA, you should still ask the insurer in writing for the specific basis of the denial and the criteria it used. To decide which process applies, see which appeal process; if the denial is clinical, see the medical-necessity appeal. This is general information, not legal or medical advice.