Tell the plan it missed its deadline
A letter that tells your plan it did not decide your claim or appeal in time, quotes what the federal rule says follows, and asks the plan to confirm in writing what it did and where you now stand.
- Private: nothing leaves this tab
- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this only after the plan's time limit has really passed. Count from the day the plan received your claim or appeal. Check first for a notice in which the plan extended its time. The letter asks the plan to state its position; it does not make a late decision a win. The rule excepts minor violations, and it does not move your other deadlines, so keep an eye on your date for asking for external review. For a job-based or Marketplace or individual plan only.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the person this is addressed to]
Re: Tell the plan it missed its deadline Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am writing about [Name of the health plan], member ID [Member ID], claim [Claim or reference number], for [The care or drug that was denied].
On [The date you filed it] I filed [What you filed], sent by [How you sent it]. I have not received a written decision. The time limit under the federal claims rule for a decision of this kind is: [The time limit that applies]. The time runs from the day the claim or appeal was filed under the plan's procedures, even if more information was still to come. That time has passed.
Please confirm in writing:
1. The date the plan received my filing. 2. The date the plan sent its decision, with a copy, or the date it will send one. 3. Whether the plan agrees that it did not decide within the time limit. 4. What the plan says my next step is.
For a plan covered by the Employee Retirement Income Security Act (ERISA), the federal claims rule provides that if a plan fails to establish or follow claims procedures consistent with the regulation, the claimant is deemed to have exhausted the plan's remedies and may go to court. For a plan or insurer that is not grandfathered, the rule provides that a failure to "strictly adhere" to the internal appeal requirements allows the claimant to go straight to external review or to court. I am asking the plan to state its position on this in writing.
The rule excepts a minor violation that causes no harm, had good cause, happened during a good-faith exchange of information and is not part of a pattern. If the plan says that exception applies, I ask for the written explanation of the violation, which the rule requires the plan to give within 10 days.
Please reply in writing within 10 days of the date of this letter. I am not giving up any right by sending it.
Enclosures: 1. Proof that you filed (certified mail receipt, fax confirmation page or portal screenshot) 2. Copy of what you filed
Sincerely, [Your name]
Before you send it
Send it to the address the plan gives for appeals, and also to the person who signed any earlier letter from the plan. Use the address on your denial notice, member card or the plan's website; do not guess one. To prove it arrived, use certified mail with a return receipt, or fax it and keep the confirmation page, or send it through the plan's portal and take a screenshot that shows the date. If you phone, write down the date, time, name and any reference number.
What to enclose
- Proof that you filed (certified mail receipt, fax confirmation page or portal screenshot)
- Copy of what you filed
What happens next
- You: check the dates. Count from the day the plan received your claim or appeal, using your proof of delivery. Look for any extension notice the plan sent.
- You: send the letter and keep the proof of delivery. Do not wait for the reply to protect your other deadlines. If you already have a final denial, for most job-based and individual plans you must be allowed at least four months after you receive it to ask for external review (a grandfathered individual policy may give less); check your notice, which controls.
- Plan: the rule gives it 10 days to explain in writing any violation it says is minor. Ask for the answer in writing and keep it.
- You: if the plan does not decide or answer, ask about independent external review, which for a plan that is not grandfathered may be open when the plan has not strictly followed its appeal rules. Ask your state insurance department or, for a job-based plan, the United States Department of Labor, Employee Benefits Security Administration, at 1-866-444-3272, how to proceed. A lawyer can advise on going to court.
The rule behind this
- 29 CFR 2560.503-1(f)(2), (i)(2), (f)(4), (i)(4) (decision deadlines and when the clock starts)
- 29 CFR 2560.503-1(l)(1) (deemed exhaustion for ERISA plans)
- 29 CFR 2590.715-2719(b)(2)(ii)(F) (strict adherence; minor violations)
- 45 CFR 147.136(b)(2)(ii)(F), (b)(3)(ii)(F) (individual and Marketplace plans)
Sources
- 29 CFR 2560.503-1(f)(2), (i)(2), (f)(4), (i)(4) (decision deadlines and when the clock starts)
- 29 CFR 2560.503-1(l)(1) (deemed exhaustion for ERISA plans)
- 29 CFR 2590.715-2719(b)(2)(ii)(F) (strict adherence; minor violations)
- 45 CFR 147.136(b)(2)(ii)(F), (b)(3)(ii)(F) (individual and Marketplace plans)