For Patients use to notify Fund Administrator of letter to the NYS Insurance Department


Note: Enclose copies of claim forms and send copies to those listed below




To Whom It May Concern:


My dentist submitted a claim for benefits on my behalf on DATE. When I did not receive my reimbursement, I phoned your staff on several occasions and have been repeatedly assured verbally that payment would be made before DATE. However, to date, payment for this claim has not been made in accordance with my benefit policy.


I trust you will process my claim in a timely manner in accordance with your obligation under the terms of her policy and New York State law Ė if you have not already done so. I have contacted the New York State Insurance Department and the US Department of Labor regarding the planís failure to provide timely reimbursement.


Further, as New York State law requires reimbursement be made on your customerís behalf within 45 days, I have reported this matter to the NYS Insurance Department for unfair claims settlement practices, seeking the imposition of the penalties and interest permitted by New York State law as well.





Patients Name



cc: Dentist


††††††††††††††††††††††† NYS Insurance Dept.

††††††††††††††††††††††† Consumer Complaints

††††††††††††††††††††††† Empire State Plaza

††††††††††††††††††††††† Albany, NY 12257


††††††††††††††††††††††† US Labor Department

††††††††††††††††††††††† Pension and Welfare Benefits Administration

††††††††††††††††††††††† 200 Constitution Avenue NW

††††††††††††††††††††††† Washington, DC 20210