For Patientís use notify the New York State Insurance Department of unfair claims settlement practice.


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






Mr. Gregory Serio

Superintendent of Insurance

NYS Insurance Dept.

Empire State Plaza

Agency Building 1

Albany, NY 12257


Dear Mr. Serio:


My dentist submitted a claim for benefits on my behalf on DATE . A copy of my claim is enclosed. I have dental benefits provided by my employer, NAME, administered by the COMPANY NAME. When I did not receive my reimbursement, I phoned COMPANY on several occasions and have been repeatedly assured verbally that payment would be made before DATE. However, to date, COMPANY has not made payment for this claim in accordance with my benefit policy.


As New York State law requires reimbursement be made on a customerís behalf within 45 days, we are compelled to report this company to the NYS Insurance Department for unfair claims settlement practices, and seek the imposition of the penalties and interest permitted by New York State law as well.





Patients Name



cc: Dentistís Name


US Labor Dept,

Pension and Welfare Benefits Administration

200 Constitution Avenue NW

Washington, DC 20210

Att: Consumer Complaints Division


NYS Dental Association Council on Dental Benefit Programs


American Dental Association Council on Dental Benefit Programs