CaseWhy Appeals — Terms of Service

1. Who we are. CaseWhy Appeals ("the Service") is a web application at appeals.casewhy.com operated by CaseWhy LLC, a Florida limited liability company ("CaseWhy," "we"). These Terms are a contract between you and CaseWhy LLC. The Service helps people understand and respond to coverage denials from Medicare Advantage plans and Medicare Part D prescription drug plans, appeal Original Medicare fast-track decisions — a skilled nursing, home health, hospice, or outpatient rehab service ending, a hospital discharge, or a change to observation status — Original Medicare claim appeals from the Medicare Summary Notice, and Medicare Secondary Payer recovery demands, appeal Medicare premium determinations — an income-related monthly adjustment amount (IRMAA), an Extra Help (Low-Income Subsidy) decision, or a Part D late-enrollment penalty — respond to a PACE (Program of All-Inclusive Care for the Elderly) organization's decision to reduce, stop, or deny a service, and appeal Medicare enrollment and entitlement decisions from the Social Security Administration — a denied or delayed application, an incorrect entitlement date, a missed Part B enrollment period, a denied premium Part A enrollment, or a request for relief from a federal employee's own error, misrepresentation, or inaction. The Service also helps you file a plan grievance, a Quality Improvement Organization (QIO) quality-of-care complaint, or a request to the Medicare Beneficiary Ombudsman — these are complaints about how you were treated or the quality of care you received, not appeals of a coverage decision, and are always free. Separately, the Service helps you find the right place to go for a Medigap (Medicare Supplement) problem — an application decline, a claim dispute, or a premium increase — since Medigap is regulated by states, not through a Medicare appeal, and CaseWhy does not handle Medigap matters directly. It is separate from CaseWhy's USCIS case-tracking service, which has its own terms.

2. What the Service does and does not do. The Service reads the denial notice, premium determination, or bill you upload, explains in plain language what it says and what the governing rule says about that kind of decision, calculates the deadlines that apply, sends reminders, and — when you buy an appeal packet — prepares an appeal or reconsideration letter, a request for a supporting letter or statement from a physician or prescriber where one applies, a filled Appointment of Representative form (CMS-1696 or SSA-1696, whichever the case requires), any Medicare Part D coverage-determination, redetermination, or late-enrollment-penalty reconsideration form the case needs, any Social Security form an IRMAA or Extra Help case needs, and follow-up letters. The Service is not a law firm and does not provide legal advice. Using it does not create an attorney-client relationship. It does not give medical advice, does not decide whether care or a drug is medically necessary, does not decide what your income actually was, and does not file or send anything on your behalf. Every rule we cite links to the source so you can check it; the rules change, and you are responsible for confirming them before you rely on them. CaseWhy is not affiliated with or endorsed by Medicare, the Centers for Medicare & Medicaid Services (CMS), the Social Security Administration (SSA), any Medicare Advantage plan, any Medicare Part D plan, any Quality Improvement Organization, or any government agency. Complaints and grievances: the same "not legal advice" limits above apply — we prepare the letter or point you to the right contact, but the plan, QIO, or Ombudsman decides the outcome. Medigap: the Service does not sell, recommend, compare, or advise on any Medigap policy or carrier; it only identifies your state's insurance regulator and SHIP program and describes rights under federal and (where verified) state law. This is not insurance advice, and you should confirm current rules with your state before relying on them.

3. No promise of outcome. Appeals and reconsiderations are decided by plans, the Social Security Administration, independent reviewers, and judges. We cannot and do not promise that any appeal will succeed, that a plan or agency will meet its deadlines, that a bill will be reduced, or that a premium or penalty will be lowered. Statistics on the Service describe published aggregate results, not your case.

4. Who may use it. You must be 18 or older. You may use the Service for yourself or for a family member or other person you help; you are responsible for having their permission to upload their documents and act on their behalf, and for using the CMS-1696 or another valid authorization where a plan requires one. One account per person.

5. Deadlines and reminders. Deadline calculations are based on the dates printed on your notices and the rules in effect when we calculate them. The notice you received controls; if it states a different date, follow the notice. Reminders are sent by email as a convenience and may be delayed or fail; you remain responsible for filing on time.

6. Fees, Appeals Plus, and refunds. Understanding your denial or determination — upload, explanation, deadlines, reminders, and the letter preview — is free. Appeals Plus (the appeal packet) is a one-time fee, paid through Stripe, which unlocks that case's letters at every appeal level for 12 months from purchase — including any later letter the case needs as it advances. The fee is $49 per case for a Medicare Advantage or Original Medicare case and $39 per case for a Medicare Part D, Medicare premiums, PACE, or Medicare enrollment and entitlement case; the price shown at checkout for your case is the price you pay. Appeals Plus is not a subscription: it is a single, one-time payment; nothing renews or recurs, and no further charge follows for that case. Each person's denial or determination is a separate case; a later denial or determination of a different service, drug, or premium issue is a new case, requiring a new payment. When you pay: you are asked to pay only after the Service has prepared your appeal letter and shown you a preview of it; if a letter cannot be prepared, you are not charged. Refunds: we do not refund based on the outcome of an appeal. Any refund is issued at our discretion; to request one, contact us. Prices may change; the price shown at checkout is the price you pay. Taxes, if any, are added at checkout.

7. Your documents and information. You keep ownership of what you upload. You give us the limited permission needed to process it to provide the Service, including sending it to an AI service to read and explain it. A dollar amount you type or upload — income, a premium surcharge tier, or a penalty amount — is automatically detected and removed before anything is saved; we do not store it. How we handle your information — what we keep, what we don't, and for how long — is in the Privacy Policy, which is part of these Terms. You agree not to upload documents about a person you are not authorized to act for.

8. Acceptable use. No use that is unlawful, that impersonates another person, that submits false information to a plan or reviewer, that scrapes or reverse-engineers the Service, or that interferes with it. We may suspend or close accounts that break these rules.

9. Third-party services. The Service runs on Vercel (hosting and AI gateway), Neon (database), Vercel Blob (file storage), Postmark (email), Stripe (payments), and Anthropic's Claude models (explanations and letter drafting). Payment card details go to Stripe and are never stored by us. Links to Medicare.gov, CMS, the Social Security Administration, state SHIP programs, Quality Improvement Organizations, and other outside resources are provided for your convenience; we do not control them.

10. Disclaimer of warranties. The Service is provided "as is" and "as available." To the fullest extent permitted by law, we disclaim all warranties, express or implied, including accuracy, fitness for a particular purpose, and non-infringement. Rules, forms, and deadlines cited by the Service may be incomplete or out of date.

11. Limitation of liability. To the fullest extent permitted by law, CaseWhy LLC is not liable for indirect, incidental, consequential, or punitive damages, or for lost coverage, unpaid bills, missed deadlines, or appeal outcomes, arising from your use of the Service. Our total liability for any claim is limited to the greater of $50 or the amount you paid us for the case concerned in the 12 months before the claim. Some states do not allow these limits; where that is so, they apply to the extent permitted.

12. Indemnity. You will hold CaseWhy LLC harmless from claims arising from documents you upload without authority, false information you submit to a plan or reviewer, or your breach of these Terms.

13. Changes; termination. We may change the Service or these Terms; material changes are announced on the site or by email 14 days before they take effect, and continued use after that is acceptance. You may delete an individual case at any time from that case's page, which permanently removes it as described in the Privacy Policy; to close your account entirely, contact us. We may close accounts for breach. Sections 2, 3, 7, and 10–15 survive.

14. Governing law and disputes. Florida law governs these Terms. Disputes are brought in the state or federal courts located in Florida, and you consent to their jurisdiction. Nothing here limits rights you have under the consumer-protection laws of your state.

15. Contact. Questions about these Terms: appeals@casewhy.com. Mail: CaseWhy LLC, 7901 4th St N, Ste 300, St. Petersburg, FL 33702.