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Appealing ERISA Life Insurance Claim Denial

Web Admin - Friday, August 21, 2015

Illinois insurance dispute lawyerThe Employee Retirement Income Security Act of 1974 (ERISA) governs certain life insurance plans offered by employers. Whether or not ERISA covers an insurance plan is important because it will impact the way in which a claim denial may be appealed. Additionally, claims governed by ERISA have more limited remedy options than under traditional state law.

What is ERISA?

Under ERISA, minimum standards are established for benefit plans offered by employers, including life insurance plans. However, ERISA is only applicable to private employers that offer employer-sponsored insurance (or other benefit plans) to employees. ERISA does not mandate that plans are offered by employers, but does set standards and rules that must be met for those employers that do offer plans. ERISA does not apply to individually purchased, private insurance plans.

Additionally, ERISA does not apply to the following plans:

  1. - A government plan;
  2. - A church plan with respect to which no election has been made under section 410(d) of title 26;
  3. - A plan maintained strictly for the purpose of complying with relevant workers’ compensation laws or unemployment compensation or disability insurance laws;
  4. - A plan maintained outside of the United States for the benefit of nonresident illegal immigrants; or
  5. - An excess benefit plan that is not funded.

Appealing a Claim Denial

The process for appeal begins with the insurance company sending a letter to the claimant explaining that the claim has been denied. A claimant has the right to receive all “relevant documents” to the case, but this must be requested. It is important to request the plan administrator to send these documents. After the claimant has all of the documents and is ready to state his or her case, the request for an administrative review should be made. However, a request for this review must be made within 180 days of the denial of the claim. It is important to note that, under ERISA-governed plans, a lawsuit is not available until an administrative review is conducted.

For the review, the insurance company will provide the reasons for denying the claim. The claimant should respond to these thoroughly and objectively. This is a critical step, because the information provided at this stage will be the information that the judge will review upon appeal in the event that the administrative review is not favorable to the claimant. Similarly, the administrative review is limited to the evidence and medical documents that have been provided to the company.

If the administrative review does not overturn the denial of the claim, the decision can be appealed by filing a federal lawsuit. ERISA does not allow for punitive damage awards or bad faith claims in these types of lawsuits. Additionally, the case is heard and ruled on by a judge, not a jury. As a result of these differences, quite often it can be beneficial to attempt to argue that ERISA does not cover the insurance plan.

Appealing denial of claims governed by ERISA can be complicated. For more information about the process and how an experienced Illinois insurance dispute attorney can help, contact us today. Drost, Gilbert, Andrew & Apicella, LLC proudly provides legal representation for communities such as Des Plaines, Crystal Lake, Palatine, Rolling Meadows, and Barrington.

Ken ApicellaAbout the Author: Attorney Ken Apicella is a founding partner of DGAA focusing in the areas of personal injury, employment, insurance coverage disputes, and civil litigation. Ken earned his J.D. from DePaul University College of Law in 1999. He has been named a SuperLawyers Rising Star and a Forty Illinois Attorneys Under Forty to Watch. Ken has written and lectured for the Illinois Institute for Continuing Legal Education and regularly serves as a moderator at Northwest Suburban Bar Association's Continuing Legal Education seminars.

Insurance Claim After an Automobile Accident

Web Admin - Friday, July 31, 2015

insurance claim, Illinois car accident lawyer, insurance disputeIn a perfect world, we would not need insurance because we would never have any accidents. Unfortunately, we do not live in such a wonderful place. If you have never been involved in an automobile accident, you may not be familiar with the process of making an insurance claim. Though we hope you never have to go through this process, understanding what to expect if you do can be helpful.

Illinois Fault-Based Insurance

When it comes to automobile accidents, Illinois is a fault-based state. This means that whoever is legally at fault for the accident is responsible for paying those individuals injured by the accident. Usually, this means that the at-fault party’s insurance carrier will pay for the damages. An individual involved in an accident caused by another driver has three options:

  1. 1. File a claim with his or her own insurance company, which will then pursue a subrogation claim against the at-fault party’s insurance company;
  2. 2. Pursue a claim directly with the at-fault party’s insurance company; or
  3. 3. File a personal injury lawsuit against the at-fault driver.

Pursuing Insurance Claims

Usually, automobile accidents involve claims with insurance companies. The requirements on automobile insurance are codified under the Illinois Insurance Code. After a claim is filed, a claims adjuster will be assigned to the case. The adjuster may contact the insured person to obtain more information about the accident. In addition, the adjuster may do the following:

  1. 1. Request a copy of the police report;
  2. 2. Contact the other driver involved in the accident;
  3. 3. Contact any known witnesses to the accident;
  4. 4. Inspect the car for damages (this may include the adjuster taking photographs of the vehicle); and
  5. 5. Contact healthcare providers for information in relation to any injury expenses.

If the accident resulted in no injuries, the only issue will be repair to the vehicle. Resolution of claims made for vehicle repairs usually involves one of the following options:

  1. 1. Use a body shop approved by the insurance company: these shops are already approved to perform automobile repair by the carrier; the claimant simply takes his or her car in for an estimate and the work is subsequently completed;
  2. 2. Obtain quotes: the adjuster may request that the claimant take the vehicle to several shops in order to obtain estimates to compare; or
  3. 3. Claimant uses their own shop: claimants may decide to use a shop of their choosing. But, this may result in the claimant having to pay the difference in cost between the shop he or she chooses and what the insurance company determines is the fair price of the work.

If injuries occur as a result of the accident, resolving the insurance claims becomes more complex. It will be necessary for the claims adjuster to receive evidence of all medical bills. This may require the claimant to sign a waiver granting the insurance company access to his or her medical records. Further, personal injury can add significant costs on top of the cost to repair the vehicle. This added cost may make coming to an agreement on who was at fault and for what amounts much more difficult and time-consuming.

Making claims against insurance companies can be difficult and frustrating. For assistance with your insurance claim, call an experienced Illinois insurance dispute attorney at 847-934-6000 today. Drost, Gilbert, Andrew & Apicella, LLC proudly provides representation for individuals throughout the northwest suburbs, in communities such as Crystal Lake, Barrington, Deer Park, Inverness, and Schaumburg.

Ken ApicellaAbout the Author: Attorney Ken Apicella is a founding partner of DGAA focusing in the areas of personal injury, employment, insurance coverage disputes, and civil litigation. Ken earned his J.D. from DePaul University College of Law in 1999. He has been named a SuperLawyers Rising Star and a Forty Illinois Attorneys Under Forty to Watch. Ken has written and lectured for the Illinois Institute for Continuing Legal Education and regularly serves as a moderator at Northwest Suburban Bar Association's Continuing Legal Education seminars.


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