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Few things are as frustrating and confusing as a denied or reduced insurance claim payout – but did you know that you can dispute the decision? Additionally, consumers have certain rights, afforded to them by law, when dealing with their insurance companies. Learn more about those rights, and how an experienced insurance dispute attorney can assist with the appeals process, with help from the following information.

About 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.

Sources:

http://www.naic.org/documents/consumer_state_reg_brief.pdf

https://mc.insurance.illinois.gov/messagecenter.nsf

People purchase insurance coverage to protect themselves when something goes wrong. Depending on the type of insurance, claims can be paid out for health issues, auto accidents, home repairs, or deaths in the family, among other things. These are already stressful events. A denied insurance claim merely serves to add more stress and difficulty to an already trying situation. The reasons for such a denial can be varied and depend on the type of insurance in question, but in these situations consumers have options available to them to contest the insurance denial.

Reasons for a Denial

The reasons for an insurance company to deny a claim on a policy vary greatly between different types of insurance. For instance, a company providing a life insurance policy may reject a policy claim based on a belief that the person’s death was actually a suicide, or a company providing health insurance could reject a claim made for a specific treatment by arguing that the treatment was not actually medically necessary. However, there are also some grounds for a denial that span across the insurance industry. One of the most common is a “material misrepresentation,” which means that the company believes that the policyholder lied or withheld important information during the application for a policy.

Exactly what qualifies as a material misrepresentation changes from industry to industry. Health or life insurance companies would argue that hiding a prior medical condition may be a material misrepresentation, while an auto insurance company would be more concerned with a past accident. Furthermore, any of these reasons could just be a pretext for a “bad faith” denial, which means that the insurance company privately believes that the policyholder has a valid claim, and simply does not want to part with its money.

Contesting a Denial

Policyholders facing a denied claim do have options available to them. The process will likely begin with the insurance company’s internal appeals process. This may involve letter writing, phone calls, or in-person interviews where the policyholder explains their position. It can be advantageous to consult a lawyer at this point for two reasons.

First, the insurance company may have lawyers involved at this stage, so it evens the playing field. Second, if the issue does proceed to a lawsuit, the lawyer will already know the case’s history and they may be able to prevent early missteps that would cause problems in litigation, which would be the next step if the internal appeals fail. The one exception to this is in the case of health insurance. Illinois recently passed a law allowing policyholders to apply for an independent external review in the case of a denied health insurance claim.

If you are dealing with a denied insurance claim, you do not need to do it alone. Reach out to a skilled Schaumburg insurance dispute attorney today. Our team represents clients across the northwest suburbs, including in towns such as Crystal Lake, Arlington Heights, and Buffalo Grove, Illinois.

About 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.