What to do When an Insurance Company Denies Your Claim

Were you involved in an accident and the insurance company denied your

Insurance company denies your claim

claim? I’ve mentioned in this blog repeatedly that insurance companies are not on your side.

These are entities that are dedicated to one thing and that’s making profits. And as a result, they will delay, they will deny they will diminish your claims any way that they can.

If you talk to insurance adjusters, they will likely dispute this. They’ll tell you that they’re being practical about how severe an accident was and that is the basis of their decision about how much to compensate people. Well, I’m sorry. I’ve seen it firsthand. I’ve seen insurance companies deny claims or diminish the value of claims, only to ultimately pay tens of thousands of dollars once a lawsuit was filed. So, trust me on this. When dealing with insurance companies, they are not on your side.

So, what do you do when an insurance company denies your claim? First of all, we have to clarify which insurance company it was. There are likely going to be insurance companies on both sides of this accident. You may have insurance and so may the guy who you think caused the accident. Insurance denials can come from either side.

What To Do When The Defendant’s Insurance Company Denies Your Claim

Let’s start with what to do when the other insurance company denies your claim. Let’s take a hypothetical. You were involved in an accident and a guy hit you from behind – a rear end accident. You get his or her insurance information and you file a claim with State Farm or Allstate or whoever that person has for their insurance.

State Farm investigates. They talk to their insured, maybe they interview you (though you may not want to provide a recorded statement to their insurance adjuster). Maybe they analyze the property damage involved in the accident. And then you get a letter from them that says that they have denied your claim. What do you do?

You don’t have many choices in that circumstance. If you only have a property damage claim, maybe you can get compensation from your insurance company.

But if you have injuries and their insurance company denied your claim, what do you do? You really only left with one choice. And that is to file a lawsuit against the other party.

That’s the only way the insurance company is going to respond. You have the right to get your impartial day in court so that you can get the facts on the record. You get to argue your case and let the judge or jury decide whose at fault for the accident.

I always recommend to people – get an attorney to represent you. But this is particularly true if you’re going to court.  Those people represented by lawyers have a far greater success rate than those who are not.

But the problem is in this case, and I’ve seen this countless times is that if your claim was already denied by an insurance company, there’s a very good likelihood that the facts that are not favorable to you and you’re asking a lawyer to get involved in a case that has already been denied.

Now I’m not saying there aren’t lawyers who will do it or who won’t do it, but I actually did a video on the various reasons why a lawyer may not get involved in a case and an insurance claim already being denied was one of them. It’s a tough burden for a lawyer to overcome though not impossible.

If you get a lawyer, the lawyer takes care of moving the case forward. What if you don’t get a lawyer – what do you do? Well, you can file a lawsuit on your own behalf.

There’s two different kinds of cases I want to talk about here. First is the small case with minimal property damage and/or very small injuries.

In Illinois, we have something called small claims court. And if you have a case worth $10,000 or less, you can pretty much file that a case or that claim on your own in small claims court. That’s what it’s made for – people to represent themselves on small claims.

If you have a larger claim, i.e., you have significant injuries, you’re going to file in district court. That’s more complicated. But if you go to your local county courthouse (in Chicago it’s the Cook County court house on Washington Street – or there are local districts like in Rolling Meadows and Skokie), there are people there who can help you through that process.

Also, it may not be that the insurance company totally denied your claim. But what if they said that you were 50% responsible for your claim? Well, then you have a choice. You can either accept their allocation of responsibility or liability, or you can fight them. Check out this blog for more information on when you might accept some fault for an accident.

Oftentimes when an insurance company puts 50% on you or 70% on you, you can negotiate a percentage of fault.

What To Do When Your Own Insurance Company Denies Your Claim

Let’s switch gears for a second. So now let’s talk about what to do when your own insurance company denies your claim or does something that you don’t like.

The first place that this often pops up as in your property damage claim. Let’s take another hypothetical. You were involved in an accident and your Toyota is a total loss. Your insurance company Allstate is compensating you but much less than you think your vehicle is worth. What do you do in that situation?

Or, let’s say that you’re filing a claim for your pain and suffering and medical bills with your own insurance under your uninsured motorist or underinsured motorist coverage and Allstate is offering you much less than you think your case is worth. What do you do?

At this point, your own insurance company becomes adverse – meaning they are basically the same as if they were the insurance company for the defendant and you’ve got to treat them as such.

I have discussed before on this site about the fact that you have to give a recorded statement to your own insurance company. So you still have an obligation to work with them, provide them your medical bills, whatever it may be. And if you don’t, they could deny your claim altogether.

I’m not saying don’t work with them. I’m just letting you know that they are now adverse. You’re trying to get money from them. And they’re going to think in their own best interests, not yours.

If they deny your claim or low-ball you, what do you do? Some people think that, you need to file a lawsuit against your own insurance company, but generally speaking, that’s not what happens.

Appeal Not Lawsuit

You need to check your insurance policy, but generally speaking, there’s an appeal process that you have an obligation to follow. FYI, it could be that you have to appeal in writing within 30 days (or another time period). So we recommend immediately requesting a certified copy of your insurance policy from your insurance company, and advising them in writing that you are appealing their decision.

Normally there’s an arbitration clause in your own insurance policy. That means you agreed by signing your insurance contract, that you’re not going to file a lawsuit. Rather, you are going to arbitrate your dispute.

The way arbitration works, generally speaking, is that you go to an association, like the American Arbitration Association and you file a request for arbitration. But again, check your specific insurance policy.

Often there will then be a three-person panel of arbitrators who are attorneys or judges in your jurisdiction. You get your ‘day in court’ except its in front of the arbitration panel. Arbitration will be less formal than going to court and that may benefit you and your case.

Once the evidence is submitted and you (and potentially other witnesses) testify about the incident, the arbitrator rules.

One reason that insurance companies like arbitration is that since the arbitrators were past attorneys or judges, they’re not going to be moved by emotion like a jury might. So, insurance companies may be able to control the amount of damages you are awarded.

By the way, you can obtain a lawyer to represent you in arbitration against your own insurance company and again we strongly recommend that you do so. Especially if you have severe medical injuries. If it’s just a property damage claim, you probably don’t need a lawyer there on your behalf.

Thanks for checking out this article on what to do when an insurance company denies your claim. If you want to speak with the attorneys at the Chicago Legal Group reach out to us.

Sidewalk Trip and Fall Injury and the De Minimis Rule in Illinois

Our firm with co-counsel recently reached a settlement on behalf of a clienttrip and fall on sidewalk that suffered a trip and fall injury on a sidewalk. The client, a senior citizen, was walking into a bank when she tripped on unlevel concrete. The sidewalk was in poor condition and in an area of heavy foot traffic. She landed face first and broke both her front teeth. Our biggest challenge in the case was overcoming the de minimis rule in Illinois.

Slip and fall law Illinois

Under slip and fall law Illinois, a defendant will be held liable to the person who fell where the injury was caused by the property owner’s negligence. To show negligence in Illinois, the plaintiff must prove that the property owner failed to fulfill its duty to prevent the fall and that it caused the plaintiff’s injuries.

If the defendant is found negligent, liability will be under a theory of contributory or comparative negligence. Contributory negligence means that the victim is at least 50% at fault for the injury. Comparative negligence means that the victim is less than 50% at fault for his or her injuries. As a general matter, it can be difficult for a victim to recover under contributory negligence. Under comparative negligence, damages will be reduced by the proportion that the victim was found to be at fault.

One important defense that the defendant may have in Illinois is the de minimis rule.

What is the de minimis rule in Illinois?

The de minimis rule applies where someone is injured in a sidewalk injury case. The de minimis rule holds that the defendant will generally be liable for the victim’s injuries where there were sidewalk deviations approaching two inches in height. However, the Illinois courts have held defendants liable for deviations less than two inches. The courts also look at other factors besides height, like congestion, nearby distractions, as well as any evidence that the defendant was aware of the defects.

For instance, in a local case from 2018, Bartkowiak v. City of Aurora, 2018 App (2d) 170406, the plaintiff was injured when tripping over a hole in a parking lot that was approximately 1.5” deep. The trial court held that the de minimis rule prevented the plaintiff from recovering. The appellate court, however, disagreed with the trial court. The court held that since the depression was in a congested area likely to be frequented by pedestrians, there was broken asphalt in the area, and the defendant was aware of the hole the defendant could be held liable.

Likewise, the deviation in the sidewalk in our client’s case was less than 2” in height. As experienced slip and fall attorneys Illinois we were able to demonstrate to the defendant that we would be able to overcome the de minimis rule at trial. Not only was the sidewalk in poor condition it was located in a heavily congested area. Many other firms would have refused to take the case, believing that the rule would result in their client’s case being thrown out. Our firm, however, has many years of experience representing clients in sidewalk injury cases.

If you or someone you know have been injured in a sidewalk injury case, it is important to consult with an experienced personal injury attorney to discuss your options. If you have previously discussed your case with counsel and were informed that your claim was barred by the de minimis rule, please contact us today for a free consultation.

Chicago Lawyer Reviews Illinois Dram Shop Act

Drinking too many alcoholic beverages at a bar or restaurant can lead to chicago dram shop lawyeralcohol-related injuries, accidents or worse. As a dram shop attorney in Chicago, I want to provide you a brief overview on the dram shop liability law in Illinois.

If you or a loved one has suffered an alcohol-related injury, contact me today at 847-305-4105 for a free consultation or read below to learn more about what you can do to recover.

Dram Shop Laws in General

Dram shop laws are a body of laws that provide a legal cause of action against the owner of a tavern, pub, restaurant or other establishment that provided alcohol to someone who caused an injury or damages.

This does not necessarily apply to social hosts who provided alcohol to guests at a social function. Check the laws of your state to determine whether social hosts are on the hook as well.

Illinois Dram Shop Act Definition

The Illinois dram shop law ensures that those who sell or dispense alcoholic beverages to obviously intoxicated individuals or minors are held responsible for any damages or injuries that those individuals cause. This can include motor vehicle accidents, physical altercations, harassment, slip and falls, property damage, and more.

Statute of limitations

Per Illinois statute, there is a one-year time limit in which to file a lawsuit under the Dram Shop Act.

Important: Note that the one-year time limit is significantly shorter than the amount of time in which you have to file a lawsuit for your injuries against the defendant. If you suspect that a pub or other establishment may be at fault for your injuries, do not delay. Contact a Chicago attorney immediately at 847-305-4105.

Elements of the cause of action

To establish a cause of action under the Illinois Dram Shop Act, a plaintiff must prove the following:

  • The alcohol was sold or dispensed by the defendant
  • The defendant could foresee that this alcohol would cause the plaintiff or perpetrator to become intoxicated
  • There are damages (medical, property, emotional, etc.)
  • These damages were caused by the patron’s or the plaintiff’s intoxication

Defenses

Illinois’ stricter laws mean that anyone who sold or gave the patron alcohol throughout the evening leading up to the incident can be held comparatively negligent.

Bars, restaurants, and vendors often use the following defenses:

  • Extraterritoriality: the alcohol was consumed outside of the state of Illinois
  • Provocation: the injuries suffered by the plaintiff are due to a provocation on their part
  • Complicity: that the plaintiff is one of the people actively contributing to the intoxication of the patron or themselves

Damages

The amount a victim can recover under the Illinois Dram Shop Act is limited. The amount changes every year. In 2018, the dram shop liability limits for alcohol-related injuries are:

  • For causes of action involving persons injured, killed, or incurring property damage on or after January 20, 2018, the judgment or recovery cannot exceed $68,777.44
  • For causes of action for loss of means of support or loss of society resulting from the death or injury of any person on or after January 20, 2018, the judgment or recovery cannot exceed $84,061.32

Note that this money is on top of the money you can recover from the defendant who caused your accident.

For a free evaluation of the viability of your Illinois Dram Shop Act case, contact our office today at 847-305-4105 for a free consultation.

Personal Injury Medical Codes

Ever wonder what those personal injury medical codes are in your medical bills and why they are important to your personal injury

Personal Injury
Personal Injury Medical Codes

case?  For example, a code might look like: “ICD S42.402A.” Those codes actually mean something and can be very important to the success of your personal injury case. For help figuring out these codes, contact our office for a free consultation at 312-848-9783.

Personal injury medical codes

For many years, medical providers and insurance companies have been using personal injury medical codes called “ICD Codes” to document the diagnoses of medical patients. ICD stands for International Classification of Diseases. If you are interested in looking up what the diagnosis is of your injury, check out this ICD website – www.icd10data.com. This is the site we use to figure out ICD codes. The reason behind using codes like this is to create uniformity within the medical world. It’s also used by auto insurance companies – many times to reduce the amount of your claim.

ICD codes were created by the World Health Organization and there have been 10 versions of ICD Codes. ICD 11 codes are currently being created. A huge jump in the number of classified diagnoses/diseases etc. occurred in the change from ICD 9 to ICD 10. ICD 9 had approximately 14,000 classification codes. ICD 10 has approximately 70,000 codes.

The biggest difference between 9 and 10 is that ICD 9’s were generic. For example, this is an ICD 9 code: “812.40 – Closed fracture of unspecified part of lower end of humerus.” Note that there is no indication whether this applies to the left or right arm and does not state whether this is the first medical visit for this issue or a subsequent visit.

Conversely, the ICD 10 code for the same injury is “S42.402A – Unspecified fracture of lower end of left humerus, initial encounter for closed fracture.” The left arm is specifically indicated as is where in the treatment process the visit occurred (initial encounter).

If you were involved in an accident and received treatment prior to September 30, 2015, use ICD 9 codes. For all injuries from October 1, 2015 and after, use ICD 10 codes.

Why are personal injury medical codes important to my case?

Many auto insurance companies use personal injury “calculators” to assess the value of your case. The most known tool is called “Colossus.” Insurance adjusters take your medical bills and everything else about your case and enter it into the software and it comes back with a settlement range within which to resolve your case.

One piece of data that insurance adjusters enter into their software programs are ICD codes. When we do a demand letter to an insurance company, we always document what ICD Codes we want entered for them. That way you can avoid a situation where an insurance adjuster misses a relevant personal injury code.

For example, in a demand letter we might insert the following:

“Emergency Room Visit

Dr. Smith instructed Ms. Jones to take Prednisone and Tylenol for pain and to return to his office in four to five days if her symptoms increased. Dr. Smith also instructed Ms. Jones to undergo x-rays of her thoracic spine which Ms. Jones dutifully did on June 20, 2017, the results of which were negative.

ICD Codes:

  • M62.830: Muscle spasm of back
  • M54.2 Cervicalgia
  • M54.6: Acute right-sided thoracic back pain
  • V89.2XXA: MVA, initial encounter”

Pros and Cons of personal injury medical codes

The idea behind using ICD Codes (and personal injury calculators) makes some sense. It provides uniformity within a system. And using ICD 10 codes provides for very specific detailing of diagnoses.

However, ICD Codes can be a pain to work with. Often, they are not listed on medical bills or in the records and you have to find them yourself online.

Also, ICD Codes are descriptive as to an official diagnosis, but they don’t measure the effect the diagnosis has on a person. In fact, it can hurt your case. For example, if you are diagnosed with a back strain or sprain – a soft tissue injury – you can be sure that the offer from the insurance company is going to be fairly low.

ICD Codes (and/or programs like Colossus) cannot measure the degree of your pain and suffering as a result of an injury. People who suffer strains and sprains can suffer significant pain and discomfort for a long period of time but that will not be reflected no matter what ICD Code you use.

Also, there is no ICD Code for aggravation or exacerbation of an injury. As such, if you had a pre-existing back injury, get rear ended, and this exacerbates your pain and discomfort, there is no ICD Code you can point to in order to explain the situation. The ICD Code will simply document “back sprain/strain.”

Pro Se Representation

Often our clients receive medical bills and send them to us. The medical bills that you receive in the mail normally do NOT include ICD Codes. As such, if you represent yourself, when you obtain your bills, make sure you request bills with the ICD Codes.

If you get injured in an accident and you want to talk to an attorney about your case, or you want clarification about how to use personal injury medical codes, feel free to contact us for a free consultation at 312-848-9783.