DISABILITY INSURANCE APPEAL PETITION
(Illinois – Administrative Proceeding)
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Appeal Procedures
3.2 Medical Evidence Requirements
3.3 Vocational Factors
3.4 Requested Relief - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title and Parties
Disability Insurance Appeal Petition (“Petition”) submitted by [APPELLANT NAME] (“Appellant”) against [INSURANCE COMPANY LEGAL NAME] (“Respondent”).
1.2 Recitals
A. Appellant is/was insured under Disability Insurance Policy No. [POLICY NUMBER] (the “Policy”).
B. On [INITIAL CLAIM DATE], Appellant filed a claim for disability benefits pursuant to the Policy.
C. Respondent denied or terminated benefits by written notice dated [DENIAL DATE] (the “Adverse Determination”).
D. Appellant timely files this Petition in accordance with Illinois state disability insurance law and all procedural requirements, seeking full reinstatement and payment of benefits.
1.3 Effective Date and Jurisdiction
This Petition is deemed effective upon filing with the designated Illinois administrative tribunal on [FILING DATE] and is governed exclusively by applicable Illinois disability insurance law (“Governing Law”).
2. DEFINITIONS
For purposes of this Petition, capitalized terms shall have the meanings set forth below.
“Administrative Court” means the Illinois administrative forum with jurisdiction over this appeal, currently [NAME OF AGENCY/TRIBUNAL].
“Adverse Determination” has the meaning set forth in Recital C.
“Benefits” means the total monthly disability income benefits and ancillary amounts payable under the Policy, inclusive of any cost-of-living adjustments.
“Claim File” means Respondent’s complete administrative record pertaining to Appellant’s claim, including but not limited to medical, vocational, and investigative documentation.
“Disability” has the meaning assigned in the Policy.
“Vocational Factors” means Appellant’s age, education, past relevant work, and transferable skills as they impact employability.
[// GUIDANCE: Add or delete defined terms to match underlying Policy language.]
3. OPERATIVE PROVISIONS
3.1 Appeal Procedures
(a) Timeliness. This appeal is filed within the time permitted by Illinois insurance regulations and the Policy’s internal appeal provisions.
(b) Exhaustion. Appellant has exhausted or is deemed to have exhausted all internal administrative remedies.
(c) Record Preservation. Respondent shall preserve the Claim File intact pending final disposition.
3.2 Medical Evidence Requirements
(a) Primary Evidence Submitted. Appellant hereby submits contemporaneous medical records from [TREATING PHYSICIAN NAMES], including objective findings (e.g., MRI, EMG, laboratory results) establishing functional impairment.
(b) Functional Capacity Evaluation. Attached as Exhibit [__] is a treating-source Functional Capacity Evaluation (“FCE”) demonstrating inability to perform material duties.
(c) Opinion Weight. Under Illinois law and accepted evidentiary standards, treating-physician opinions are entitled to controlling or substantial weight when well-supported and uncontradicted.
3.3 Vocational Factors
(a) Transferable Skills Analysis. Vocational expert report attached as Exhibit [__] concludes Appellant lacks transferable skills to perform any occupation within the national economy consistent with physical restrictions.
(b) Earnings Threshold. Any hypothetical alternate occupation fails to meet the Policy’s minimum earnings replacement percentage.
3.4 Requested Relief
Appellant respectfully requests:
1. Immediate reinstatement of ongoing Benefits;
2. Retroactive payment of past-due Benefits from [BENEFITS CESSATION DATE] through the present with applicable interest;
3. Continuation of waiver-of-premium status; and
4. Such other relief deemed just and equitable, including injunctive relief compelling prompt benefit payment.
4. REPRESENTATIONS & WARRANTIES
4.1 Appellant represents that all submitted documentation is true, correct, and complete to the best of Appellant’s knowledge.
4.2 Respondent warranted, under the Policy and Illinois insurance law, to administer claims in a fair, prompt, and non-arbitrary manner.
4.3 Survival. The representations and warranties herein shall survive determination of this appeal.
5. COVENANTS & RESTRICTIONS
5.1 Cooperation. Appellant shall reasonably cooperate with any lawful request for additional evidence that is material and not unduly burdensome.
5.2 Non-Retaliation. Respondent shall refrain from retaliatory acts, including but not limited to policy cancellation or premium increase arising from the filing of this Petition.
6. DEFAULT & REMEDIES
6.1 Event of Default. Failure of Respondent to issue a determination within statutory timelines or to comply with a final administrative order constitutes a default.
6.2 Notice and Cure. Upon default, Appellant will provide written notice; Respondent shall have ten (10) days to cure unless a shorter period is mandated by Governing Law.
6.3 Remedies. If default is uncured, Appellant may:
(a) Seek enforcement in circuit court;
(b) Petition for penalties and attorney’s fees as permitted by Illinois law; and
(c) Obtain injunctive relief to compel immediate benefit payment.
[// GUIDANCE: Adjust cure period to match any mandatory regulatory deadline.]
7. RISK ALLOCATION
7.1 Indemnification. Not applicable.
7.2 Limitation of Liability. Respondent’s liability is, at minimum, co-extensive with total Benefits due under the Policy, inclusive of statutory interest and any penalties expressly provided by Illinois law.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Petition is governed by Illinois state disability insurance law and related administrative regulations.
8.2 Forum Selection. Exclusive jurisdiction lies with the Administrative Court unless and until judicial review is sought pursuant to the Illinois Administrative Review Law.
8.3 Arbitration. Not available.
8.4 Jury Waiver. As an administrative proceeding, the parties waive any right to a jury trial.
8.5 Injunctive Relief. Nothing herein limits Appellant’s right to seek emergency injunctive relief to compel payment of Benefits.
9. GENERAL PROVISIONS
9.1 Amendments. This Petition may be amended only by written supplement filed with and accepted by the Administrative Court.
9.2 Assignment. Neither party may assign rights or obligations arising out of this Petition without prior written consent of the other party and approval of the Administrative Court.
9.3 Severability. If any provision is found unenforceable, the remaining provisions shall remain in full force.
9.4 Integration. This Petition, together with all attached exhibits, constitutes the entire submission regarding Appellant’s appeal.
9.5 Electronic Signatures. Electronic signatures shall be deemed originals for all purposes permitted under Illinois law.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the undersigned executes this Petition as of the Effective Date.
APPELLANT
Signature: ______
Name: [APPELLANT NAME]
Address: [ADDRESS]
Phone: [PHONE]
Email: [EMAIL]
COUNSEL FOR APPELLANT
Signature: ______
Name: [ATTORNEY NAME], Esq.
Firm: [LAW FIRM NAME]
ARDC No.: [_____]
Address: [ADDRESS]
Phone: [PHONE]
Email: [EMAIL]
[NOTARY ACKNOWLEDGMENT, if required]
[// GUIDANCE:
1. Attach all referenced exhibits, including medical and vocational evidence.
2. Verify that filing complies with Illinois administrative rules (format, margins, service requirements, etc.).
3. Confirm deadlines: Illinois typically requires filing within 180 days of Adverse Determination unless Policy allows longer.
4. Consider confidentiality legends if Claim File contains sensitive PHI.
5. Tailor Limitation of Liability language if punitive damages or statutory penalties may exceed aggregate Benefits.]