FORMAL APPEAL OF CLAIM DENIAL
Insurance Policy No. [POLICY NUMBER]
Claim No. [CLAIM NUMBER]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Parties.
(a) Claimant: [FULL LEGAL NAME OF INSURED / CLAIMANT], having an address at [ADDRESS] (“Claimant”).
(b) Insurer: [FULL LEGAL NAME OF INSURANCE COMPANY], an insurance company authorized to transact business in Illinois, having an address at [ADDRESS] (“Insurer”).
1.2 Effective Date. This Appeal is effective as of [DATE] (“Effective Date”).
1.3 Recitals.
A. Claimant is the insured under Policy No. [POLICY NUMBER] issued by Insurer (the “Policy”).
B. A covered loss occurred on [DATE OF LOSS] (the “Loss”).
C. Insurer issued a denial letter dated [DATE OF DENIAL LETTER] (the “Denial Letter”) refusing coverage for the Loss.
D. Claimant timely submits this Formal Appeal pursuant to (i) the Appeals Procedure set forth in the Policy; (ii) 50 Ill. Admin. Code Part 919 (Unfair Claims Practices); and (iii) Claimant’s rights under 215 ILCS 5/155.
NOW, THEREFORE, Claimant respectfully demands reconsideration and payment as set forth below.
[// GUIDANCE: Keep the Recitals concise and factual; do not incorporate legal arguments here—those belong in §3.]
2. DEFINITIONS
For clarity and consistency, the following terms have the meanings indicated below and apply throughout this Appeal:
“Appeal” means this Formal Appeal of Claim Denial, together with all schedules and exhibits.
“Bad Faith” means any unreasonable and vexatious delay or refusal to pay a claim as referenced in 215 ILCS 5/155.
“Business Day” means any day other than Saturday, Sunday, or Illinois-recognized legal holiday.
“Claim” means Claimant’s demand for coverage under the Policy arising out of the Loss.
“Claim File” means Insurer’s entire internal and external files, logs, notes, recordings, e-mails, and electronic data pertaining to the Claim.
“External Review” means any review by an independent third party as provided under Illinois law and, where applicable, the Affordable Care Act.
“Policy Limits” means the maximum amount of coverage available under the Policy with respect to the Claim.
[// GUIDANCE: Add or delete definitions as needed. Keep them alphabetical.]
3. OPERATIVE PROVISIONS
3.1 Appeal and Demand for Reversal.
(a) Claimant hereby appeals the Denial Letter in its entirety and demands that Insurer rescind the denial, accept coverage, and tender payment of all amounts due, not to exceed Policy Limits.
(b) Claimant further demands statutory interest and applicable penalties for any Bad Faith, together with reasonable attorneys’ fees pursuant to 215 ILCS 5/155.
3.2 Basis for Reversal.
(a) Factual Grounds:
(i) Coverage in Force. The Policy was valid and in full force on the date of the Loss.
(ii) Covered Cause of Loss. [DESCRIBE WHY LOSS IS COVERED – e.g., Fire damage within “Covered Perils” section.]
(iii) Satisfactory Proof of Loss. Claimant timely submitted all proofs of loss, estimates, photographs, and supporting documentation.
(b) Legal Grounds:
(i) Illinois Fair Claims Practices. The denial contravenes 50 Ill. Admin. Code 919.40(b) requiring claims to be investigated promptly and fairly.
(ii) Ambiguity Construed Against Insurer. Any ambiguity in the Policy must be construed in favor of coverage under Illinois law.
(iii) Bad Faith Exposure. Unreasonable refusal exposes Insurer to penalties under 215 ILCS 5/155.
3.3 Supplemental Evidence. Concurrently with this Appeal, Claimant submits the following exhibits:
(a) Exhibit A – Proof of Loss (sworn);
(b) Exhibit B – Independent Expert Report dated [DATE];
(c) Exhibit C – Photographic Evidence;
(d) Exhibit D – Itemized Damages Spreadsheet.
3.4 Requested Relief.
(a) Payment of the Claim in full, up to Policy Limits.
(b) Pre-judgment interest from [DATE OF LOSS] at the statutory rate.
(c) Reimbursement of attorneys’ fees and costs incurred in prosecuting this Appeal.
(d) Any other relief a court or arbitrator may deem just and proper, including injunctive relief compelling payment.
3.5 Required Response. Pursuant to 50 Ill. Admin. Code 919.50(c), Insurer shall acknowledge receipt of this Appeal within 15 Business Days and issue a final written determination within 30 Business Days of the Effective Date.
[// GUIDANCE: Adjust deadlines where the Policy provides a shorter timeframe. Ensure the Appeal is sent by certified mail or another trackable method to establish proof of receipt.]
4. REPRESENTATIONS & WARRANTIES
4.1 Claimant’s Representations.
(a) All statements, records, and documents submitted with this Appeal are true, accurate, and complete to the best of Claimant’s knowledge and belief.
(b) Claimant has disclosed all material facts known at this time.
(c) Claimant is the lawful holder of all rights under the Policy with respect to the Claim.
4.2 Survival. The representations and warranties in §4.1 survive Insurer’s resolution of this Appeal.
5. COVENANTS & RESTRICTIONS
5.1 Cooperation. Claimant will reasonably cooperate with Insurer’s further investigation, including providing access to damaged property, subject to §5.2.
5.2 No Waiver of Rights. Claimant’s cooperation shall not be construed as a waiver of any legal or equitable right, including the right to litigate or pursue External Review.
5.3 Confidentiality. All documents provided are furnished solely for claim handling purposes and may not be disclosed outside Insurer’s claim department or counsel except as required by law.
6. DEFAULT & REMEDIES
6.1 Events of Default. Each of the following constitutes an Insurer Default:
(a) Failure to respond within the timeframe stated in §3.5;
(b) Failure to rescind denial and tender payment within 10 Business Days after agreeing to coverage;
(c) Reaffirmation of denial without a reasonable basis in fact or law.
6.2 Cure Period. Insurer may cure any Insurer Default within 5 Business Days of receiving written notice of default from Claimant.
6.3 Remedies. If an Insurer Default is not timely cured, Claimant may:
(a) File suit in the Circuit Court of [COUNTY], Illinois for breach of contract and Bad Faith;
(b) Seek statutory penalties and attorneys’ fees under 215 ILCS 5/155;
(c) Petition for injunctive relief compelling claim payment;
(d) Initiate optional binding arbitration under §8.3.
7. RISK ALLOCATION
7.1 Limitation of Liability. Insurer’s monetary liability is limited to the Policy Limits, except as increased by penalties, interest, and fees recoverable under 215 ILCS 5/155 or other applicable law.
7.2 Indemnification. Not applicable.
7.3 Force Majeure. Neither party will be liable for delays in performance caused by events beyond their reasonable control; provided, however, this §7.3 does not excuse Insurer’s statutory obligations under Illinois law.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Appeal and any related dispute are governed by the laws of the State of Illinois, without regard to choice-of-law rules.
8.2 Forum Selection. The parties consent to the exclusive jurisdiction of the state courts of Illinois located in [COUNTY], subject to §8.3.
8.3 Optional Arbitration.
(a) Either party may elect binding arbitration by delivering written notice within 15 Business Days after Insurer’s final determination.
(b) Arbitration shall be administered by [AAA / NAM] under its Commercial Arbitration Rules, conducted in [CITY], Illinois.
(c) The arbitral award may include all remedies available under Illinois law and may be entered in any court of competent jurisdiction.
8.4 Jury Trial Preservation. Nothing in this Appeal constitutes a waiver of Claimant’s constitutional right to a jury trial.
8.5 Injunctive Relief. Claimant may seek emergency or permanent injunctive relief in a court of competent jurisdiction to compel coverage or payment notwithstanding §8.3.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers. Any amendment to or waiver of this Appeal must be in writing and signed by Claimant; no course of dealing or delay shall operate as a waiver.
9.2 Assignment. Claimant may assign rights under the Policy to mortgagees, contractors, or other third parties only with Insurer’s written consent, except assignments made in connection with the prosecution of this Claim.
9.3 Severability. If any provision of this Appeal is held invalid or unenforceable, the remaining provisions remain in full force.
9.4 Entire Appeal. This document, together with its exhibits, constitutes the entire appeal submission and supersedes prior oral or written communications regarding the Claim.
9.5 Counterparts; Electronic Signatures. This Appeal may be executed in counterparts, each of which is deemed an original. Signatures delivered electronically (e.g., DocuSign, PDF) are equally enforceable.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the undersigned has executed this Formal Appeal as of the Effective Date.
| Claimant | |
|---|---|
| _________ | Date: ___ |
| [NAME], in an individual capacity / as authorized representative of [ENTITY] |
[Optional Acknowledgment by Insurer for Internal Tracking Purposes]
| Insurer | |
|----------|--|
| _____ | Date: ___ |
| [NAME], Title: _____ | |
[// GUIDANCE: Send this Appeal via (1) certified mail, return receipt requested; (2) e-mail to the claim adjuster; and (3) the Insurer’s designated “appeals” address, if any. Retain proof of delivery for litigation or DOI complaint purposes.]
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