healthcare

By: Andrew B. Bryant

On February 6, 2018, the Illinois Appellate Court issued a significant decision safeguarding healthcare benefits for injured public safety employees under the Illinois Public Safety Employee Benefits Act (“PSEBA”) (820 ILCS 320/1 et seq).

In the case, a City of Des Plaines Police Officer stopped a truck for operating with an apparently overweight load. At a local weigh station, the overweight violation was confirmed by the officer. The officer then climbed a ladder to inspect the truck’s load in order to complete administrative paperwork required by the City. While climbing the ladder, the officer injured his leg and was ultimately diagnosed with left medial and lateral meniscus tears in his left knee, ending his police career. The officer was awarded a line-of-duty disability pension, but his petition for healthcare benefits under the PSEBA was contested by the City. The City argued that although the officer suffered a qualifying “catastrophic” injury under the PSEBA, the activity that the officer was engaged in at the time of the injury was not a qualifying activity that warranted the award of healthcare benefits under the PSDEBA.

Under the PSEBA, healthcare benefits can be awarded to public safety employees when a qualifying injury occurs as a result of (1) response to fresh pursuit, (2) response to what is reasonably believed to be an emergency, (3) the unlawful act perpetrated by another, or (4) the investigation of a criminal act. The Court noted the officer was clearly not engaged in fresh pursuit or responding to an emergency, and the traffic code violation did not qualify as a “criminal act” under Illinois law. Therefore, the case turned on whether the officer was injured as a result of the truck driver’s unlawful act of hauling an overweight load. In affirming the trial court’s award of PSEBA healthcare benefits, the Appellate Court held that the officer was duty bound to take action in response to the truck driver’s violation of the law. Therefore, as the officer’s injury was indisputably a clear consequence and effect of the truck driver’s unlawful act of driving his truck in contravention of the Illinois Vehicle Code, the injury occurred because of an unlawful act perpetrated by another as set forth in the PSEBA.

See Marquardt v. City of Des Plaines (2018 IL App 1st 163186).

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The content provided here is for informational purposes only and should not be construed as legal advice on any subject.

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healthcare

With the passage of the Affordable Care Act in 2014, pre-existing conditions were addressed on a federal level. Since Illinois is a guaranteed issue state, health insurance claimants in Illinois enjoy thorough protections with regard to their pre-existing conditions and the way in which their health insurers handle their claims.

Pre-Existing Conditions Cannot Justify Claim Denial

In Illinois, an insurer cannot deny coverage on the basis of a pre-existing condition.  For example, if you are suffering from a persistent immune system disorder (i.e., Lupus) for several years prior to signing onto a new insurance plan, your insurer cannot thereafter deny coverage on the basis of that condition.  In the past, when pre-existing condition regulation was more piecemeal, insurers attempted to avoid these protections through various means, such as establishing an exclusion period for pre-existing conditions.

Previously, exclusion periods led to some challenging situations for those with serious pre-existing conditions.  Take the above example involving Lupus.  An insurer might institute a pre-existing condition exclusion period of 12 months where you would not be entitled to make a health insurance claim relating to Lupus.  Only after waiting out the exclusion period could you make a claim.

Fortunately, changes in the law have led to much greater protections for those suffering from pre-existing conditions.  In Illinois, if your insurer denies your claim on the basis of a pre-existing condition, you would likely be entitled to appeal the denial.  If that appeal fails, a skilled Chicago insurance attorney at Bryant Legal Group is prepared to pursue trial litigation for damages and you might even be entitled to sue for bad faith, which could result in an award of punitive damages.

Failure to Report May Lead to Penalties

Given how recently the laws have changed with regard to pre-existing conditions, many policyholders are unaware of their rights and the protections granted to them pursuant to both state and federal law.  As such, some may engage in conduct such as including false information to avoid being identified with a pre-existing condition.  It’s important to note that a policyholder’s failure to report their pre-existing conditions may lead to potential liability for fraud.  Further, if you fail to report your pre-existing condition and thereby provide false information to your insurer, they are not required to renew your insurance contract.  This could lead to a gap in coverage that puts you in a vulnerable position.

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Pre-Existing Provisions Permissible in Disability Insurance Policies

The laws, however, that provides these policyholder protections in the case of health insurance do not apply to disability insurance. Pre-existing conditions can be considered in the sale of disability insurance policies and provisions can be included in disability insurance policies that may preclude collection of benefits for disability due to a pre-existing condition. If you have had a long standing health issue and are considering the purchase of a disability insurance policy or making a claim under a policy you already have, do not hesitate to contact us.

Call Today to Connect to an Experienced Chicago Insurance Attorney

If you are currently in a dispute with your health insurer over a denied, delayed, or undervalued claim, then it’s important that you get in touch with an experienced Chicago insurance attorney in a timely manner, so that your claims can be properly evaluated and the appeal (and potentially, litigation) process can begin.  Here at Bryant Legal Group, P.C., our team of health insurance attorneys have decades of experience successfully representing policyholder-clients in a range of disputes with their insurers, from ERISA appeals to bad faith litigation brought under Illinois state law.  We are committed to our clients from the very beginning of the engagement process, and believe that effective dispute resolution requires open lines of communications with the client to keep them apprised of developments in their case.

Call (312) 561-3010 to speak with one of our qualified insurance attorneys today.  We look forward to assisting you.

The content provided here is for informational purposes only and should not be construed as legal advice on any subject.

Contact Bryant Legal Group

Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.

Request Your Free Consultation

Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.

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