Dallas Fort Worth Insurance Lawyer Blog

It is easy to say "you know when you know". Most people will sense something isn't right. Often times the insurance company sends you a letter saying your claim for benefits is being denied and state as a reason, something you absolutely know is wrong.

Let's look at what the Texas Insurance Code says. Section 542.055 is titled "Receipt of Notice of Claim". This section gives guidance to the first actions an insurance company is suppose to take when a claim is filed. It says that not later than the 15th day after the date they receive notice of a claim that they shall, (1) acknowledge receipt of the claim, (2) begin their investigation of the claim, and (3) request from the person making the claim all statements, and forms that the insurance company believes it will need to evaluate the claim. It then says that the insurance company may make additional requests for information if during the investigation of the claim the additional requests are necessary. Also, they are suppose to acknowledge the claim in writing or make a written record of how the acknowledgement was made.

Section 542.056 is titled "Notice of Acceptance or Rejection of Claim". This section is a little complicated and varies depending on the type of claim made, but does have deadlines for when the insurance company is suppose to make their determination. Also it is in these actions required of the insurance that they are most likely to be making mistakes. If the claim is one they should be paying, a letter from an Insurance Law Attorney at this point usually gets them acting properly in a hurry. If they are not sure whether they should be paying the claim or not, the requirements of this section and a letter from an Insurance Law Attorney makes the insurance company take a stand or be in further violations of these sections or others in the Insurance Code. The Insurance Law Attorney wants the insurance company to make that stand rather than continuing to string out the matter.

The above two paragraphs are just starting points for finding out if your Texas insurance company is doing its job. The law in Texas on this matter is the same whether you are in Dallas, Fort Worth, Arlington, Grand Prairie, Weatherford, or in any other city in the State. Also, it is the same for Dallas County, Tarrant, Parker, etc.

The Texas Department of Insurance has the authority to punish insurance companies and agents who commit wrongs. The punishment can be fines or in some cases "cease and desist" orders are issued.

When an insurance company or one of their agents commits a violation of the Texas Insurance Code, the person who sustains actual damages may bring an action for those damages caused by the person or company engaging in the wrongful action. Section 541.151 of the Texas Insurance Code allows for this private cause of action. Any violation of Subchapter B, defined to be an unfair method of competition or unfair or deceptive act or practice in the business of insurance, or Section 17.46(b) of the Texas Business & Commerce Code, may bring this private cause of action against the insurance company or its agent.

A person who prevails in their claim against the insurance company or its agent may obtain the amount of actual damages plus court costs and reasonable and necessary attorneys' fees, plus any other relief the court determines is proper. If the insurance company is found to have knowingly committed the act complained of, the judge or jury may award an amount up to three times the amount of actual damages.

The above is not a limit of the claims that can be asserted against the insurance company or its agent. There are other claims that can be made in the appropriate situation for violations of other provisions of the Texas Insurance Code and violations of the Texas Deceptive Trade Practices Act. Further, depending on the circumstances, claims can be asserted for Breach of Contract, Fraud, Misrepresentation, Negligence, and several other causes of action.

The important thing to keep in mind in an insurance situation is, when you think you are being mistreated or something just does not seem right, you need to talk with an Insurance Law Attorney. There are lots of attorneys in Dallas, Fort Worth, Arlington, Grand Prairie, Weatherford, and other large and small cities across the state who do Criminal Law, Family Law, Probate, Injury, Bankruptcy, etc., but not that many who do Insurance Law. Only an attorney who does lots of Insurance Law is going to fully understand all your rights under the various laws of the State.

A United States Federal District Court in Texas recently discussed the above in a case. The life insurance policy was for $200,000. The policy was provided through a voluntary plan the beneficiary of the policy had with his employer and was an ERISA plan. ERISA stands for Employee Retirement Income Security Act. The case was Carmichael Khan v American International Group, Inc.

Like many people in Dallas, Fort Worth, and surrounding cities and counties Khan was a voluntary participant in a plan provided by his employer. The facts and issues in the case centered around Khans' employment terminating around April 7, 2006 and his wife having died in a car wreck on April 20, 2006. There were issues about termination paperwork Khan had filled out prior to his termination and his intent to covert coverage he had through his employer to continuing coverage once he left American. Also, there were issues about deductions from Khans last pay check for coverage. The fact pattern is long and the legal battle is also long and complicated. In the end the Federal Court ordered the case back to the Plan Administrator for further determinations to be made by the Plan Administrator. This case will likely continue over the next several months and possibly years unless a settlement is reached among the parties involved.

One of many things to be drawn from this case is that when a life insurance policy is in an ERISA plan, there is an administrative process that has to be exhausted before an appeal to a Federal Court can be fully litigated. All ERISA disputes are fought out in Federal Courts rather than State Court because ERISA issues are a matter of Federal Jurisdiction. Insurance companies prefer Federal Court for fighting their battles whereas attorneys who represent claimants prefer State Courts.

Continue reading "Life Insurance Policies, Interpretation, and ERISA" »

An accident happens. A loss is incurred. A lawsuit is filed. You say "no problem I got insurance to protect me". Well, do you?

The Texas Court of Appeals in Houston recently discussed this question in the case, Accufleet, Inc. v. Hartford Fire Insurance Company. This case involved a discussion of the definition of "auto". Accufleet is an aviation support business. In January 2003, a ground tug, transporting luggage, rear ended another vehicle causing injuries. When a lawsuit was filed, Hartford denied coverage arguing that the ground tug was not an auto.

The Court in this case, got into a discussion of how to determine whether or not the language of the insurance policy requires the insurance company to defend its insured in a lawsuit and pay on a claim or whether it can get away with refusing to do so. The court draws two distinctions. One, is what does the policy language say as far as its duty to pay, if liable. Two, how is this different from the duty to defend in a lawsuit.

The plain language of an insurance policy, like that of any other contract, must be given effect when the parties' intent may be discerned from the plain language used in the policy. If the policy language has only one reasonable interpretation, then it is not ambiguous and the court decides it as a matter of law. If the contract is susceptible to two or more reasonable interpretations, then it is ambiguous and the uncertainty is resolved by adopting a reading that favors the insured as long as that construction is not unreasonable.

The duty to defend is distinct from, and broader than, the duty to pay. An insurance company must defend its customer if the lawsuits factual allegations "potentially" support a covered claim. So even though the facts may not play out in such a way as to require payment on the claim, the allegations themselves are what trigger whether or not the insurance company must hire attorneys and defend the claim.

The previous two paragraphs are what is known as the "eight corners rule". The first four corners are the pages of the contract or policy and the language with-in the four corners of that document. The second four corners are the pleading used in the lawsuit. Do the allegations used as the facts made the basis of the lawsuit, give notice that if the lawsuit is successful, the claim will have to be paid by the insurance company. If the answer is yes, then the duty to defend the lawsuit is placed on the insurance company. The general rule being that the insurance company is obligated to defend the lawsuit if there is, potentially, a case under the complaint within the coverage of the policy.

Continue reading "Determining Coverage In Texas Insurance Policy" »

Before discussing the topic of this writing, a little side note. When suing insurance companies, they of course do not want to be sued, but when that happens they prefer to fight their battles in Federal Court rather than State Court. The Plaintiffs, who are the people usually suing the insurance companies would prefer to be in State Court. There are many reasons for this but what is important to know is, one, only an experienced Insurance Law Attorney fully understand what was just said and, two, only an experienced Insurance Law Attorney knows ways of preventing an insurance lawsuit from being removed to Federal Court, if it can be done.

Texas Insurance Law requires that the insured person cooperate with their insurance company when the company is investigating a claim. This is true whether the claim is being made by the insured person against their insurance company for benefits or the claim is being made against the insured person by a third party. The reasoning for this is not difficult. The insurance company needs to know what happened so that they can evaluate the claim being made. An obvious example of the insurance refusing to pay on a claim is found in a recent Federal Court case, State Farm Lloyds vs. Tony Ray Brown.

In Brown, the insured, Brown, had shot another person in the face. Brown would not cooperate with his insurance company in any way when he was sued for the shooting. He did not turn the lawsuit papers over to his insurance company, he did not cooperate with their investigation as to the shooting being an accident or deliberate, he did not cooperate with the insurance company's efforts to determine if the victim had done anything wrong in causing or contributing to the shooting. Brown simply did nothing. The only thing the insurance company knew about the incident was what the victim and the victims lawyers said. This case was a blatant "lack of cooperation" and thus the Court voided the insurance coverage.

Here is the problem. When an insurance company investigates a claim that is being made against them, they are not just trying to determine the value of the claim. They are also investigating and looking for ways to keep from paying the claim or if they know they are going to have to pay, they are looking for ways to lessen the total amount to be paid on the claim. Any time an insurance company starts asking for lots of paperwork or wants to take a recorded statement and especially if they want to take a statement under oath, then these are signs they are looking to deny or diminish the value of your claim. That is also the time to seek the advise of an experienced Insurance Law Attorney.

An Insurance Law Attorney knows how to assist an insured in cooperating with their insurance company without the insured person saying something that would cause the coverage to be denied or the value of the claim being diminished. If you find yourself in a situation where the insurance company is asking for a recorded or under oath statement then you need to get in touch with an experienced Insurance Law Attorney.

The State of Texas regulates insurance companies by way of the Texas Department of Insurance. Texas has laws telling the insurance companies and the Texas Department of Insurance how they should be conducting their business and these laws are found in the Texas Insurance Code.

These Texas insurance laws are applicable to all citizens and businesses through-out Texas. So whether you live in Dallas, Fort Worth, Arlington, Grand Prairie, South Texas, East Texas, west to Weatherford and Parker County or all the way to El Paso, the law is the same. This is a good thing in that a person or company knows what to expect when it comes to insurance policies and the guiding principles for their interpretation.

The problem with Texas Insurance Laws is the elephant in the room most people do not know about and lawyers usually wished did not exist. This elephant is the Federal Laws that pre-empt, or trump, State Law. The relevant Federal law in the insurance arena is known as the "Employee Retirement Income Security Act", also known as ERISA.

This law passed by the Federal Congress is a thorn in the side of Texas Insurance Attorneys. Even though an Insurance Attorney may know about this law and how it works, it has powers that severely limits rights claimants have under Texas Law. The tricky part in this area of Insurance Law is knowing the distinctions between when ERISA controls and when Texas Insurance Law is controlling. The recent case, Lone Star OB/GYN Associates vs. Aetna Health Inc., is a case where the courts allowed Texas Law to be controlling in the dispute and thus allowed for a recovery against the insurance company that otherwise would not have been allowed.

Continue reading "Texas Insurance Law vs. ERISA (The Elephant)" »

The above title is a good question. Here is my good answer. See an attorney who handles Insurance Law issues.

A Dallas County case decided in 2008, confronted this issue when trying to decide what "replacement" meant in an insurance policy issued by three underwriters on some apartments. On July 2, 2004, fire damaged the property in dispute. A claim was made under the insurance policy for the loss, and the underwriters paid the insureds almost $300,000 as the actual cash value of the property. The apartments were eventually demolished, and the lots remained vacant.

On March 14, 2006, the insureds purchased an interest in an industrial property located in Houston. The insureds notified the underwriters that they were now "replacing" their previous loss and because the insurance policy provided for more money in "replacement" costs, the insureds sought to recover a little over $200,000 more.

The court in this case went into a discussion of various policy terms and the meaning of those terms. A lot of the discussion was favorable to the insureds but eventually the court decided that replacement meant something more similar to what originally existed. In this case it was apartments that were destroyed and the insured did not have to rebuild or replace on the same lot some more apartments. But replacing the apartments with an industrial building in Houston was too much of a stretch.

These cases can be difficult to analyze. Giving good advice to a client who wants to know all their advantages and benefits under a policy of insurance can be difficult for even an experienced insurance attorney. The thing to know is that an attorney who practices law in this area is most familiar with the way the courts analyze these issues.

Continue reading "How Do You Know What You Are Entitled To When You Make An Insurance Claim In Texas?" »

Every time a Texas resident in the Dallas Fort Worth area purchases a life insurance policy they are going to be asked who they want to be named as the beneficiary of the insurance policy. The beneficiary "is the person to whom the insurance policy is payable".

The beneficiary can be an estate, a trust, a trustee, and other people or entities. Most of the time the life insurance is going to name a spouse or child, a spouse being the most common.

What happens if the spouse is named as a beneficiary and the next day, the next year, or 20 years later you divorce your spouse? Easy - just change the name of the beneficiary whom you want to receive the monies upon your demise. Ok, but what if you forget?

This issue was recently discussed in the case, Rachael Ruiz v. The Prudential Insurance Company of America. This was a United States District Court Case filed in the Fort Worth Division of North Texas. The exact residence of the parties is unknown but may have been in the Grapevine, Weatherford, Azle, or Colleyville areas of Tarrant or Parker County.

In this case, the deceased husband had named his wife as a 25% beneficiary of his life insurance policy in October 2005. The couple got divorced in September 2006 in Arkansas, then the husband died in October 2006, without having changed or removed his ex-wife from being named as the beneficiary on the policy. The case addresses other legal questions but points out and discusses how complicated the issues regarding the named beneficiary can sometimes be.

In Texas, the issue of a couple getting divorced without making changes in their insurance policies is addressed in the Texas Family Code. The Family Law statute renders the provision in the policy in favor of the insured's former spouse as "not effective". There are a few exceptions that have to be looked at carefully.

Continue reading "Wife (Ex-wife), Spouse Named As Beneficiary In A Texas Insurance Policy" »