Articles Posted in Bad Faith Insurance

Claiming an insurance company has committed fraud, as in all fraud claims, it must be stated who communicated the fraud, what was said, when it was said, where it was said, and how the statement was fraud.  All of this is particularly true when the lawsuit is in Federal Court where the pleading requirements are much more stringent.

This is illustrated in the case discussed in an earlier blog styled, Nancy Roberson v. Allstate Vehicle and Property Insurance Company.  The case is from the Southern District of Texas, Houston Division.

This case arises from a tree falling on the home of Roberson, who was insured by Allstate.  Roberson made a claim and the adjuster assigned by Allstate came back with a repair estimate that was far below what Roberson believed was needed to compensate her for her loss.  Roberson filed a lawsuit alleging many causes of action against Allstate but the one discussed here is her allegation of common-law fraud.

Here is a situation where the insured won at the trial level of the case but ended up losing on appeal.  The case is from the Amarillo Court of Appeals and is styled, State Farm Lloyds v. Robert MacKeen and Rebecca MacKeen.

The facts in the case are not particularly long or confusing but there were certain aspects of the case wherein State Farm admittedly did not handle the claim properly and as a result State Farm paid the damages incurred plus penalty pursuant to the Texas Insurance Code, Prompt Payment of Claims Act.

However, there were other parts of the claim that were still in dispute and the resulting lawsuit went to trial.  The jury in the MacKeen’s case found in the MacKeen’s favor and this appeal followed.

Demand letters to an insurance company can be used as evidence to make even a small case subject to federal jurisdiction.  This is illustrated in a case from the Western District of Texas, San Antonio Division.  It is styled, Veronica Horton v. Allstate Vehicle and Property Insurance Company, Pilot Catastrophe Services, John Suther.

In this case Horton made a claim with Allstate for property damage to her home after a storm.  Allstate hired Pilot and Suther to adjust the claim.  It was alleged that Suther and Pilot did not know what they were doing and made mistakes that can be found in the opinion, and that Allstate accepted their report and ignored Horton’s report.  That this was done intentionally.

Horton sent a demand letter to Allstate requesting payment of $28,384.28 in damages, calculated as follows: (1) $18,554.34 for repairs, (2) $4,629.94 in interest pursuant to the Texas Prompt Payment Act and $1,200 in attorney fees, both incurred up to the date of the letter.  The letter expressed to Allstate that they should pay the offer or risk exposure to a judgment of $100,000 to well over $1 million.

For an insurance attorney to know the insurance adjuster did something wrong when it comes to a lawsuit is not good enough.  When filing a lawsuit, the allegations of wrongdoing by the adjuster must be properly alleged in the lawsuit papers.  This is illustrated in the Southern District, Corpus Christi Division, opinion styled, Esteban Cruz v. State Farm Lloyds.

This case was filed against State Farm in State Court and State Farm caused the case to be removed to Federal Court based on diversity jurisdiction.

State Farm seeks dismissal of the extra-contractual claims for “failure to state a claim upon which relief can be granted” pursuant to Rule 12(b)(6)Rule 8(a)(2) requires a short and plain statement of the claim showing that the pleader is entitled to relief.  This includes sufficient factual allegations to indicate that the claim is plausible.

A 1994, Texas Supreme Court opinion styled, Chicago Title Ins. Co. v. McDaniel, is a case that says title insurance is different than your normal insurance.

This is a summary judgment case in favor of the insurer.  This Court affirmed the finding in favor of Chicago Title.

In September 1983, the McDaniel’s purchased on home from Couch Mortgage Company and at closing the McDaniel’s also purchased a title policy from Chicago Title.  In relevant part the title policy reads, that Chicago Title “for value does hereby guarantee to the Insured … that as of the date hereof, the Insured has good and indefeasible title to the estate or interest in the land described or referred to in this policy.”

Texas Insurance Code, Section 541.060(a)(1), says it can be bad faith for an insurer to misrepresent to a claimant a material fact or policy provision relating to a coverage issue.

The 1990, Texas Supreme Court opinion, Black v. Victoria Lloyds Ins. Co., provides some guidance on this topic.

Wood Brothers purchased a liability insurance auto policy that excluded coverage while the automobile was not being used exclusively in the business of the insured.  Wood Brothers leased the automobile to Daniel.  Daniel did not request or receive a copy of Wood Brothers’ insurance policy.  Subsequently, Daniel’s daughter was involved in an accident while on personal business and was sued by the injured party.

Texas Insurance Code, Section 541.060(a)(7) requires an insurance carrier to conduct a reasonable investigation when refusing to pay a claim.

The Texas Supreme Court 2009, opinion styled, Tex. Mut. Ins. Co. v. Morris, found there was sufficient evidence to support finding the insurance carrier refused to pay a claim without conducting a reasonable investigation.

The jury had before it proof that medical and non-medical personnel for the carrier initially authorized a surgery; that the carrier’s adjuster disputed coverage the same day she first reviewed the file, ignored accepted methods of investigating a claim, may or may not have spoken briefly with the claimant’s former employer, never spoke with the two people who would know the most about the initial injury and/or the current state of the claimant’s spine, and did not speak with any other treating physician before deciding to dispute the claim – that the carrier complained that it had trouble getting claimant’s medical records, yet claimant’s attorneys faxed his records to the carrier on more than one occasion, claimant’s wife signed a release for claimant’s medical records, and claimant himself signed a release for his medical records – twice the carrier sent medical records to its medical expert claiming that those were all the records when, in fact, one key page detailing multiple visits to claimant’s chiropractor was left out of the file, that the page left out of the records sent to the carrier’s medical expert showed that the claimant saw his chiropractor between the injury in 2000 and the surgery in 2003 – the carrier’s medical expert informed the carrier that he would give claimant the benefit of the doubt if claimant’s records supported ongoing trouble with his back and if he had back trouble prior to 2000.  The carrier neither did not know its files well enough to know that it had a page of treatment notes from the claimant’s chiropractor showing the visits between 2001 and 2–3, or it chose not to give the sheet to its medical expert.

An inconsistent investigation and the insurance company relying on it is bad faith according to the 1988, Dallas Court of Appeals opinion, Harco Nat’l Ins. Co. v. Villanueva.  The owner of a truck reported the theft of the truck to his insurance company, Harco.  Harco’s investigator stated  that he saw the man he believed to be the truck owner sitting with others in a vehicle similar to the stolen truck.  Harco, based on the investigator’s report, denied the claim.  At trial, the jury found that Harco had breached its duty of good faith and fair dealing to the truck owner and further, found that Harco’s claim denial was gross negligence.  This appeals court agreed.  Harco’s denial was based solely on information discovered by the unlicensed investigator.  Harco did not ask it’s insured for any corroborating evidence.  The insured had no criminal record, had never submitted an insurance claim before, and appeared to be in god financial condition.  Thus, there was sufficient evidence for a jury to determine that Harco’s reliance upon the report of the investigator did not constitute a reasonable basis for denial of the claim; and there was sufficient evidence to support a finding of gross negligence.

In a different case an expert was deemed to not be biased only because he wanted to obtain business from the insurance company he was doing work for.  The case is a 2003, Fort Worth Court of Appeals opinion styled, Allstate Tex. Lloyds v. Mason.  While investigating a homeowner’s claim, Allstate retained Tolson, an engineer, to inspect the house and determine whether the damage to the house was caused by a plumbing leak.  During these inspections, Tolson learned about the history of the house, examined the failed pipe and plumbing diagnostics, and obtained soil data.  During his investigation, Tolson also reviewed a report discussing the house’s sub-structure drainage and foundation problems.

Based on his investigation, Tolson concluded that sub-surface drainage caused the clay soil under the house to swell, leading to the foundation upheaval, and that the sub-surface drainage combined with the soil expansion was alone sufficient to damage the house.  After Allstate denied the claim, the homeowners brought suit, alleging breach of contract, and the duty of good faith and fair dealing.  They also alleged that Tolson’s conclusions should be disregarded based on the fact that he has worked for insurance companies in the past in conducting investigations.

An insurance company may breach its duty of good faith and fair dealing by failing to reasonably investigate a claim.  As an example, in the 1997, Texas Supreme Court opinion, Universe Life Ins. Co. v. Giles, the insurer could not escape liability merely by failing to investigate the claim so that it could contend that liability was never reasonably clear.

Here is what happen in the 1998, Texas Supreme Court opinion, State Farm Fire & Cas. Co. v. Simmons.  After leaving for a day trip, Simmons home burned down.  Previously, Simmons had reported a theft loss.  State Farm immediately tagged the claim as “suspicious,” denied the claim and asserted an arson defense in the subsequent lawsuit.  By the time State Farm denied the claim, legitimacy of the burglary had been proven.  State Farm failed to investigate potential arson suspects (other than the policyholder) and erroneously compiled information concerning the policyholder’s financial obligations.  The Court held a jury could infer that a reasonable insurer would have approached its insured to resolve apparently conflicting information and would have eventually concluded that the insured lacked a sufficient motive to commit arson.  Accordingly, the Court concluded that the evidence was legally sufficient that State Farm denied the claim based on a biased investigation intended to construct a pretextual basis for denial.

In another case the Court concluded that once the insurance company and the public adjuster hired by the building owner reached an agreement on the estimate method, it was no longer reasonable for the insurance company to rely on contrary opinions of other experts.  This was the 2014, 14th District Court of Appeals opinion, United Nat’l Ins. Co. v. AMJ Invs., LLC.

As was stated in the 1997, Texas Supreme Court opinion, Universe Life Ins. Co. v. Giles, an insurer violates its duty of good faith and fair dealing by denying or delaying payment of a claim if the insurer knew or should have known that its liability was reasonably clear.  However, an insurance company may withhold UIM benefits until the insured’s legal entitlement is established.

Statutory liability may also be imposed on an insurer that delays payment of a claim under Texas Insurance Code, Section 542.051 and those sections following, if the insurer delays payment for more than 60 days from the date it received all the information reasonably requested and required, the insurer must pay the claim along with the statutory penalty.  An insurer’s failure to comply with the requirements of this Prompt Payment of Claims section will result in imposition of statutory penalties, even if the delay in payment is in “good faith.”  If an insurer promptly interpleads policy proceeds, it cannot be subjected to statutory penalties for delayed payment.  However, in the 2007, Texas Supreme Court opinion, State Farm Life Ins. Co. v. Martinez, the court held an insurer may be liable for statutory penalties for interpleader filing after the prompt payment deadlines.

To recover the statutory penalties available under the Prompt Payment of Claims Act, an insured must first prove that the insurer is liable for the underlying claim.  The insured must establish three elements: (1) a claim under an insurance policy; (2) that the insurer is liable for the claim; and (3) that the insurer has failed to follow one or more sections of the Prompt Payment of Claims Act with respect to the claim.