Articles Posted in Claims Handling Process

Does an insurance company making a partial payment of a claim mean that they are responsible for the claim.  The answer to this question and a couple of other questions was answered by the United States 5th Circuit in the April 2020, opinion styled, Sandford T. Pulley v. Safeco Insurance Company of America.

Safeco was the insurer for Pulley on some property he owed.  The District Court granted summary judgment in favor of Safeco and this appeal followed.

Pulley argues that summary judgment for Safeco was improper because, in Pulley’s view, by initially sending him a check in response to his insurance claim, Safeco conceded liability.  Since the check was insufficient to offset his repair costs, Pulley argues that the only remaining issue in the case is the amount of damages.  Pulley cites neither the terms of the policy nor any legal authority for the proposition that Safeco’s partial payment of his claim is an admission of liability.  As a result, and because Pulley fails to address the District Court’s basis for dismissing his claims, the summary judgment was affirmed.

Providing an insurance company with a “Sworn Proof Of Loss” is a requirement under most insurance policies.  This is illustrated in the 2020, Amarillo Court of Appeals opinion styled, City of Spearman, Texas v. Texas Municipal League Intergovernmental Risk Pool.

This case is an appeal from a summary judgment granted in favor or Texas Municipal League (TML).

TML insures Spearman with property insurance and on September 16, 2016, Spearman submitted a “Claims Notice” reporting “hail damage to buildings” from a hailstorm occurring on May 16, 2016.  TML sent an adjuster who inspected five building and estimated the damage at $5,437.66.

Almost all insurance policies contain a requirement that the insured submit to an examination under oath (EUO) as often as is necessary for the insurance company to complete its investigation of the claim.

EUO”S were the topic in a Western District of Texas, Austin Division, opinion recently.  The opinion is styled, AXO Staff Leasing, LLC v. Zurich American Insurance Company, McCreadie & McCreadie, Inc., and Lassiter Ware Insurance.

The lawsuit is an insurance coverage dispute between Zurich and AXO.  Briefly, AXO contends that its former Chief Financial Officer (CFO), John Herzer, embezzled $4.7 million, and that the loss is covered by the Zurich policy.

Insurance lawyers need to know the various ways other insurance lawyers have attempted to pursue an insurance company and the ways that work and the ways that do not or have not worked.  Here is a different approach that failed to work.

This is an opinion from the Northern District of Texas, Dallas Division.  It is styled, Corinne Pearson v. Allstate Fire and Casualty Insurance Co.

Corinne filed suit in State Court alleging Allstate improperly denied or underpaid a claim after a storm damaged her home.  Allstate removed the case to this Federal Court and obtained an abatement pending an appraisal of the damage to her home.  In June 2019, the Court was notified that appraisal had been completed and the case was reopened.  Allstate immediately filed this motion for summary judgment.

Insurance policies are of two types of it relates to the coverage of a claim. One is called an “occurrence” policy.  An occurrence policy covers losses that occur during the policy period.  The other type of coverage is a “claims made” policy.  A claims made policy covers claims that are made only while the policy is effective irregardless of when the event/claim actually occurred.

This distinction was discussed in 2019, Amarillo Court of Appeals opinion styled, In Re Landmark American Insurance Company.  This is a mandamus case.

Landmark, the insurer, petitioned the appeals courts seeking an Order for the Judge in the underlying case to vacate his Order allowing a deposition of a Landmark representative.  This appeals courts conditionally granted the writ.

Here are some new laws enacted in the State of Texas that went into effect on September 1, 2019.  There were several transparency and consumer protection bills that were passed in the wake of Hurricane Harvey.  The most significant bills were related to flood, wind, and hail, although significant legislation related to adjusters was also passed.

Senate Bill (SB) 442 requires any insurance company that issues residential property insurance policies without coverage against flood loss to provide written notice to the insured.  This bill gives the Texas Insurance Commissioner rule making authority to issue the form and content of the notice.

House Bill (HB) 1306 provides for additional flood coverage access under insurance policies issued by surplus lines insurance companies.  Surplus lines coverage is only to be used if the full amount of coverage cannot be obtained in the Texas market.

Many people think of insurance for covering something you own when it is damaged, such as your home or auto.  Or, people thing if health insurance and life insurance.  But there is another type of insurance that is important to all of us.  That is liability insurance.  This is the insurance that is suppose to protect you when someone sues you for something they allege you did wrong.

Here is some information from the State Bar of Texas, Insurance Section, Journal.

Under Texas law, the duty to defend depends on the language of the policy setting out the contractual agreement between insurer and insured.  Whether an insurer has a duty to defend its insured is a question of law.  An insurer must defend its insured if a plaintiff ’s factual allegations potentially support a covered claim, while the facts actually established in the underlying suit determine whether the insurer must indemnify its insured.  Thus, an insurer may have a duty to defend but, eventually, no obligation to indemnify.  The initial burden is placed on the insured to demonstrate that coverage exists considering only the policies and the underlying lawsuit papers.  The burden then shifts to the carrier to establish that one or more of the policy exclusions apply to negate any otherwise-applicable duty to defend.  Courts consider the factual allegations without regard to their truth or falsity, and resolve all doubts regarding the duty to defend in favor of the insured.  Further, in making the determination, courts  look to the factual allegations showing the origin of the damages claimed, not the legal theories or conclusions alleged.  If the petition asserts one claim that could potentially be covered by the insurance policy, the insurer must defend the entire suit.  The duty to defend is a sprawling topic on which Texas law and the Restatement of Insurance agree on many issues.  For example, it is well settled that an insurer’s right to conduct the defense includes the authority to select the attorney who will defend the claim and to make other decisions that would normally be vested in the insured as the named party in the case.  Likewise, the Restatement outlines the scope of an insurer’s right to control the defense as follows:

Here is another Federal opinion discussing Texas Insurance Code, Section 542A.  The opinion is from the Eastern District of Texas and is styled, John McAdams v. Palomar Specialty Insurance Company, Wellington Claim Service, Inc. and Nicholas Abdallah.

McAdams had a homeowners insurance policy with Palomar when he suffered damages alleged to have been caused by Hurricane Harvey.  Palomar assigned Wellington to investigate the claim and Wellington assigned adjuster Nicholas to inspect the claim.

The claim was not sufficiently covered according to McAdams and he eventually filed suit against Palomar, an out of state defendant, and against Wellington and Nicholas, both in-state defendants.  McAdams alleged wrongs committed in the claims handling process.

Texas Insurance Code, Section 542A, is being used regularly now by insurance companies to prevent Plaintiffs from defeating diversity jurisdiction.

This Insurance Code Section was discussed by a court in the Southern District of Texas, Houston Division, in a case styled, Robert Ewell v. Centauri Specialty Insurance Company, et al.

Ewell filed a claim with Centauri, who insured Ewell’s home, for property damage alleged to have occurred during a severe storm on August 25, 2017.  Steven Wiley is the adjuster assigned to investigate the claim.  Centauri is alleged to have failed to pay the full amount of the claim.

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