Articles Posted in Claims Refusal

The wrongs committed by insurance companies would surprise most people.  A person pays his premiums and maybe has friendly conversation with their agent and they figure that when they make a claim, the claim will be properly paid.  While most insurance claims are handled without the need for lawyers to be involved, there are too many instances of the insurance company trying to work against they insured/customer.

This is illustrated in an article from Argus Leader.  The article is titled “Lawsuit Accuses Doctor Of Bias In Denying Injury Claim.”

The article tells us a woman who suffered a debilitating neck injury while at work has accused an insurance company who denied her benefits of hiring a doctor that it knew would dispute her injury claim.

Here is another case looking at experts in insurance cases.  The case is from the Eastern District, Sherman Division, and is styled, La Verdure & Associates v. Depositors Insurance Company.

Plaintiff, La Verdure filed suit against Depositors for alleged violations of the Texas Insurance Code, the DTPA, and breach of contract.  A Scheduling Order was entered into which set a deadline of March 24, 2017, for naming expert witnesses.

Plaintiff named its experts on April 7, 2017.  On May 19, Defendant filed its Motion to Strike or Limit Expert Testimony.  Plaintiff filed its Motion for Leave to Amend Designation of Expert Witnesses.

The above question is usually not easy to answer.  Aledo insurance lawyers need to read a 1976 case from the Waco Court of Appeals.  The opinion is styled, Westchester Fire Insurance Co. v. English.

Posing as husband and wife when in fact they were not married, a couple purchased a house and at closing, also purchased home owners insurance coverage.  The house burned down three months later.  After the fire, the Westchester learned for the first time that the couple were not married.

The policy provides in part that it ‘shall be void if, whether before or after a loss, the insured has willfully concealed or misrepresented any material fact or circumstance concerning this insurance, or the subject thereof, or the interest of the insured therein, or in case of any fraud or false swearing by the insured relating thereto.’

What happens when an insurance does not pay a claim that it was suppose to pay?  That issue is dealt with in the Texas Insurance Code by statute and by courts interpreting the statute.

A particularly strict deadline for insurance companies is the requirement in Texas Insurance Code, Section 542.058(a) that the insurance company pay a valid claim within 60 days after receiving all required items requested from the claimant.  This means that if the insurance company ultimately loses on the coverage issue and has to pay the claim, then it necessarily has violated the 60 day payment provision and is subject to the 18% damage set forth in Section 542.060(a) and attorney’s fee provisions of the statute.  This is true even if the delay on the part of the insurance company was in good faith.

In a 5th Circuit Court of Appeals opinion from 1997, styled, Higginbotham v. State Farm Mutual Automobile Insurance Company, the court held that by rejecting the claim, the insurance company necessarily failed to pay within 60 days, in violation of the statute.  As the court put it:

A Weatherford insurance lawyer will always tell you “read the policy” or risk losing on a case where you otherwise thought you had coverage.  A recent case may change that advice, depending on the facts.

When a plaintiff fails to read an insurance policy, they usually don’t have much of a case against an insurer if they’re denied coverage.

But one insurance lawyer recently convinced Houston’s Fourteenth Court of Appeals that his client could sue an insurance company over a policy he’d never laid eyes on before filing a claim.

Lancaster insurance attorneys will occasionally see a claim covered by the National Flood Insurance Program. Each of these types of government programs are governed in their own particular way. The United States District Court for the Southern District of Texas, Galveston Division issued a ruling that attorneys handling these types of claims need to know about and read. The style of the case is, Ruby Pal v. Texas Farmers Insurance Company.

This is a summary judgment ruling wherein Farmers sought to have the court dismiss the case filed by Pal.

Pal’s property was damaged in flooding during Hurricane Ike in September 2008. At the time, Pal had insured the property for $110,000.00 against flood loss with Farmers, a WYO insurer with the National Flood Insurance Program. Pal’s initial claim was adjusted and paid, on December 29, 2008, in the amount of $53,610.45. The extended deadline for filing a Proof of Loss (POL) for Hurricane Ike claims expired on August 7, 2009. Seven months later, on March 11, 2010, piled filed her second POL seeking policy limits. Farmers negotiated Pal’s claim and by April 7, 2010, determined she was due an additional $7,644.68. The parties requested a waiver of a timely POL for that amount which was approved by FEMA on April 13, 2010. On October 1, 2010, Pal sued Farmers seeking additional proceeds under her policy. The parties continued to negotiate her claim, but reached impasse around May 30, 204. As a result, Farmers filed the summary judgment motion.