Filing an insurance claim is often more complicated than it first appears. Someone who has never filed before may assume the process is simple: notify the carrier of the loss and wait to be paid. What many don’t realize is that the responsibility to show that covered property was damaged by a covered cause of loss falls on the policyholder. A common and costly misunderstanding is the belief that the carrier owes payment unless it can prove otherwise. That’s backwards, and it usually leads to frustration.

Before deciding to file, a policyholder should understand two points about how property claims generally work:

1. The policyholder is responsible for showing that a covered cause of loss damaged covered property.
2. The insurer is responsible for showing that an excluded cause of loss produced the damage, if the insurer intends to deny on that basis.

Too often, a policyholder notices a symptom — a ceiling leak, for example — and files a roof claim without knowing what actually caused the leak or whether that cause is covered. They ask the carrier to send an adjuster out to “pay the claim,” having done nothing to establish coverage.

The company’s adjuster works for the insurance company and protects its interests. That adjuster has no duty to prove a covered cause of loss caused your damage. The adjuster’s job is to gather information and evidence — and, where an exclusion may apply, to build the support the company would need to deny or limit the claim. When the adjuster is unsure about what he’s seeing or whether an exclusion applies, he may bring in a third party such as an engineer, architect, or consultant to assist.

By the time that investigation is done, the carrier is prepared to argue against coverage — while the typical policyholder, who never built a case that a covered cause of loss damaged covered property, is not.

So the prudent policyholder investigates the claim before inviting the carrier to investigate it. Here’s what I generally recommend:

1. Know what is damaged and what caused it — as best you can. If you can’t determine this yourself, get the opinion of a trusted professional who is skilled with the damaged material. If your roof is leaking, have a roofer identify the source of the leak and what caused it.
2. Collect the evidence. Preserve physical and photographic proof of the damage and its cause, and obtain a written repair estimate from a trusted contractor to restore the property to its pre-loss condition. (Avoid letting your contractor negotiate directly with the carrier. A contractor typically doesn’t know your coverage and has a financial interest in the work — a combination the adjuster can exploit.)
3. Determine whether the damage is covered. Read your policy and talk with your agent. If a question turns on what your policy language legally means, that’s a question for an attorney. If you want help organizing your claim and presenting your damages, a licensed public adjuster can represent you in that process.
4. Give your evidence to the carrier when you file — or when the adjuster inspects, if that’s more convenient. If you aren’t comfortable handling this yourself, a public adjuster can manage it for you.
5. If the carrier won’t cooperate after you’ve documented your loss, get help. A public adjuster can represent you on the claim itself; an attorney can advise you on your legal rights and options.

The goal is simple: don’t hand your claim to the insurance company before you’ve done the work to support it. Prepared policyholders get better outcomes.

James H. Bushart is a licensed Missouri public adjuster. This article is general information about the claims process, not legal advice.

James H. Bushart

Jim Bushart is a licensed public adjuster helping Missouri home and business owners negotiate insurance claims for property loss and damage.

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