Do You Become the Enemy When You File an Insurance Claim?

Photo by Pavel Danilyuk on Pexels.com

   “I have paid my premiums on time for twenty years and have never filed a claim.  Now, it is difficult for me to tell who has caused me more damage — the storm or my insurance carrier.”

     The above exclamation, or words similar to it, is something that I hear almost on a daily basis from Missourians who have had the misfortune of needing to file an insurance claim for damage to their homes and businesses.  Do you really become “the enemy” of your insurance carrier when you file a claim?  Do they really consider you more as an adversary than a customer?  

     I received an email today from an attorney representing an insurance carrier from out of state and who sells insurance policies in Missouri who provided a clear and convincing answer to those questions.

     My client, a commercial business, had incurred extensive and obvious hail damage to multiple buildings and filed an insurance claim.  Their insurance company hired an independent adjustment firm to inspect the damage who reported their observations to the carrier.  The carrier, after receiving their report and photographs, decided to hire an engineer who regularly assists insurance carriers in denying coverage for hail damage to properties in Missouri.

     With the hail damage being as obvious as it was, there was no legitimate reason to have an engineer look at the same dents, gouges, and tears that their independent adjuster had just seen and photographed.  I suspected that the independent adjuster had actually recommended that the claim be paid against the carrier’s wishes, and I requested a copy of his report.  Insurance companies almost always share their reports when their report supports a claim denial.  For some reason, the carrier did not want to share this one and I was suspicious of their intention.

     When I submitted a formal written request for a copy of the report from their independent adjuster that I believed supported my client’s claim for damages, I received a letter from the carrier’s attorney in response that confirmed my suspicions.  In part, it read as follows:

     “Under Missouri law, the relationship between an insured and the insurer with regard to first-party claims becomes adversarial when a claim is made on the policy.  Therefore, the insurer is entitled to assert work product privileges to prevent access to materials found in the claim or investigative file.”

     Because my client had filed a claim, he became an “adversary” to his insurance carrier and was not entitled to see documents in his file that might support his claim.  In return for his annual premiums exceeding $80,000.00 per year, this is what his money bought for him.  An adversarial relationship.

     Of course, we’re suing.  Soon, that report and all of the other documents in the file will be in the hands of his attorney.  He will recover all of the money owed to him by his insurance carrier along with (most likely) punitive damages and his attorney fees.  He is, indeed, an “adversary” to his insurance company – but not because he filed a claim.  Rather, it was the insurance carrier that decided to vexatiously withhold money that was due to him under his contract rather than to pay him what he was entitled to.  That action taken by them, and not his claim, is what made him an adversary … and a worthy one, at that.

Looking for a Public Adjuster in Arkansas?

Photo by fotografierende on Pexels.com

     I receive many telephone calls and email inquiries from insurance policyholders living in Northwest Arkansas who are seeking assistance with improperly denied or underpaid insurance claims.  Sadly, I must turn them away.

      Thanks to their elected officials and the lobbyists from the insurance industry who help to fund their reelections, Arkansas home and business owners who file claims and are improperly denied coverage or underpaid by their insurance companies have fewer options than most other Americans.  

     If you own property in Arkansas, your insurance adjuster’s word is final.  What he offers is all you get unless you hire an attorney and sue.

     The Department of Insurance in Arkansas, in a very unusual way, actually considers their restrictions that limit the options for their citizens to be fully indemnified under their insurance policy as a service to them.  The folks who I have spoken to do not agree.

     Every politician in Arkansas holds their office with the permission of the people they serve.  When enough politicians in that state decide it to be more profitable to serve their constituents than lobbyists, good things might come to the good people of Northwest Arkansas.  Until that happens, your home and financial status rest totally in the hands of your insurance adjuster and the insurance company he is paid to serve.

Is Your Home Under Insured?

Photo by Gabby K on Pexels.com

Did you pay $200,000 for a house and insure it for $200,000 thinking that you are fully covered if your home is destroyed?  Many do.  Many are wrong.

The resale value of your home or the amount that you borrowed to buy it is NOT what you should insure.  Why?  The first reason is that the policy itself excludes coverage for “loss of value”.  A reduction in the value of your house is not covered under your policy.  The second reason is that, should the home be totally destroyed, the cost to rebuild it will depend upon the inflated values of building materials and labor at the time you rebuild it which is likely to far exceed the amount that you paid for it.

Since the Spring of 2020, the costs of construction materials have increased from 15% to 75%, with lumber leading the way.  The cost of building and reconstructing similarly sized homes has increased by many tens of thousands of dollars in only the last year.  That number will continue to rise for some time to come.

Your mortgage lender will insist that their interest in the home be covered.  Thus, at a minimum, your lender will require your home to be insured for the amount they loaned you.  That covers and protects THEIR financial interest in the home, but what about yours?  If the loss is not a total loss, will the amount of your total insurance be enough to cover today’s costs for lumber and other material while you rebuild and keep up on your house payments during the reconstruction process?

Seek the advice of a reputable builder in your area as to the cost per square foot of building a new home similar to the style of your home.  Multiply that figure by the size of your home in square feet.  That figure will closely represent the dollar amount for which your home should be insured.

 

 

Missouri Law and Your Insurance Company

Photo by Sora Shimazaki on Pexels.com

Not everything that is unethical is illegal.  There are ways of stepping right up to the line without crossing it and no one can do it better than some insurance companies with their vast financial resources and lobby power at the state government level.

But how far is too far? 

This is how the law reads …

Universal Citation: MO Rev Stat § 375.1007.

Improper claims practices.

375.1007. Any of the following acts by an insurer, if committed in violation of section 375.1005, constitutes an improper claims practice:

(1) Misrepresenting to claimants and insureds relevant facts or policy provisions relating to coverages at issue;

(2) Failing to acknowledge with reasonable promptness pertinent communications with respect to claims arising under its policies;

(3) Failing to adopt and implement reasonable standards for the prompt investigation and settlement of claims arising under its policies;

(4) Not attempting in good faith to effectuate prompt, fair and equitable settlement of claims submitted in which liability has become reasonably clear;

(5) Compelling insureds or beneficiaries to institute suits to recover amounts due under its policies by offering substantially less than the amounts ultimately recovered in suits brought by them;

(6) Refusing to pay claims without conducting a reasonable investigation;

(7) Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed and communicated to the insurer;

(8) Attempting to settle a claim for less than the amount to which a reasonable person would believe the insured or beneficiary was entitled by reference to written or printed advertising material accompanying or made part of an application;

(9) Attempting to settle claims on the basis of an application which was materially altered without notice to, or knowledge or consent of, the insured;

(10) Making a claims payment to an insured or beneficiary without indicating the coverage under which each payment is being made;

(11) Unreasonably delaying the investigation or payment of claims by requiring both a formal proof of loss form and subsequent verification that would result in duplication of information and verification appearing in the formal proof of loss form;

(12) Failing in the case of claims denial or offers of a compromise settlement to promptly provide a reasonable and accurate explanation of the basis for such actions;

(13) Failing to provide forms necessary to present claims within fifteen calendar days of a request with reasonable explanations regarding their use;

(14) Failing to adopt and implement reasonable standards to assure that the repairs of a repairer owned by or required to be used by the insurer are performed in a workmanlike manner;

(15) Failing to promptly settle claims where liability has become reasonably clear under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.

 

Fighting the Good Fight

Fighting the good fight

Photo by Pavel Danilyuk on Pexels.com

 

     I recently read a touching and inspiring tribute written by an attorney who advocates for policyholders and who had recently lost a valuable partner and fellow advocate to cancer.  Together, they would fight the good fight. There are not enough fighters like them in this arena, and in his tribute to his partner, he described her drive and enthusiasm for battling with insurance companies on behalf of their clients.

     Being one who shares in the same fight (though not at such grand of a scale), I felt a great sense of personal loss.  Even though I did not know her, personally, I know her heart and I have shared similar pain with the clients who had purchased insurance for peace of mind but found, when disaster came to their door, that this peace was only a temporary illusion.

     Though Missouri law tasks an insurance company to provide prompt and fair assistance to its policyholders in exchange for payment of premiums, minimizing risk, and filing a claim only upon sustaining damage – some insurance companies, to protect their own financial interest, inflict more stress and financial harm upon their policyholders than the destructive event that prompted their claim, and at a time when the policyholder is most vulnerable with the least financial reserve.  Instead of providing the warm professional care and assistance projected by their televised mascots, the policyholder is frequently met with fierce opposition and obstruction intended to exasperate, wear down, and break the resolve of the most committed policyholder defending his own rights under the very insurance policy he bought for “peace of mind”.

     Fighting through a barrage of tactics used by insurance companies to delay, deny, and defend against the policyholder is certainly not an enjoyable experience for either the policyholder or his advocate.  It is, however, something that must be done in order to receive a dollar-for-dollar payment for the incurred loss.  That is the reality that is not shown on friendly and warm television commercials.

     We lost a fighter.  Who will take her place?

 

 

 

 

 

Are the Engineer Reports Purchased By Insurance Companies to Deny Claims Accurate and Truthful?

engineer report to deny claim

Photo by Pixabay on Pexels.com

     In search of an expert to provide them with a reason to deny a claim, many insurance companies will turn to the engineering profession. 

     There are highly respected and valued professional licensed engineers who design and build bridges and skyscrapers, who safely and efficiently channel waterways through and around large cities, who design and test the durability of aircraft and automobiles, who meet and overcome construction and building challenges around the globe – and then there are those who market themselves to insurance carriers for the purpose of providing written reports for them to use to deny insurance claims for wind and hail damage to homes and businesses.  There is money in it.  Insurance companies will pay them upwards of $2,500.00 per report.  Most of these reports provide little more than boilerplate narratives regarding simple roofing materials and most of them contain little or no scientific or engineering data – but aside from their apparent lack of relevance, how accurate is the information that is provided?

     As a public adjuster representing business and homeowner policyholders with their insurance claims, I read many of these reports and too often find errors, misrepresentations, and ambiguities salted among information intended to present a “scientific” spin on what are usually simple, routine observations that virtually anyone can make.

     Much of what you will find in these reports, sometimes as much as two-thirds or more of the entire report, is a boilerplate filler of generic information that could be (but not always) relevant to their observations.  It looks impressive at first glance, just as it is intended to, but is it even correct?  Not always.

     An engineer in several of his recent reports used by various insurance companies to deny claims includes the following language:  “According to the National Roofing Contractors Association (NRCA), the lifespan of a roof is 20 years.”  His report was peer-reviewed and stamped by another engineer with his firm – an engineering firm widely used by insurance carriers throughout the country. This claim by the engineer caught my attention because he was writing about a certain type of roofing material that carried a 30-year warranty and, as most people familiar with roofing materials know, various roofing materials have various lifespans – some as high as over 50 years.  

     I did not believe that the National Roofing Contractor’s Association would be so uninformed as to publish what he claimed they did, so I wrote to them and inquired as to where I could find the information from them that this engineer was quoting in his report used to support a denial of a cliam.  The Vice President of Technical Services for the NRCA responded to me, as follows:  “The 20-year figure is not from the NRCA.  Lifespans vary greatly.”  Thus, the engineer was not only wrong in his peer-reviewed statement of fact regarding the lifespan of a roof, but he also misrepresented the source for his errant facts.  

     Some engineers will provide comments and conclusions about the density or speed of hailstones as being less than required to damage roofing material and provide absolutely no information as to how they were able to measure the density or speed of the hailstone that melted away months or years before their observation.  We are to simply take their word for it, like the quotations from the NRCA, perhaps.

     The engineer paid by the insurance company might use ambiguous language that appears to say something but doesn’t.  For instance, did the engineer say that large hailstones did not strike your roof, or did he simply say that he did not observe evidence of large hail strikes?  There is a difference.  Could there be evidence that he did not “see”, such as bruised indentations on weathered asphalt composite material that is soft to the touch?  Did he say this, or did he leave it to the insurance company to use in the manner of their own choosing?

     Insurance carriers, being corporations who have a fiduciary duty to protect the financial interests of their shareholders as well as a contractual duty to fulfill their promises to their policyholders, will often find this conflict of interest resulting in their wrongful actions of grossly underpaying or wrongfully denying their policyholders’ claims.   The misuse of engineer reports is one of the ways they do this.

     Often, insurance companies will knowingly allow the engineer’s errant attempts to interject policy interpretations into his report to be used to deny a policyholder’s claim.  I have personally reversed an attempt by an insurer to deny an insurance claim because the engineer reported that the damage to the roof “could not be seen from the ground” when there was nothing in the policy to exclude damage for that reason, as one of many examples.  

     An expert witness in court must present his credentials, provide his testimony under oath, and be subjected to cross-examination, but insurance companies present biased hired guns as experts in the claims process and deprive vulnerable policyholders of necessary funds to restore their homes and businesses, with impunity.

     The advice to not believe everything you read should be extended to engineer reports paid for by your insurance company to deny your insurance claim.  Have them closely reviewed by your own expert for accuracy, relevancy, and truth before accepting that your claim should be denied as a result of an engineer’s report.  Whatever you do, do NOT let the insurance company’s engineer be the final word on the validity of your claim.

Missouri Homeowners/Business Insurance and the Roof

 

Photo by Gabby K on Pexels.com

     There are basically two kinds of roofs on Missouri homes and business structures.  There are those that have storm damage and those that will have storm damage.  Understandably, the various insurance companies from all over the country that sell policies in our state will offer a wide variety of coverage options that are not always or fully understood by the property owners before disaster strikes.  

     Learning after the roof has been damaged that you have been saving pennies per year by NOT including coverage to match replacement shingles or siding, or learning that hail dents that destroy the appearance of your metal roof is not considered “damage” by your insurance company, can result in costly out of pocket expenses that you thought were covered by insurance.  

     The Missouri Department of Insurance has created an informational and interactive website that helps you to generally understand your roofing coverage for each insurance carrier.  While I recommend that you visit their site, I urge you to take the time to actually read and understand your insurance policy, as well.  Have your agent clearly explain to you, when necessary, what it does and does not provide and ask lots of questions.

     Considering that when an insurance company’s claims department is on its very best behavior, its job is the same as any corporation that is run by a board of directors.  That job is to put the financial interests of their shareholders (not their policyholders) at the top of their priority list.  Their duty to you, as a policyholder, is not fiduciary (as it is with their shareholders) but contractual.  Thus, even when you are dealing with a fair and reasonable adjuster,  you need to know what your contract with them says.  That contract is your insurance policy.

     Your insurance company is prepared and well-practiced to fight and defend their rights under that contract.  How prepared are you?  Don’t let the first large claim be the first time you read it.  Caveat emptor.

If My Neighbors Had Damage From the Storm, I Do Too, Right?

 

Photo by GLEIVE MARCIO RODRIGUES DE SOUZA on Pexels.com

     This argument on its face seems logical.  A severe storm has recently passed through your neighborhood and your surrounding neighbors have filed claims for roof damage and received settlements from their carriers.  You must have roof damage, too right?  Wrong.  Many policyholders make this mistake.

     Let’s look at hail damage, for example.  Most roofing materials are specifically designed to withstand hail strikes to certain degrees, but much depends upon the type of roofing material that is on the roof, its age and condition before the storm, the angle of the hail strike, the number of layers of roofing materials (particularly shingles), the proximity of trees and other structures taller than the building, and other variables.  Since not all of these factors are typically identical with every home in a neighborhood, not all homes will be damaged, equally damaged, or damaged in the same manner.

     While it is not a sure thing that you have incurred an insurable loss, when storm damage is present in the buildings around you it is prudent to  have your roof inspected by a professional contractor in your area.  Storms invite “traveling contractors” from “various parts unknown” who drive through neighborhoods alerting homeowners of damage, but avoid them and find a contractor who is known and trusted and ask him to evaluate your home for damage – and don’t limit the inspection to the roof.  Hail will damage siding, gutters, downspouts, decks, porches, and windows as well.  When you have established that YOU … and not your neighbors … have damage to your home that will exceed your deductible, then it is time to call your insurance company and file a claim.

     It is important to know that you, as a policyholder, have the burden to prove to your insurance company that you have incurred an insurable loss.  Reporting to them that you have a loss simply because your neighbors do will fall significantly short of that burden. 

     Ask your contractor to provide you with photographs of the damage and ask him to be present with you when you (not the contractor) present your loss to the adjuster. Do not let the contractor speak on your behalf or represent your claim to the insurance company.  In Missouri, he is not allowed to by law, and insurance companies have no duty to fully or accurately inform him of your coverage since he is not a party to the contract that you have with them.  He’s easy for them to push around which is why, in spite of the law, adjusters will sometimes pretend to negotiate with them. But he is your expert in presenting the damage he found and answering questions about it.  Having him there can be a plus.

     Prove your loss to yourself, first.  Then file your claim and prove it to your insurance company … in that order.

     

 

Shareholders or Policyholders? Who matters most?

Photo by Polina Tankilevitch on Pexels.com

     

Shareholders or policyholders.  Who matters most?  Take this quiz:

The Board of Directors of my insurance company has a lawful duty to protect:

a.  the financial interests of the policyholders.

b. the financial interest of the stockholders.

c.  both of the above.

d.  none of the above.

The answer is (b).  The Board of Directors of an insurance company’s first (or fiduciary) duty is to the shareholders that elected them. 

This means that the financial interests of the shareholders come before those of the insured policyholder when that corporation is an insurance provider.  Profits come to a business from paying out less than what they take in.  Shareholders demand this in return for their investment.  Insurance companies comply.   Know this as you shop. 

The National Law Review has published a list of the “eleven worst insurance companies” and I encourage you to read it.  Before you take too much comfort in finding that your home insurance provider did not make the list, you should consider that many that made the list are providers of health insurance.  The factors that were used for the home and business insurers that made the list, however, are not unique to them but are commonly shared among smaller companies that would have at least made “dishonorable mention” if the list did not include other types of insurers.

     What this list should teach those of us who buy insurance is the need for us to carefully select an insurance provider based on something other than cute or funny television commercials.  Sweet talking lizards that collect your insurance premium can quickly become vicious and vexatious crocodiles defending the company against your valid claim.  If you can learn this before you become vulnerable as a result of catastrophic loss, the better off you will be.     

The Missouri Department of Insurance publishes a complaint index to help Missouri consumers determine how likely they may find displeasure with an insurance company’s claim handling process.  Considering how few unsatisfied policyholders will actually go through the red tape to file a complaint with the State government , when an insurance company exceeds the normal rate of complaints under such circumstances – it really says something.

Caveat emptor.

“No hail damage” Concluded Before the Roof Inspection?

no hail damage before roof inspection

Photo by Olya Kobruseva on Pexels.com

 

The engineer’s report I read today concluded, as follows:  “There was no functional damage due to hail observed on any of the roofs on the buildings at the subject property.  If hail occurred at the subject property, it did not have sufficient size, density, or speed to cause functional damage to the roof covering.”

My first reading of this conclusion sent up a red flag as I read “If hail occurred at the subject property …” since the report contained weather data showing that hail greater than 1.25″ had fallen at the site of the fifteen-year-old shingled roof on the date of loss and observations of hail dents were reported on all metals on and surrounding the roof.  How could “if hail occurred” even be a factor in a conclusion about the damage clearly reported to be caused by it, I wondered.  Then I began to look deeper.

My second reading of the report was an intense search for any mention of the engineer’s measurement or calculation of the density of the hailstones that he knew to have struck the roof or a determination of the distance or angle of their descent.  There was none.  Without that, how could the engineer, who had now come to question “if” hail had struck the roofing materials, conclude that the hail was known to have lacked the density or speed to cause damage?

I checked my files and found three other reports written by the same engineer from other claims I had represented.  Like this one, all of them were written at the request of an insurance company and all of them concluded the same absence of “observed” damage to the roof.  Oddly, however, each of the four reports stated the exact same conclusion in the exact same words – verbatim.

2017 – “There was no functional damage due to hail observed on any of the roofs on the buildings at the subject property.  If hail occurred at the subject property, it did not have sufficient size, density, or speed to cause functional damage to the roof covering.”

2020 – “There was no functional damage due to hail observed on any of the roofs on the buildings at the subject property.  If hail occurred at the subject property, it did not have sufficient size, density, or speed to cause functional damage to the roof covering.”

2021 – “There was no functional damage due to hail observed on any of the roofs on the buildings at the subject property.  If hail occurred at the subject property, it did not have sufficient size, density, or speed to cause functional damage to the roof covering.”

2021 – “There was no functional damage due to hail observed on any of the roofs on the buildings at the subject property.  If hail occurred at the subject property, it did not have sufficient size, density, or speed to cause functional damage to the roof covering.”

Not one of these narratives was supported with information as to how or if the density and speed of the hailstones were measured by the engineer to conclude their insufficiency to cause damage.  Nor did they report the direction of the storm, the angle at which the hailstones struck the roofing materials, the speed or direction of the wind at the time of the storm, or other relevant data required for scientific analysis of hail damage.  In other words, if one were to remove the boilerplate language apparently common to all of his reports, nothing appeared in the narrative that required an engineer to cite.  The same ambiguous and noncommital descriptions could have been just as easily written by a shingle salesman with poor marketing skills.

Last, but certainly not least, please pay special attention as to how this carefully worded boilerplate conclusion did not say there was no damage to the roof caused by hail.  Instead, the engineer simply stated that based only on his powers of observation, he didn’t see it.   

Could it be that these conclusions, like the language used to communicate them, had been predetermined prior to the inspection?

Copyright 2021, James H. Bushart, Licensed Adjuster LLC

 

 

This Blog/Web Site is made available by James H. Bushart, Public Adjuster LLC for educational purposes only as well as to give you general information and a general understanding of the work of a public adjuster, not to provide specific legal advice. The authors and/or site manager make no representations as to accuracy, completeness, currentness, suitability, or validity of any information on this site and will not be liable for any errors, omissions, or delays in this information or any losses, injuries, or damages arising from its display or use. By using this blog site you understand that there is no public adjuster/client relationship between you and James H. Bushart, Public Adjuster LLC.  The Blog/Web Site should not be used as a substitute for competent legal advice from a licensed professional attorney in your state.

%d bloggers like this: