Tag Archives: Claims

Protecting Yourself from Claims Predators After a Disaster

April 13, 2026 By in Property Insurance Tags: , , , , 1 Comment

Don’t sign ANYTHING.

A fire has just torn through your home. The flames are still being beaten back by firefighters. Hoses snake across your lawn. Smoke fills the air and your eyes sting from the heat. Your family is standing in the street in whatever you managed to grab on the way out. You don’t know yet what you’ve lost, what’s left, or where you’ll sleep tonight.

And then someone walks up and hands you a contract.

It sounds almost unbelievable. Unfortunately, for far too many Missouri homeowners, it’s a scene that plays out all too often.

Who Are These People — and Why Are They at Your Fire Scene?

Some public adjusters — mostly from out of state who work claims here, but a few licensed and working in Missouri — hire paid local solicitors specifically to drum up business at disaster scenes. These solicitors are often the first non-emergency personnel to arrive at a loss. They scan police scanners, monitor fire department radio frequencies, and show up while smoke is still rising from the rubble, clipboard and contract in hand.

Their job is simple: get your signature before you have a chance to think.

Public adjusters are professionals who represent policyholders in insurance claims — and legitimate ones can provide real value, especially in complex losses. But the tactics used by the predatory fringe of this industry are a different matter entirely. When someone approaches a grief-stricken, disoriented homeowner at the scene of a disaster and pressures them to sign a legal contract, that’s not advocacy. That’s exploitation.

The Problem with Signing Under Duress

In the immediate aftermath of a fire, flood, or other catastrophic loss, you are not in a position to make clear-headed legal and financial decisions. That’s not a character flaw — it’s simply human nature. Trauma, shock, and fear are powerful forces, and they impair judgment in ways that even intelligent, capable people don’t always recognize in the moment.

Public adjuster contracts are legally binding agreements. They typically grant the adjuster the authority to communicate with your insurer on your behalf and entitle them to a percentage of your settlement — often between 10% and 15%, sometimes higher. Signing such a contract at the scene of a loss, before you even know the full extent of your damages, means you are committing a significant portion of your recovery funds to someone you met minutes ago, under circumstances no reasonable person could call voluntary.

Many homeowners who signed these agreements later reported feeling they had no choice, that the solicitor implied it was necessary to get the claims process started quickly, or that they were simply too stunned to push back. Some didn’t even fully understand what they had signed until weeks later.

A Legislative Gap That Leaves Policyholders Vulnerable

You might expect that showing up at an active fire scene to solicit business from disaster victims would simply be illegal. In many states, it should be. But legislators have often been reluctant to outright prohibit this kind of solicitation, instead attempting to address it through disclosure requirements, waiting periods, and contract cancellation rights.

While those protections have some value, they rely on policyholders knowing their rights and having the presence of mind to exercise them at one of the most disorienting moments of their lives. That’s a fragile safety net at best.

Until stronger protections are in place, the burden of self-defense falls largely on you.

How to Protect Yourself

The single most important thing you can do in the aftermath of any disaster is this: do not sign any contract, agreement, or authorization with anyone until you are ready.

That means waiting until you are somewhere safe and calm. It means waiting until you have had time to assess the full scope of your loss. It means waiting until you have spoken with your insurance company, understood what your policy covers, and had the opportunity to consider every option available to you.

You have time. Despite what a pushy solicitor may imply, your insurance claim will not be lost or compromised because you took a few days — or even a few weeks — before hiring a representative. Your insurer is legally obligated to work with you. Your rights as a policyholder do not expire.

Here are a few practical steps to take immediately after a loss:

  • Call your insurance company directly to report the claim and begin the process. You don’t need a third party to initiate this.
  • Ask for identification from anyone who approaches you at the scene claiming to represent your interests. Get their name, company, and license number.
  • Never feel pressured to make decisions on the spot. Any legitimate professional will respect your need for time.
  • Consult someone you trust — a family member, attorney, or financial advisor — before signing anything.
  • Know your cancellation rights. Missouri law gives policyholders the right to cancel a public adjuster contract within a set period after signing. But it’s far better not to sign under pressure in the first place.

The Bottom Line

Disasters are devastating. The recovery process is long, complicated, and emotionally exhausting. There are honest, ethical professionals who can genuinely help you navigate an insurance claim — and if you decide you need one, you should have the time and clarity to choose one wisely.

Don’t let anyone take that choice away from you in the chaos of the worst day of your life. Put the contract down. Step back. Breathe. The decisions you make in the days and weeks ahead will shape your recovery for years to come — and you deserve to make them on your own terms.

James H. Bushart, Licensed Missouri Public Adjuster
MO License #8207067 | SCLA | NAPIA
314-803-2167 | missouripublicadjuster.org

Missouri Insurance Claims and Politicians Don’t Mix Well

April 13, 2026 By in Property Insurance Tags: , , , , , 3 Comments
map of missouri

The Great State of Missouri

 

There is a disconnect between Missouri legislative promises and regulatory reality in Missouri property insurance claims. Here, what THEY don’t know can hurt YOU.

In the world of property insurance, the language we use to set consumer expectations matters. Currently, Missouri’s proposed Senate Bill 1543 is attempting to change, among other things, how consumers interact with public adjusters. There are some good provisions in this bill, but a close look at the bill’s mandated language reveals a massive gap between what legislators are promising and what state regulators can actually deliver.

The Legislative Promise: “Free Help”

Missouri SB 1543 proposes that public adjusters must include a very specific, bold-text disclaimer in their contracts. It requires them to tell the consumer: “YOU DON’T HAVE TO HIRE A PUBLIC ADJUSTER TO FILE A CLAIM WITH YOUR INSURANCE COMPANY… IF YOU NEED HELP WITH YOUR CLAIM, THE MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE WILL HELP YOU FOR FREE”.

It is true that a policyholder does not have to hire a public adjuster to assist with their insurance claim, just as a taxpayer does not need to hire a tax preparer or CPA to prepare their taxes.  Particularly, when the firetruck is still at your home spraying water on the fire and a public adjuster or solicitor is there trying to get you to sign a contract for representation before you have had a chance to consider your entire situation (yes, unfortunately, this happens), this warning is certainly valid and useful. I enthusiastically endorse it. However, when you have already filed a claim and are seeking help with it, is the Missouri Department of Commerce and Insurance able to represent you in the same way I can for free? 

In the context of the bill, which tightly regulates who is allowed to “negotiate” a claim—defined as discussing or exchanging offers with an insurance company to reach a settlement amount—this mandatory disclaimer strongly implies that the Department of Insurance will step in and act as a free alternative to a hired public adjuster.

The Regulatory Reality: “No Authority to Determine Loss”

However, if we look at the actual letters sent by the Missouri Department of Commerce and Insurance when consumers today request this “free help,” a completely different reality emerges.

When responding to consumer complaints regarding property claim disputes, the Department explicitly clarifies the strict limits of its power. A standard response from a Department complaint investigator plainly states: “I do not have the authority to determine the amount or extent of loss you have incurred”.

Instead of negotiating the dollar value of the damage or debating the scope of repairs with the insurance company, the Department outlines a strictly regulatory role:

  • Finding out the current status of the claim file.
  • Evaluating how the insurance company is handling the situation.
  • Assisting in claim resolution if possible, primarily by ensuring “the company is compliant with Missouri insurance laws”.
  • Cannot address property claim denials or partial denials.
  • Cannot establish the facts regarding any other disagreement between you and another party.

How much “help” can they really provide without determining or negotiating the amount of the loss, the scope of the damage, or the merits of the claim they are presumably helping with for free when the claim has been denied or underpaid?

The Danger of Over-promising

The difference between these two documents is staggering. The proposed contract language suggests to consumers that they can forgo professional representation because the state will step in and “help” them resolve their claim for free. Yet, when the state actually arrives, they legally cannot evaluate the damage, determine the cost of the loss, or negotiate the financial settlement.

If an insurance company relies on an engineer to deny structural damage or limit a roof replacement, the Department of Insurance does not have the authority to argue the engineering merits or negotiate a higher payout on the consumer’s behalf. They merely check to see if the insurer followed the statutory timelines and processes. When they have finished helping you for “free” and informed you that the insurer who has denied or underpaid your claim has violated none of the particular rules they govern, is not the insurer who denied or underpaid your claim even more solid in their partial or full denial of your claim? What can you do at that point other than sue?

Conclusion

For property owners facing devastating losses, clarity is essential. Suggesting that a regulatory body can replace the active negotiation and valuation services of a public adjuster is not just misleading; it leaves the consumer fundamentally unprotected during the most critical phase of their claim.

In short, while the state will offer its regulatory review for free, they will not—and legally cannot—act as a free public adjuster to negotiate the financial value or factual merits of either a residential or company’s commercial insurance claim.

Legislators must ensure that the statutory notices they force upon professionals accurately reflect the actual powers of the state agencies they promote. If those lobbying for this bill to become law are successful, Missouri policyholders will need to know that the promise of “free” help in this contract language may not be true.

James H. Bushart, Licensed Missouri Public Adjuster
MO License #8207067 | SCLA | NAPIA
314-803-2167 | missouripublicadjuster.org

Mistakes To Avoid When Filing an Insurance Claim

March 17, 2023 By in General Home Issues, Home Owner Insurance Issues, Property Insurance Tags: , , , , , Leave a comment

 

James H. Bushart, Public Adjuster LLC

 

Insurance claims for property damage can be a complicated process and avoiding mistakes can be a challenge. It requires proper documentation and timely submission of relevant paperwork. Any mistake in filing the claim could result in delayed or denied coverage, leaving the policyholder to bear the entire cost of the damage. Therefore, it is essential to understand the do’s and don’ts of filing an insurance claim for property damage and to know when to get help. In this essay, we will discuss the mistakes that policyholders should avoid when filing an insurance claim for property damage.

Failing to Document the Damage:

The first and most common mistake that policyholders make is failing to document the damage properly. It is essential to take pictures and videos of the damaged property as soon as possible after the incident occurs. This documentation will serve as evidence for the insurance company to determine the extent of the damage and the amount of coverage required. Without proper documentation, it can be challenging to prove the damage, and the insurance company may deny the claim. 

Photographs or video of the hailstones that struck the property, for example, are valuable evidence since some weather reports might report the nearest hailstorm to have been miles away on the date of loss.  Photographs of interior water damage taken before clean-up measures began help preserve evidence of fresh damage.  Proving your claim is YOUR responsibility.  Leave it up to the insurance company to prove it for you and you are likely to be disappointed in the result of their half-hearted efforts.

 

Waiting Too Long to File the Claim:

Another common mistake that policyholders make is waiting too long to file the claim. It is crucial to report the damage to the insurance company as soon as possible after the incident occurs. Most insurance policies have a specific timeframe within which the policyholder must report the damage. Failing to report the damage within this timeframe could result in a denied claim. Additionally, waiting too long to file the claim could result in delays in the claims process, which could cause further damage to the property.

Failing to Provide Accurate Information:

When filing an insurance claim for property damage, it is essential to provide accurate and detailed information about the incident. This includes the date and time of the incident, the cause of the damage, and the extent of the damage. Providing inaccurate or incomplete information could result in delays or denials of the claim. Additionally, it could result in the policyholder being accused of insurance fraud, which could result in legal consequences.

Not Reviewing the Insurance Policy:

Before filing an insurance claim for property damage, it is essential to review the insurance policy to understand the coverage and exclusions. Many policyholders make the mistake of assuming that their insurance policy covers all types of damage, only to realize later that the damage is excluded from the policy. Therefore, it is essential to review the policy and understand the coverage and exclusions before filing the claim.  Your insurance policy is a contract worth hundreds of thousands (sometimes millions) of dollars.  READ IT.

Attempting to Repair the Damage Before Filing the Claim:

Some policyholders make the mistake of attempting to repair the damage before filing the claim. It is essential to notify the insurance company before making any repairs to the property. The insurance company will likely send a claims adjuster to assess the damage and determine the amount of coverage required. Failing to notify the insurance company before making repairs could result in a denied claim, as the insurance company will not have the opportunity to assess the damage.

Failing to Mitigate Further Damage:

When property damage occurs, it is essential to take steps to mitigate further damage. This includes taking steps to prevent water damage or securing the property from further damage. Failing to take steps to mitigate further damage could result in a denied claim, as the insurance company may view the policyholder as negligent in protecting the property.

Not Understanding the Claims Process:

Filing an insurance claim for property damage can be a complicated process. It is essential to understand the claims process and follow the guidelines provided by the insurance company. Failure to understand the claims process could result in delays or denials of the claim.  If you need help with this, contact a licensed public adjuster or attorney for advice or assistance.

Not Following Up on the Claim:

After filing an insurance claim for property damage, it is essential to follow up with the insurance company regularly. This includes following up on the status of the claim and providing any additional documentation required. 

Not Seeking Assistance from Unbiased Sources:

When you find your insurance provider putting more effort into denying your claim than paying it or you feel that you are getting unfair resistance or treatment, consult a licensed public adjuster or an attorney to assist you.

Is Your Property Fully Insured?

July 14, 2021 By in Property Insurance Tags: , , Leave a comment

 

 

After considering the adversarial posture of an insurance company toward its policyholder in the event of a claim and assuming the best – that you would be successful in recovering the most that your policy provides to restore your property after a catastrophic loss – did you buy enough insurance to actually restore your property?

Some people will negotiate a terrific deal when purchasing a commercial building or residential dwelling and then will insure that building for the amount of money they paid for it.  The mortgage lender is certainly happy with that amount of insurance for it fully protects their financial investment, but is the market value of a structure sufficient to rebuild it if it were destroyed?  Most likely, it would be significantly less, and it is probably not your plan after a major loss to simply pay off your loan, remove the rubble at your own expense, and live or conduct business on an empty lot.

Even before the current exponential increase in costs for building materials, the market value of a structure did not reflect the cost of replacing all or most of it which, in the event of a major fire or storm, would be the purpose of an insurance policy.

A general contractor or builder in your immediate area will be able to tell you what an average cost per square foot would be to replace all or most of your building today if it were significantly damaged.  Take that cost and multiply it by the square footage of the building you are insuring and then add a few dollars for next year’s inflation.  This will tell you whether or not your home or business structure is insured for a sufficient amount of money.

Until such time the costs of building materials begin to stabilize, this is probably something that you want to do prior to your renewal each year.

 

How to Help Your Insurance Company Deny Your Claim

July 13, 2021 By in Property Insurance Tags: , , 1 Comment
tombstone in graveyard depicting a dead insurance claim

Killed by the policyholder.

     

Believe it or not, many policyholders unintentionally help their insurance company deny their claim and withhold money they might otherwise receive. Of course, they don’t mean to sabotage their insurance claim — but the denial often stems more from the policyholder’s own actions than from anything the insurance carrier does. To understand how insurance companies let policyholders defeat themselves, it is essential to remember three key points about insurance claim denial:

  1. The policyholder must prove that they have a covered loss.
  2. The insurance company has no duty or obligation to assist the policyholder in proving that they have a covered loss.
  3. The insurance company has the duty to pay the claim for a covered loss unless they can prove that an exclusion named in the open-peril policy applies. The burden of proof for any exclusion rests squarely on the insurance company.

If you have damage to your home or business, you must present proof of the loss and proof that it is covered under your policy — without expecting your insurance company to help you. You must prove your claim. If you do, they pay you — unless they can prove an exclusion applies. If they cannot prove the exclusion, they must pay.Keep these three points in mind as you read the following real-world examples of how policyholders I have recently spoken with helped their insurance companies deny their claim:

  1. “A hailstorm struck my neighborhood recently, and everyone within a quarter mile of my house had their roofs replaced by their insurance companies, so I filed a claim too,” the policyholder told the claims adjuster.

This is one of the most common ways policyholders trigger an insurance claim denial. When reporting a claim like this, the policyholder has no personal knowledge of hail damage to their own property and therefore no proof to provide the insurance carrier. Arguing that “everyone else got paid” is both inconsistent with the insurance policy and completely irrelevant. It would be just as illogical for the carrier to say, “We’re denying your hail claim because no one else within a quarter mile reported damage.” Neighboring damage does not prove your damage.The adjuster might happen to find hail damage during inspection, but don’t count on it. Even if you receive a small settlement above your deductible, the long-term increase in your insurance premium could easily exceed the payout — especially if the carrier now views you as someone who files claims without proof of damage. Re-read point #1 above: Know you have a covered loss before you file.

  1. “I have water leaking through my ceiling. I filed a claim for damage to my roof,” the policyholder told the claims adjuster.

In most states, including Missouri, it is rare for hailstones to strike roofing material hard enough to create an actual hole. Roof leaks are far more often the result of maintenance issues — deteriorated flashing, aged repairs, or worn-out materials. Before filing any roof damage claim, you (or a trusted roofing professional) must determine the exact source and cause of the leak. If the cause was sudden and accidental (for example, wind damage or a fallen tree limb), include clear photographs of both the damage and the cause with your claim. If the leak resulted from normal wear and tear or lack of maintenance, your claim will almost certainly be denied because you failed to prove a covered loss. Knowing this before you file protects both your claim and your future premiums.Always prove to yourself first that a covered peril caused the damage. When you file, clearly describe the damage and the sudden, accidental cause. Then be ready with evidence when the adjuster arrives.

  1. “We had heavy rain for three days. There are six inches of water flooding my basement. I filed an insurance claim.”

Standard homeowners insurance policies do not cover flood damage. Unless you have a specific endorsement for sump pump failure or water backup, water entering from outside the home is typically excluded. Before filing, determine exactly where the water came from and gather physical or photographic evidence. When reporting the claim, do not describe the damage as “flood” damage if it was actually caused by a broken pipe or backed-up drain inside the home.

Relying on the adjuster to investigate and prove your loss for you is a fast track to insurance claim denial.Once you have properly presented proof of a covered loss, the insurance company should pay — unless they can prove an exclusion applies. To strengthen their case, carriers often hire engineers and consultants they have long-standing relationships with.
These professionals are paid to find exclusions, not to advocate for the policyholder.That is why it is almost always a mistake for a policyholder to demand that the insurance company “hire an engineer” when they disagree with the adjuster. The engineer works for the company paying the bill — not for you.Another common way to help your insurance company deny your claim is to delay or refuse to provide requested documents or site access.
Insurance policies impose duties on both parties. Missing deadlines for documents or inspections can give the carrier legitimate grounds for denial.If you feel uncomfortable preparing and presenting your claim with the necessary proof, hire a licensed public adjuster to represent you.
If you receive a denial or lowball settlement and believe it is unfair, have the entire file reviewed by an attorney or licensed public adjuster before deciding on the next step.Protecting your insurance claim starts and ends with you.
Prove your covered loss clearly and completely — or risk helping your insurance company deny your claim.
James H. Bushart, Licensed Missouri Public Adjuster
MO License #8207067 | SCLA | NAPIA
314-803-2167 | missouripublicadjuster.org

What Is Insurance Fraud in Missouri?

July 7, 2021 By in General Home Issues, Property Insurance Tags: , Leave a comment

What constitutes insurance fraud in Missouri?

Insurance fraud is an affirmative defense used by insurance companies to deny claims.  The burden of proving fraud to deny an insurance claim is not as stringent as it is to prove insurance fraud for a criminal conviction.  This post is intended only to generally inform the reader of the statute that governs the Class E and Class D felonies of insurance fraud in the State of Missouri and describe how insurance companies use this defense to deny insurance claims.  It is not to be construed as legal advice.

According to the Missouri Revised Statutes:

375.991.  1.  As used in sections 375.991 to 375.994, the term “statement” means any communication, notice statement, proof of loss, bill of lading, receipt for payment, invoice, account, an estimate of damages, bills for services, diagnosis, prescription, hospital or doctor records, x-rays, test results or other evidence of loss, injury or expense.

2.  For the purposes of sections 375.991 to 375.994, a person commits a “fraudulent insurance act” if such person knowingly presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, purported insurer, broker, or any agent thereof, any oral or written statement including computer-generated documents as part of, or in support of, an application for the issuance of, or the rating of, an insurance policy for commercial or personal insurance, or a claim for payment or other benefits pursuant to an insurance policy for commercial or personal insurance, which such person knows to contain materially false information concerning any fact material thereto or if such person conceals, for the purpose of misleading another, information concerning any fact material thereto.

6. A fraudulent insurance act for a first offense is a class E felony. Any person who is found guilty of a fraudulent insurance act who has previously been found guilty of a fraudulent insurance act shall be guilty of a class D felony.

7. Any person who pleads guilty or is found guilty of a fraudulent insurance act shall be ordered by the court to make restitution to any person or insurer for any financial loss sustained as a result of such violation. The court shall determine the extent and method of restitution.

8. Nothing in this section shall limit the power of the state to punish any person for any conduct that constitutes a crime by any other state statute.

Be reminded that acts of fraud, both civil and criminal, include the application for the insurance policy as well as the filing of an insurance claim.  

When the policyholder makes false statements or conceals material facts or evidence when applying for insurance coverage or during the course of a claims investigation with the intent to deceive the insurance carrier, it is not necessary for the insurer to actually pay the claim for the act of fraud to be committed.  Courts have held that fraud attempted, even when the policyholder argues that he was merely using negotiation tactics, is still fraud.

As for the claim, fraud in any aspect of a claim is a bar to coverage for the entire claim.  This means if a policyholder made a material misrepresentation about his loss from fire of personal property but made no misrepresentation about damage to his house, the claim can be denied for BOTH the personal property and the house.

If you are handling your claim on your own and without the assistance of an attorney or public adjuster, it is important to be aware and understand that your words matter.  Since misrepresentation and fraud are defenses that allow the insurance carrier to deny a claim, there is a significant financial incentive for the adjuster conducting the investigation to discover or interpret certain acts and information, accordingly.  Be truthful, precise, and present to the insurance company only what you know to be true.

What Must I Prove When Filing an Insurance Claim?

July 2, 2021 By in Property Insurance Tags: , , , , 2 Comments

 

Burden of proof with insurance claim

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.

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

June 19, 2021 By in Home Owner Insurance Issues Tags: , , , 1 Comment

Enemy for filing a claim

   “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 like it, is something that I hear daily 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 recommended that the claim be paid against the carrier’s wishes, and I requested a copy of his report.  Insurance companies will 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 the other documents in the file will be in the hands of his attorney.  He will recover all 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 their claim, is what made him an adversary … and a worthy one, at that.

Missouri Law and Your Insurance Company

May 16, 2021 By in Home Owner Insurance Issues, Property Insurance Tags: , , , , Leave a comment

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 statute 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

May 5, 2021 By in Home Owner Insurance Issues, Property Insurance Tags: , , , , , , Leave a comment
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?