Tag Archives: insurance claim

“Forensic Engineer” — What That Title Really Means (and Doesn’t Mean) Under Missouri Law

May 16, 2026 By in Property Insurance Tags: , Leave a comment
Forensic Engineer

Forensic Engineer?

Every day, insurance companies send engineers to inspect damaged properties. Those engineers write reports that determine — often decisively — whether a policyholder gets paid. Many of those reports are signed by someone calling himself a “forensic engineer.”

It sounds authoritative. It sounds specialized. It is meant to sound that way.

But here is what Missouri law actually says about that title — and why every policyholder, attorney, and claims professional should understand the difference between a credential and a marketing label.

Missouri Does Not License “Forensic Engineers”

Let’s start with the foundational fact: Missouri issues one license — Professional Engineer (PE). There is no forensic engineering license. There is no forensic engineering specialty registration. The Missouri Board for Architects, Professional Engineers, Professional Land Surveyors and Professional Landscape Architects does not examine, certify, or regulate any engineer as a “forensic” practitioner.

Under RSMo § 327.181, a licensed PE may use the word “engineer” preceded by any modifier — including “forensic” — so long as that use is “reflective of that person’s profession or vocation.” The title itself is not prohibited, and no statute requires a special credential to use it.

That means any licensed PE in Missouri can call himself a forensic engineer on a report. No additional training. No demonstrated forensic methodology. No peer review. No credential of any kind.

The Title Is Permissible — But It Creates a Professional Obligation

Here is where it gets important.

Missouri’s Code of Professional Conduct at 20 CSR 2030-2.010(3)(B) requires every licensed engineer to “undertake to perform professional engineering services only when they are qualified by education, training, and experience in the specific technical areas involved.”

Forensic engineering is a specific technical area. It is not simply civil engineering applied to a damaged building. It involves:

  • Systematic investigation methodology
  • Causation analysis and failure analysis
  • Preservation and documentation of physical evidence
  • Report writing designed to withstand adversarial scrutiny
  • Familiarity with standards such as ASTM E3176 (Standard Guide for Forensic Engineering Expert Reports)

The National Academy of Forensic Engineers (NAFE) — the profession’s leading credentialing body — requires candidates for membership to hold a PE license, demonstrate actual forensic practice experience, and provide references from attorneys and senior claims professionals personally familiar with their forensic work. Board Certification in Forensic Engineering through NAFE requires meeting those standards.

A civil engineer who designs roads and bridges holds a PE license. That does not automatically qualify him to render forensic opinions on storm damage causation, building envelope failure, or insurance claim investigations — any more than a general contractor’s license qualifies someone to perform electrical work.

Missouri’s professional conduct rules also prohibit licensees from misrepresenting or exaggerating their professional qualifications (20 CSR 2030-2.010(3)(H)). When an engineer without genuine forensic qualifications presents himself as a “forensic engineer,” that rule is squarely in play.

The title is not the violation. The gap between the title and the actual qualifications is.

Questions Worth Asking

Regardless of your role in a property insurance claim, an engineering report that carries the “forensic engineer” label deserves a closer look. Some reasonable questions:

  • What is this engineer’s actual training and experience in forensic investigation?
  • Does the report reflect a recognized forensic methodology, or is it general engineering opinion dressed in forensic language?
  • Does the engineer hold any recognized forensic credential — such as NAFE membership or Board Certification in Forensic Engineering?
  • Is the conclusion supported by documented observations and objective analysis?

A PE license number tells you the engineer passed a licensure examination. It does not tell you whether he was qualified to perform the specific forensic work in that report. Those are different questions — and they matter.

The Bottom Line

“Forensic engineer” is a description of a specialty practice. In Missouri, it is a title any PE can place on a report. The law does not prohibit it — but Missouri’s own professional conduct rules require that an engineer be genuinely qualified before performing the work, and prohibit misrepresentation of qualifications.

The gap between what that title implies and what some engineers actually bring to the work is one of the most underexamined issues in property insurance claim disputes.

It deserves more scrutiny — from policyholders, from the professionals who serve them, and from everyone with a stake in an honest claims process.

James H. Bushart, missouripublicadjuster.org, 314-803-2167. Free claim review.

 

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 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 Overpromising

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

Missouri Policyholders and Missouri-Based Public Adjusters

April 9, 2026 By in Property Insurance Tags: , , , Leave a comment

The Great State of Missouri

Why Missouri Policyholders Are Better Served by a Missouri-Based Public Adjuster

After a significant property loss, the decisions a policyholder makes in the first few days can shape the outcome of the entire claim. One of the most consequential of those decisions is who to hire to represent them. Public adjusters from outside Missouri sometimes work claims in this state, and some hold valid Missouri licenses. But licensure alone doesn’t make someone the right advocate for your claim. Where a public adjuster lives, works, and has built their career matters — and for Missouri policyholders, hiring someone with deep roots in this state carries real, practical advantages that an out-of-state adjuster simply cannot match.

Missouri Law Is a Specialty of Its Own

Insurance is regulated at the state level, and Missouri has its own statutes, administrative rules, and regulatory history that govern how claims must be handled. The Missouri Department of Commerce and Insurance sets the rules carriers must follow — including how quickly they must acknowledge a claim, respond to communications, and issue payment decisions. Missouri courts have interpreted policy language and insurer obligations in ways that are specific to this jurisdiction.

A public adjuster who primarily works in other states may hold a Missouri license, but that doesn’t mean they have a working command of Missouri’s regulatory environment. Knowing when an insurer is out of compliance with Missouri’s prompt payment requirements, understanding how the Department of Commerce and Insurance handles complaints, and being familiar with how Missouri arbitration and appraisal processes tend to unfold — these are things that come from sustained experience working Missouri claims, not from passing a licensing exam.

They Know the Market — Your Market

One of the most important functions a public adjuster serves is helping to create an accurate, well-supported estimate of what it will actually cost to restore your property. That estimate needs to reflect real-world costs in your area, not national averages or figures derived from markets hundreds of miles away.

A Missouri-based public adjuster who has worked claims across the state understands what licensed contractors charge in your region, what materials cost in your local supply chain, and what code upgrades are commonly required by Missouri municipalities during restoration work. They’re familiar with the contractors who do quality insurance restoration work and can identify when an insurer’s estimate falls short of what the job will genuinely require.

An adjuster who primarily works in coastal markets or high-population metros may rely on estimating software defaults that don’t translate well to Missouri conditions. Those discrepancies can cost policyholders real money.

Relationships With Missouri Carriers Matter

Missouri’s insurance market has its own cast of carriers, third-party administrators, and independent adjusting firms. A public adjuster who has worked this market for years knows how different companies approach claims, which carriers tend to engage constructively and which ones require more pressure, and which individuals within those organizations are empowered to make decisions. That institutional knowledge informs strategy at every stage of the claim.

Out-of-state adjusters encounter Missouri carriers as relative strangers. A Missouri-based public adjuster walks into that negotiation with context that shapes how the conversation goes.

Accessibility When It Counts

Property claims can move quickly, especially in the early stages. An adjuster who can be on-site promptly — to document damage before it’s disturbed, to meet with the carrier’s representative during inspections, or to walk through the property with a contractor — provides a level of engagement that’s hard to replicate remotely. A Missouri-based public adjuster can be there. Someone operating primarily out of Florida or Colorado cannot offer the same responsiveness.

This matters not just at the start of a claim but throughout it. Claims often require follow-up site visits, reinspections, or additional documentation as new damage is uncovered during demolition or repairs. Ongoing, in-person engagement is part of thorough claim representation, and proximity makes that possible.

Accountability That Outlasts the Claim

An adjuster with an established Missouri practice has professional reputation and community standing at stake in every claim they handle. They work in this market year-round — not just after major storm events — and they depend on referrals and repeat business from Missouri policyholders, attorneys, and contractors. That ongoing accountability shapes how they work.

An out-of-state adjuster operating in Missouri on a temporary or opportunistic basis has fewer long-term stakes here. If a dispute arises after the claim is closed, or if supplemental issues emerge months later, a locally rooted adjuster is far more accessible and motivated to see things through. Their reputation depends on it.

The Long Tail of a Claim

Many policyholders don’t realize how long a property claim can remain active. Supplements arise. Disputes over scope or pricing can extend negotiations. Repairs reveal hidden damage that wasn’t visible during the initial inspection. The policyholder’s need for representation doesn’t always end when the first check arrives.

A Missouri-based public adjuster is positioned to stay engaged through all of it. They’re a phone call and a short drive away, not a flight and a time zone difference.

Choosing the Right Advocate

When you hire a public adjuster to represent your Missouri property claim, you’re not just hiring a license — you’re hiring a person’s knowledge, relationships, and commitment to your outcome. A public adjuster who has built their career in Missouri brings all of that to the table. One who is passing through brings a credential and a plane ticket.

For Missouri policyholders, the choice is clear.

 

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

Public Adjuster Hannibal, Missouri

April 8, 2026 By in Property Insurance Tags: , , , , Leave a comment

Welcome to Hannibal, MO

Hannibal and Marion County sit along the Mississippi River in a region that sees its share of severe storms, hail, flooding, and high winds every year. Property damage claims in northeast Missouri are often disputed by insurers — and many policyholders don’t realize they have the right to push back.

I’m James H. Bushart, a licensed Missouri public adjuster serving Hannibal and the surrounding area. I represent policyholders, not insurance companies.

Free Hannibal area claim review: 314-803-2167

Who I Represent

Hannibal homeowners and business owners whose claims have been denied, underpaid, or disputed after storm, hail, wind, fire, water, or flood damage. If the insurer’s offer doesn’t cover your actual losses, that number may be negotiable.

What I Do

I review your policy, independently inspect all damage, document what the insurer missed, and negotiate on your behalf. SCLA designation. NAPIA member. Missouri-licensed since 2012. I’ve handled disputes with all Missouri insurance providers, including Allstate, Nationwide, State Farm, Church Mutual, Shelter, Columbia Insurance, and others across Missouri.

No Fee Unless I Recover More

Contingency basis — you owe nothing unless I recover more than the insurer’s offer. See all Missouri areas I serve.

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.

How NOT to Insure an Older Commercial Building

July 27, 2021 By in Property Insurance Tags: , , , 3 Comments

commercial building

It is likely that your older building complied with all applicable building codes when it was originally constructed. However, unless it has undergone major renovations or upgrades since then, it probably does not meet current building standards — and is generally not required to until significant restoration or renovation work becomes necessary.
What many commercial property owners do not realize is that standard property insurance policies often contain an exclusion that denies coverage for the additional costs of complying with current building codes and local ordinances after a loss.
For example, if lightning strikes the building and damages only a small portion of the original electrical system, local building codes may require a complete rewiring of the entire building to meet today’s standards. In that case, the insurance company would typically pay only for repairing the damaged section and leave you responsible for the much more expensive code-upgrade work.
If you own a commercial building that is twenty years old or older, I strongly recommend speaking with your insurance agent or broker. They can determine whether your policy already includes — or whether you should add — an endorsement for Ordinance or Law Coverage (also known as code upgrade coverage). This protection can help shield you from significant out-of-pocket expenses following a covered loss.

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

Engineer Speak – “Cosmetic” Versus “Functional” Damage

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

Once there was a maintenance man who worked in a famous art museum and was directed by his supervisor to touch up the white paint on the wall of a certain gallery within the museum.  As he was ascending his ladder he accidentally tipped over his gallon of white paint and it splashed across the surface of a 550-year-old painting from a world-famous artist that hung in the gallery.

Of course, the painting was insured and the curator immediately filed a claim.  The insurance adjuster took a few photos and shared them with his boss who said “We need to send out an engineer.”  

The engineer arrived to examine the painting and noted that the framed canvas was designed and intended to hold paint of various colors.  Since the canvas and frame were still intact, he recorded that the painting was still “functional”.  The painted surface had white paint splashed across the smiling face of a woman named “Lisa” or something, but he reported the damage was “cosmetic” in that it did not interfere with the “function” of the canvas to hold paint.  It was, after all, covered with paint … and the gallery was filled with various paintings with random splashes and colors.  He concluded that there was no “functional” damage and the insurance company denied the claim.

This story is fictional, of course … but the actions described represent those that are quite common with home and business property insurance claims.

Let’s look at the shingles on your roof, for example.  The manufacturer of your shingles produces them in a wide variety of colors, shapes, and styles.  When you selected them (or selected the house that already had them), you noted their color and design in context with the features of the rest of the structure, didn’t you?  Of course, their designed purpose is to protect the roof from wear and water intrusion but they also were carefully and creatively designed to enhance the beauty of the home.

When a sudden storm pounds them with hail, along with the metal appurtenances, gutters, downspouts, and other surrounding materials, they will often be damaged.  When they are damaged, you might contact your insurance carrier to file a claim for direct physical damage or loss to your roofing materials.  The insurance adjuster will arrive, take a few photographs, and return to speak to his boss.  When the boss does not want to pay you for your damage … he will send an engineer.

The engineer will often look at your shingles and surrounding metals for gaping holes.  Finding none, he declares that the shingles and metals are still shedding water as they were designed to do, and the damage to them is not “functional” but merely “cosmetic”.  Based on this report, the manager will deny the claim – for this is the very reason the engineer was hired.

Denying the claim because of an engineer’s definitions of damage rather than the insurance policy’s definitions of damage, however, can be improper.  Some insurance companies have been successfully sued for such actions, as in the case of North-Shore Co-Owner’s Association versus Nationwide Mutual Insurance Company.

When you believe that your insurance carrier is trying harder to deny your claim than pay your claim, you may be the victim of improper claim handling, bad faith, or vexatious actions on the part of your carrier.  When this happens, seek the advice of your attorney or a licensed public adjuster.

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.