Claims Denial

Insurance Coverage And Willful Acts

December 14, 2024 | Mark S. Humphreys

Insurance usually covers accident that happen or acts of God, negligence, etc., things that are Unintentional. Policies will rarely cover willful or intentional conduct that causes harm.

The above is illustrated in a 2024 opinion from the Eastern District of Texas, Sherman Division. The opinion is styled, Jacksonville, Realty, LLC v. Certain Underwriters At Lloyds.

The Plaintiff, Jacksonville, filed a summary judgement seeks the Court to rule that the policy contract had been broken by the Defendant. The policy at issue is an errors and omissions policy. Miller Title acted as the escrow agent for a real estate transaction between Jacksonville and IBF Retail I, LLC. As part of the transaction, IBF deposited $2,750,000 in earnest money with Miller Title.

Cooperation Requirement With Insurance Company

November 30, 2024 | Mark S. Humphreys

Cooperating with the your own insurance company when making a claim for policy benefits is almost always a requirement in the policy. An opinion discussing this was issued by the Tyler Court of Appeals in 2024. The opinion is styled, Kenneth R. Cade v. State Farm Lloyds.

On April 18, 2019, a windstorm blew a large tree onto a portion of Cade’s house that was insured by State Farm. Cade eventually made a claim for damage to the structure and contents. Several inspections were made and payment was made totaling approximately $30,000. The personal property claim was not made until about 18 months later, claiming several items of personal property were damaged or destroyed. A lawsuit resulted after State Farm denied paying further damages citing a lack of cooperation by Cade with the claim. State Farm filed a motion for summary judgement which was granted.

The opinion details many more of the facts and testimony in the case which should be read. This article will cite the law related to this type of claim.

Duty To Cooperate With Insurance Company

November 16, 2024 | Mark S. Humphreys

The duty to cooperate with the insurance company investigation of a claim is something a lot of people don’t realize. When it is your own insurance company, the insurance contract requires the insured to cooperate with the insurance company investigation of the claim.

This issue was the point of contention in a 2024 opinion from the Southern District of Texas, Houston Division. The opinion is styled, Raymond Funes v. Allstate Vehicle And Property Insurance Company.

In this case, the facts are generally undisputed. Plaintiff filed a claim in or around February 2021 for broken pipes at his property that was insured by Defendant. He withdrew the claim in March 2021, but then retained an attorney and pursued the claim with Defendant in February 2023. Defendant inspected the property and found that the home had been re-piped. It requested the plumbing report and or invoice for the re-piping, but Plaintiff failed to oblige. As such, Defendant denied the request for appraisal for “lack of cooperation by the insured.” Subsequently, Plaintiff brought this suit.

Homeowner’s Claim And Damage Segregation

November 2, 2024 | Mark S. Humphreys

Here is a 2024 opinion from the Western District of Texas, Austin Division, that deals with segregating damages in a homeowners claim. The opinion is styled, David Espinoza v. State Farm Lloyds.

Espinoza had a State Farm homeowners policy in force when a storm caused damage to his home. The claim was partially paid but State Farm but denied as to the full claim with State Farm alleging some of the damages were caused by matters not covered by the policy. State Farm filed a motion for summary judgment based on Plaintiff being unable to segregate the covered damages from the uncovered damages.

For an insurance company to be liable for a breach of its duty to satisfy a claim presented by its insured, the insured must prove that its claim falls within the insuring agreement of the policy.

Statute Of Limitations On First Party Insurance Claims

October 12, 2024 | Mark S. Humphreys

It is important to understand the time frame under which lawsuits must be filed. As part of that, reading the insurance policy is vital. A 2024 opinion from the Western District of Texas, Del Rio Division, discusses limitation periods written into insurance policies. The opinion is styled, Antonio Caballero v. Allstate Vehicle And Property Insurance Company .

This case was decided on the summary judgment motion filed by Allstate.

This matter arises from an insurance claim. The Plaintiff alleges hail storm property damage in excess of $20o,000. The Plaintiff filed a claim with the Defendant on December 13, 2018. The Defendant denied the Plaintiff’s claim on October 11, 2019. The Plaintiff filed suit in Texas state court on August 21, 2023, asserting: violations of the Texas Insurance Code and breach of contract among other causes of action.

Claims Denial For Failure To Cooperate

September 28, 2024 | Mark S. Humphreys

An insured under an insurance policy has a duty to cooperate with an insurance company investigation of a claim. This issue is discussed in the 2024 opinion, Henry & Lydia Ansah v. Nationwide Property and Casualty Insurance Company. The opinion is from the Southern District of Texas, Houston Division.

The Plaintiff’s allege that Nationwide underpaid their property insurance claim. Nationwide ended up filing a motion for summary judgement arguing the Plaintiffs are not entitled to further coverage because they failed to make the damaged property available for inspection or to document the damages.

On February 18, 2021, Defendant received from Plaintiffs a claim for damages to their dwelling and personal property caused by a freeze event that occurred the day before. On March 5, 2021, Defendant contacted Plaintiffs to discuss their claim and the claims process. Defendant began investigating Plaintiffs’ claim and paid $87,122.07 for dwelling damage and at least $35,984.83 personal property damage. Plaintiffs disputed Defendant’s valuation of their loss and invoked the Policy’s appraisal provision. The appraisers determined that the actual cash value of the dwelling damage was $78,936.05 less than what Defendant had paid.

Claims Denial Due To Misrepresentation

September 14, 2024 | Mark S. Humphreys

A misrepresentation in an insurance application is grounds for denial of a claim but it is not necessarily a win for the insurance company. This issue is discussed in a recent opinion from the Texas 14th Court of Appeals. The opinion is styled, Jose Palma v. Allied Trust Insurance Co.

This case was a summary judgment win for the insurance company but there is a clear distinction with this case and the vast majority of cases regarding misrepresentations.

Palma purchased an insurance policy for his home with appellee. During the policy period, there was a fire at Palma’s home. Palma submitted an insurance claim under the policy. Allied investigated and found that Palma had a prior conviction for insurance fraud that was not disclosed on his application for

The Insurance Policy Definitions

May 18, 2024 | Mark S. Humphreys

Here is a 2024 opinion from the Northern District of Texas, Dallas Division, that deals with an insurance policy. Specifically, the wording of an insurance policy. The opinion is styled, Johnetta Askew Hunt v. Meridian Security Insurance Company State Auto Insurance Companies.

This is a summary judgment opinion regarding “residing” at a premises. The case deals with the coverage provided by a policy and where an insured, Hunt, tries to get more coverage than the policy provides.

In Texas, interpretation of an insurance policy begins with its actual words, because it is presumed parties intend what the words of their contract say.

Insurance Claims And Statute Of Limitations

May 11, 2024 | Mark S. Humphreys

Insurance lawyers need to read this November 2023, opinion from the Southern District of Texas, McAllen Division. It is styled, Bertha Salinas v. State Farm Lloyds.

The relevant facts are undisputed, Bertha sued State Farm for denying her claim against her homeowners policy due to a weather event on July 26, 2020. State Farm paid some sums of money on the claim but did not pay what Bertha alleges she was owed. On April 16, 2021, State Farm sent a letter explaining it was denying further payment on the claim. Upon receipt of the letter, Bertha invoked the appraisal provision under the policy. State Farm participated in the appraisal but did so under a reservation of rights. In the appraisal process an umpire ultimately ruled against State Farm on March 30, 2023. The attorney for Bertha sent a written inquiry about payment of the appraisal. On June 30, 2023, State Farm stated they would not be paying the appraisal award. State Farm argued about problems with the appraisal. Bertha filed suit on July 18, 2023.

State Farm moved for summary judgment on the case due to the statute of limitations having run on two years after their April 16, 2021, thus, the filing date of July 18, 2023, was too late.

Attorney Fees In Insurance Lawsuits

May 4, 2024 | Mark S. Humphreys

When can a person recover attorney fees in an insurance lawsuit? There is not an easy answer to that question. It is dependent on the facts of the case and the theories of law being alleged against the insurance company.

A 2024 opinion from the Southern District of Texas, Houston Division, addresses this issue when the claim is filed invoking Texas Insurance Code, Section 542A.003(a) and 542A.007(d). The style of this opinion is, Ashley and Walter Burke v. Liberty Mutual Insurance Company.

The Burks (Plaintiffs) filed this action against Liberty for breach of contract, common law bad faith, violations sections 541 of the Texas Insurance Code, and violations of the Texas DTPA. Plaintiffs allege that they sent a presuit letter to Liberty on January 24, 2022, outlining Plaintiffs’ alleged damages and expenses pursuant to Section 542A.003.