Claims Denial

Insurance Policy Conditions

February 13, 2011 | Mark S. Humphreys

For someone in Grand Prairie, Arlington, Dallas, Fort Worth, Irving, Hurst, Euless, Bedford, Garland, Mesquite, Carrollton, Richardson, or anywhere else in Texas, it is sometimes difficult to understand the conditions that are written in a policy and how those conditions apply to a claim the insured person is making to the insurance company.

An insurance contract may impose conditions on the insured. For example, almost all policies are going to require that the insured give notice of the claim as soon as is practicable when a claim arises. The insured also has a duty to to co-operate with the insurance company in its investigation of the claim. Most policies require that the insured file a formal proof of loss, if the insurance company requests it. When the insured commits a material breach of the insurance contract, the insurance company is excused from its obligation under the insurance contract. In this regard, it then becomes important to understand what a “material” breach is.

In trying to understand what a “material” breach is, the case, Rueben and Anita Hernandez v. Gulf Group Lloyds, decided in 1994, by the Texas Supreme Court is a good case to look at for guidance.

Disability Claim Denied

January 29, 2011 | Mark S. Humphreys

If someone in Dallas, Fort Worth, Grand Prairie, Arlington, Irving, Mesquite, Garland, Richardson, Plano, Coppell, Mansfield, Cedar Hill, or anywhere else in Texas has a claim under their disability insurance policy denied, what can be done?

Start with the legal reality that an insurance policy is a contract. When a party to a contract is obligated by the contract to another, absolutely repudiates the obligation without justification, the obligee is “entitled to maintain his action in damages at once for the entire breach, and is entitled in one suit to receive in damages the present value of all that he would have received if the contract had been performed, and he is not compelled to resort to repeated suits to recover the monthly payments.” This was stated in the 1937, Texas Supreme Court case, Universal Life & Accident Insurance Company v. Sanders.

Here are some of the facts of the Sanders case:

Suicide And Life Insurance Claim Denial

December 12, 2010 | Mark S. Humphreys

Suicide by someone in Arlington, Dallas, Fort Worth, Grand Prairie, Keller, Roanoke, Aledo, Burleson, Granbury, or anywhere else in Texas. Does that negate an insurance policy?

The first thing anybody should know about life insurance and suicide is that if life insurance benefits are denied because the cause of death was a suicide, the intended beneficiary should seek the advice of an experienced Insurance Law Attorney.

The Texas Insurance Code, Section 1101.055(b), says in part:

Criminal Acts And Automobile First Party Insurance

December 9, 2010 | Mark S. Humphreys

Victims of crime in Dallas, Fort Worth, Arlington, Grand Prairie, Mansfield, Bedford, Hurst, Euless, Burleson, Granbury, or other places in Texas might wonder, What happens if I get injured when I am the victim of a crime? The answer is a lawerly answer: It depends.

The Pittsburg Tribune-Review published an article on December 1, 2010, that gave some insight into a possible answer to the above question. The article was authored by Rich Cholodofsky and is titled, “Firm Denies Benefits To Mt. Pleasant Township Family of Slain Samaritan.”

According to the article, an Erie insurance company asked a Westmoreland County judge for permission to withhold benefits to the family of a Good Samaritan who was shot to death as she tried to assist the wife and daughter of her alleged killer.

Life Insurance – Denial Of Benefits

November 30, 2010 | Mark S. Humphreys

Someone in Dallas, Fort Worth, Grand Prairie, Mesquite, Arlington, Cleburne, Aledo, Weatherford, or anywhere else in Texas, purchases a life insurance policy. They expect the policy benefits to be paid when the insured passes away. But that does not always happen.

The Los Angeles Times ran an article on November 21, 2010, titled “Flaws Can Cancel Life Insurance – After Death.” The article is written by Lisa Girion and Sandra Poindexter.

This article has tells of three examples where someone takes out a life insurance policy and then when a claim for benefits is turned in to the insurance company the company cancels the policy without paying the benefits.

Life Insurance Claim Denial

November 13, 2010 | Mark S. Humphreys

If you live in Grand Prairie, Dallas, Fort Worth, Arlington, Grapevine, Crowley, Cleburne, Granbury, Weatherford, Mesquite, or anywhere else in Texas, and you have a life insurance policy the following case should be interesting to you.

On August 31, 2010, the Court of Appeals, Fort Worth, issued an opinion in a case regarding a live insurance policy. The style of the case is, Glenda and Larry Rice v. Metropolitan Life Insurance Company.

Here are some underlying facts of the case:

Insurance Policy – Excluded Driver

October 1, 2010 | Mark S. Humphreys

“Excluded Driver”? Someone in Grand Prairie, Dallas, Arlington, Fort Worth, Garland, Mansfield, Crowley, Benbrook, Cleburne, or anywhere else in Texas may ask what does that means.

An “excluded driver” is someone who not covered on an automobile insurance policy while that person is driving or operating an insured vehicle. In an automobile insurance policy this is usually referred to as a “515A endorsement” or a “515A exclusion”. The Texas Department of Insurance allows insurance companies to exclude drivers from a policy but does require that anybody who is excluded to be named as an “excluded driver” and for there to be a signature by the person taking out the policy, to acknowledge the exclusion with their signature.

The most common situation where this occurs is when a child becomes sixteen and it is time to add them to the policy. The parents get a bill that is substantially higher than what they are use to paying and when they discover the reason for the increased rate is their teenage son or daughter they complain to the insurance agent. The agent then lets the parents know that they can keep their older / cheaper rates by not having the teenager on the policy. But because the teenager lives in the same house as the parents, there is a belief that the child will have access to the insured vehicles. Since the teenager usually exposes the insurance company to a greater risk and the child has access to the family vehicles the insurance agent will inform the parents that the only way they can not include the teenager in the rates being charged is to have the parents sign the “excluded driver” document. This document says there is not coverage for any damage the “excluded driver” does to the insured vehicle nor will there be coverage for any damage the “excluded driver” does to others.

Cancellation Of Insurance Policy

September 28, 2010 | Mark S. Humphreys

Insured persons in Grand Prairie, Frisco, Arlington, Aledo, Fort Worth, Dallas, Mesquite, Garland, and other places in the state may be adversely affected when an insurance company cancels a policy. If no claim is being made, or in the process of being made, then it may be a case of “no harm, no foul.” But what if the cancellation is first brought up when a claim is made?

This is what happened in a 2001, case styled, Lois Jones v. Ray Insurance Gency a/k/a Azteca Insurance and / or Alamo Insurance, and Collision Clinic, Inc., State & County Mutual Fire Insurance Company and Harbor Insurance Managers. This is a Corpus Christi, Court of Appeals case that was affirmed in 2002 by the Texas Supreme Court.

Here are the facts:

Auto Insurance And Excluded Drivers

September 12, 2010 | Mark S. Humphreys

A question that may be asked by a resident of Grand Prairie, Arlington, Dallas, Mansfield, Irving, Mesquite, Garland, Fort Worth, Duncanville, or other places in Texas might be; What is an “excluded driver?”

An excluded driver is essentially someone who is driving a car without insurance because that person is excluded from coverage by the insurance policy. This usually happens with teenage drivers who the parents have excluded from coverage on the insurance policy to avoid having to pay the higher premiums the teenage driver would cause by being on the policy.

An excluded driver case was decided by the Court of Appeals of Texas, Houston (14th Dist.), on August 12, 2010. The case is styled, Jose A. Perez and Nancy C. Perez v. Old American County Mutual Fire Insurance Company. The courts’ opinion was issued by Justice, Tracy Christopher.

Automobile Insurance Policy

September 11, 2010 | Mark S. Humphreys

Oops! That’s what someone from Aledo, Hurst, Euless, Bedford, De Soto, Dallas, Fort Worth, Grand Prairie, Arlington, and other cities might say when they wait too long to consult with an experienced Insurance Law Attorney. When a claim is denied it is vital that the person who has that claim denied contact an attorney asap.

The Court of Appeals of Texas, El Paso, rendered a decision on August 24, 2010, where it appears the claimant waited too long to make their claim. The style of this case is, Sonia Caballero de Rangel and Eliazar Rangel v. Progressive County Mutual Insurance Company. The opinion is written by Justice, Ann Crawford McClure.

Here are some facts. On October 20, 2001, the Rangels purchased a vehicle. On the same day they obtained insurance coverage from Progressive for the vehicle. On June 3, 2006, the Rangels drove the vehicle to Juarez, Mexico, and it was stolen. Ms Rangel told a claims adjuster that she drove the vehicle to Juarez on a daily basis because her mother cared for her children. When the adjuster asked if she had driven it thirty times to Juarez in the month, Ms Rangel stated, “No, approximately 20 times per month … I would estimate.” Progressive denied the Rangels theft claim based on a provision in the policy excluding coverage if the vehicle was driven into Mexico more than ten times in the thirty day period leading up to the actual date of loss.