Claims Handling Process

When Should I Get A Check From The Insurance Company?

August 27, 2013 | Mark S. Humphreys

Tarrant County Insurance lawyers should be able to give you a response to the above question.

The first place to look for guidance is the Texas Insurance Code, Section 542.057(a). This section requires payment by the fifth business day after the claim is accepted by all insurance companies except surplus lines insurance companies. Surplus lines insurance companies have 20 business days to make payment.

The 1998, case Daugherty v. American Motorists Insurance Company is from the Houston Court of Appeals [1st Dist.] and has held that oral notice that the insurance company intends to pay the claim is not sufficient.

Why Did The Insurance Company Deny The Claim?

August 25, 2013 | Mark S. Humphreys

Tarrant County attorneys who handle insurance cases need to understand the rules related to the Texas Prompt Payment of Claims Act.

Texas Insurance Code, Section 542.056(c) says “If the insurer rejects the claim, the notice required by Subsection (a) or (b) must state the reasons for the rejection.” Arguably, an insurance company that fails to comply with this requirement could be held to have waived additional reasons that were not timely raised. However, this argument was rejected in a 2005, 5th Circuit Court of Appeals case. That court stated that the insurance company could raise an additional defense, where there was no allegation that the initial reason was unreasonable or made in bad faith.

Here is something to think about:

Insurance Company Responsibility To Accept Or Reject Claim

August 24, 2013 | Mark S. Humphreys

Dallas County insurance attorneys will understand the responsibilities of an insurance company to accept or reject an insurance claim.

Usually the first thing an experience Insurance Law Attorney will ask of a potential new client who says their claim has been denied, is a copy of the rejection letter.

Texas Insurance Code, Section 542.056(a), is the statute that requires an insurance company to give written notice it is accepting or rejecting a claim. A telephone call from the insurance adjuster notifying the claimant of the amount of the loss will not constitute “notice of payment of claim,” because the statute requires that the acceptance or rejection be in writing. This was an issue that went against the insurance company in the Houston, 14th District, Court of Appeals case styled, Daugherty v. American Motorists Insurance Company. Further, the insurance company’s written response acknowledging only that a claim has been received does not constitute an acceptance or rejection under the statute. This was made clear in the Corpus Christi Court of Appeals case styled, Northern County Mutual Insurance Company v. Davalos.

Duty To Co-operate With Insurance Investigation Of Claim

August 18, 2013 | Mark S. Humphreys

Dallas insurance attorneys need to know about this recent Federal Court case. The style of the case is Mario Santacruz v. Allstate Texas Lloyds, Inc.

Mario, “Plaintiff” claimed that he reported the damage to Allstate “Defendant”, but Defendant could not inspect the home at that time. Based on a contractor’s recommendation, Plaintiff had the roof repaired to prevent further damage. Defendant then denied coverage for the claim. Plaintiff raises causes of action against Defendant for (1) breach of the common law duty of good faith and fair dealing; (2) violations of the Texas Deceptive Trade Practices Act (“DTPA“); (3) violation of Texas Insurance Code bad faith sections 541.060(a)(2)(A) and (a)(7); and (4) intentional infliction of emotional distress.

Defendant states that immediately after the storm that is alleged to have damaged Plaintiff’s roof, a tarp was placed on the roof to prevent further water intrusion. Plaintiff did not know whether the shingles were blown off by the wind. The next morning, Plaintiff reported the damage to Defendant and spoke to employee Almirna Martinez. Plaintiff told Martinez about the storm and about the roof being tarped and stated that he had workers at the house ready to fix the roof. Because the workers were already on site, Plaintiff requested that Defendant send someone to his home to examine the roof. Martinez informed Plaintiff that Defendant could send an adjuster to his home in a couple of days. Nevertheless, Plaintiff had the entire roof replaced that day. Thus, when Defendant’s adjuster arrived at Plaintiff’s home two days later to inspect the roof, it had already been replaced. Defendant claims that due to its inability to investigate the loss, it did not indemnify Plaintiff’s claim.

Accept Or Reject Claim

August 17, 2013 | Mark S. Humphreys

Arlington insurance attorneys need to know one case real well as it relates to an insurance company accepting or rejecting a claim.

The case is a 1999, Tyler Court of Appeals case styled, Dunn v. Southern Farm Bureau Casualty Insurance Company. This case tells insurance lawyers many things.

1) That each separate claim filed by an insured requires written acknowledgement. It is arguable that separate acknowledgements are required for separate claims arising from the same accident.

Duties Of Insurance Company When Claim Is Made

August 15, 2013 | Mark S. Humphreys

Dallas insurance lawyers should be able to discuss all of the enclosed with you.

The Texas Insurance Code, Section 542.055, says an insurance company shall acknowledge receipt of a claim within 15 days after they receive notice of a claim and begin its investigation and request from the claimant all they reasonably need at that time to further their investigation. So what happens after that?

No additional deadlines are triggered until the insurance company receives all items, statements, and forms reasonably required by the insurance company. Once the insurance company receives that information, seven new responsibilities arise:

Making A Claim

August 11, 2013 | Mark S. Humphreys

Parker County attorneys who deal with insurance companies need to understand the obligations of insureds making a claim.

Though an insured may end up doing many things, the actions are boiled down to two basic duties:

1) to give the insurance company notice of the claim; and 2) to give the insurance company all items they reasonably need to secure proof of loss. Texas Insurance Code, Section 542.055(a) starts the deadline for the insurance company to act, once they receive notice of the claim. Section 542.056(a) imposes other deadlines once they receive all information required to secure final proof of loss.

Knowledge Of Insurance Misrepresentations

May 23, 2013 | Mark S. Humphreys

Fort Worth Insurance Attorneys need to know an important statute in the Texas Insurance Code.

That statute is Section 705.105.

The 1969, San Antonio Court of Appeals case, Prudential Insurance Company of America v. Torres, does a good job of explaining the statute. Here are some relevant parts of that case:

Insurance Law Attorney – Example Of Why To Get One

May 18, 2013 | Mark S. Humphreys

Arlington insurance law attorneys would find this case to be a good case to show clients when trying to explain why the client needs an attorney.

The style of the case is, Amy Warmbrod v. USAA County Mutual Insurance Company. This is an El Paso Court of Appeals opinion issued in April 2012.

Amy Warmbrod filed suit against USAA alleging various causes of action and seeking damages arising out of USAA’s handling of her underinsured motorist (UIM) claim. Warmbrod appeals the summary judgment granted in favor of USAA.

Your Duty To Co-operate After A Loss

April 11, 2013 | Mark S. Humphreys

Dallas insurance attorneys must know that when a person makes a claim for coverage under his own insurance policy, that the person has a duty to co-operate with the insurance company in their investigation of the claim.

The insured is required by the policy to co-operate with the insurance company investigation by submitting the claim promptly, completing claim forms, providing access to damaged property and records, and signing sworn proofs of loss. As stated by the United States 5th Circuit Court of Appeals in the 1999 case, Griggs v. State Farm Lloyds, these requirements on the insured constitute a condition precedent to coverage under a policy of insurance. This means the insurance company has no duty to provide benefits under the policy until this co-operation has been given.

A typical homeowners policy would provide for these requirements: