Claims Handling Process

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.

Can An Insurance Lawyer Tell You Who Recovers On A Policy

February 6, 2011 | Mark S. Humphreys

Residents of Grand Prairie, Arlington, Grand Prairie, Mansfield, Cedar Hill, De Soto, Duncanville, Dallas, Fort Worth, Burleson, and other places in Texas may need an attorney to tell them who has rights under an insurance policy. For the best and most informative information an experienced Insurance Lawyer needs to be consulted.

So, who can recover on an insurance policy?

Of course, the named insured, as a party to the insurance policy, may file a lawsuit on the policy. Obviously, someone named as a beneficiary may also enforce the contract with the insurance company. This was stated in a Texas Supreme Court in 1967, in the case, McFarland v. Franklin Life Insurance Company.

Claims Made Policies

February 5, 2011 | Mark S. Humphreys

Most people in Grand Prairie, Arlington, Dallas, Fort Worth, Mansfield, Cedar Hill, De Soto, Duncanville, Lancaster, Weatherford, Aledo, Azle, Hudson Oaks, or any other place in Texas would not know the difference between a “claims-made” insurance policy and any other type of insurance policy.

The Texas Supreme Court decided a case in March of 2009, that discussed one of the distinctions in a “claims-made” policy. The case is styled, Prodigy Communications Corp. v. Agricultural Excess & Surplus Insurance Company, et al.

This case is a declaratory judgment action. Agricultural Excess & Surplus Insurance Company (AESIC) brought this action asking the court to declare that they have no obligations in this case to defend or indemnify in the lawsuit brought against Prodigy Communications Corp (Prodigy).

Duty Of Good Faith And Fair Dealing

November 21, 2010 | Mark S. Humphreys

What if someone in Dallas, Fort Worth, Grand Prairie, Arlington, Irving, Richardson, Hurst, Euless, Bedford, or somewhere else in Texas, thinks the insurance company is denying their claim for insurance benefits for the wrong reason? Can anything be done? As with so many legal answers – it depends.

The Texas Supreme Court issued an opinion in 1993, in the case styled, Golda A. Lyons v. The Millers Casualty Insurance Company of Texas, that helps with the above question. As the court stated, “This case presents us with the opportunity to clarify the method by which Texas courts should conduct legal sufficiency review of factfindings of bad faith against an insurer.”

Here are the facts:

Delay In Paying The Claim

November 20, 2010 | Mark S. Humphreys

How long can an insurance company take to pay a claim to an insured in Dallas, Fort Worth, Arlington, Grand Prairie, Mesquite, Richardson, or anywhere else in Texas. The answer is – as long as they want – and even if they have good reason for the delay – it is going to cost them.

A 1997 case decided by the United States Court of Appeals, Fifth Circuit, is a good example of what can happen when an insurance company doesn’t pay a claim in a prompt manner. The style of the case is, John Higginbotham v. State Farm Mutual Automobile Insurance Company.

Here are some facts in the case:

Delay In Paying Claim In Texas

November 16, 2010 | Mark S. Humphreys

Someone in Dallas, Fort Worth, Grand Prairie, Arlington, Mansfield, Mesquite, Garland, Plano, Weatherford, or anywhere else in Texas, may experience a delay in being paid when making a claim against their insurance company. Is that ok? The answer is no, according to the Texas Prompt Payment of Claims Act.

The Texas Supreme Court decided a case in 2004, wherein the topic had to do with how the Texas Prompt Payment of Claims Act impacted the decision in the case. The style of the case is, Republic Underwriters Insurance Company v. Mex-Tex, Inc. The court phrased the issue this way: We must decide whether the commercial property insurer in this case breached its policy obligation to replace a damaged roof with one of “like kind and quality”, and if so, whether the insurer’s tender of partial payment of the claim avoided, on that amount, the 18% per annum delay penalty imposed by the Prompt Payment of Claims Act of the Texas Insurance Code.

Following a May 25, 1999 hail storm in Amarillo declared by the Texas Department of Insurance to be a weather-related “catastrophe for the purposes of claims processing”, Mex-Tex, Inc. notified its property insurer, Republic Underwriters Insurance Co., of damage to the roof of Signature Mall, a retail shopping center that Mex-Tex owned. Mex-Tex claimed that the roof had been destroyed and should be replaced. Republic immediately investigated the claim but disputed the amount of damage attibutable to hail.

Insurance Policy Appraisal Clause

November 14, 2010 | Mark S. Humphreys

If you have an insurance policy in Dallas, Fort Worth, Grand Prairie, Arlington, Mansfield, or anywhere else in Texas, you should look at it closely. It probably has an “appraisal clause” in it.

The United States Western District of Texas, Austin Division, decided a case on October 27, 2010. The style of the case is Orleans Harbor Homeowners Association, Inc. v. Public Service Mutual Insurance Company. The main issue in the case dealt with the appraisal clause in the insurance policy between Orleans Harbor Homeowners Association, Inc. (Orleans) and Public Service Mutual Insurance Company (Public).

Here is some background:

Insurance Policy And Appraisals

November 7, 2010 | Mark S. Humphreys

If you live in Grand Prairie, Arlington, Irving, Dallas, Fort Worth, Burleson, Keller, or anywhere else in the state of Texas and you have a homeowners insurance policy the policy is likely to contain an “appraisal” provision. So what does that mean?

The Texas Court of Appeals, Houston 14th District, issued an opinion on a case

September, 23, 2010, wherein the main issue dealt with an appraisal clause in an insurance policy. The policy at issue was a commercial policy but is essentially the same as those found in homeowners policies. The style of the case is, In re Continental Casualty Company.

Insurance Policy Responsibilities For Insureds

September 14, 2010 | Mark S. Humphreys

Grand Prairie residents, residents of Arlington, Mansfield, Duncanville, Benbrook, Crowley, Weatherford, Aledo, Azle, and all other locations in Texas will almost all have one responsibility in common in their insurance policies. That one responsibility in common is to co-operate with their insurance company in the insurance copanies investigation of the claim. One other responsibility is to keep the insurance company informed of relevant events related to your coverage.

On July 22, 2010, the Houston Court of Appeals, (14th) Dist.) decided a case before them that dealt with this issue. The style of the case is, Darrell Dean Valenzuela v. State & County Mutual Fire Insurance Company. This was an appeal from the 164th District Court, Harris County, Texas.

In this case, Darrell Dean Valenzuela and Armando Rodriguez Torres were in a motor vehicle accident in 2002, and Valenzuela claimed he sustained injuries from the accident. Valenzuela sued Torres in August 2007. At the time of the accident, Torres was covered by a standard form personal auto policy from State & County. The policy insured the automobile Torres drove on the day of the accident. The case went to trial, and Valenzuela obtained a judgment for $12,100.00, prejudgment interest in the amount of $4,502.11, and court costs in the sum of $1,941.67. State & County did not receive notice of the lawsuit until Valenzuela delivered a copy of the final judgment on Septmenber 10, 2007. State & County claimed its policy provisions required Torres to provide proper and timely notice regarding any pending lawsuits so State & County could participate in Torres’s defense.

Hospital Liens In Texas And Insurance

July 14, 2010 | Mark S. Humphreys

What if someone in Fort Worth, Arlington, Mansfield, Mesquite, Garland, Irving, Grand Prairie, Dallas, or anywhere else in Texas, is involved in an accident and goes to the hospital for treatment? Are there any special laws that apply?

The answer is yes. It depends on the circumstances, but often times, what is called a “hospital lien” comes into play. If this hospital lien is not properly dealt with it could cost a lot of money and heartache.

Texas public policy strongly supports hospital liens, and it is important to understand that these liens are not just applicable to hospitals; they may also operate for the benefit of EMS providers and doctors at teaching hospitals whose bills are not already included in the bill. The rights of hospitals and certain other medical providers to be paid from settlement proceeds or a judgment begins with the Hospital Lien Statute. This is found in the Texas Property Code, Chapter 55. It says, in relevent part, that a lien attaches to “any cause of action, judgment, or settlement” received as a result of an accident for which the person was admitted to a hospital within 72 hours of the injury, as well as any hospital to which the injured person is subsequently transferred for the same injuries. This is found in Texas Property Code, Section 55.002. These hopital liens must be filed prior to settlement in order to be valid, and hospital liens are limited to “reasonable and regular” charges within the first 100 days following the injury. Even the attorney representing the injured person may have to wrestle with the hospital for first priority, as seen in the Texas Supreme Court case styled, Bashara v. Baptist Memorial Hospital System, decided in 1985.