Claims Refusal

National Flood Insurance Program Law

August 6, 2015 | Mark S. Humphreys

Lancaster insurance attorneys will occasionally see a claim covered by the National Flood Insurance Program. Each of these types of government programs are governed in their own particular way. The United States District Court for the Southern District of Texas, Galveston Division issued a ruling that attorneys handling these types of claims need to know about and read. The style of the case is, Ruby Pal v. Texas Farmers Insurance Company.

This is a summary judgment ruling wherein Farmers sought to have the court dismiss the case filed by Pal.

Pal’s property was damaged in flooding during Hurricane Ike in September 2008. At the time, Pal had insured the property for $110,000.00 against flood loss with Farmers, a WYO insurer with the National Flood Insurance Program. Pal’s initial claim was adjusted and paid, on December 29, 2008, in the amount of $53,610.45. The extended deadline for filing a Proof of Loss (POL) for Hurricane Ike claims expired on August 7, 2009. Seven months later, on March 11, 2010, piled filed her second POL seeking policy limits. Farmers negotiated Pal’s claim and by April 7, 2010, determined she was due an additional $7,644.68. The parties requested a waiver of a timely POL for that amount which was approved by FEMA on April 13, 2010. On October 1, 2010, Pal sued Farmers seeking additional proceeds under her policy. The parties continued to negotiate her claim, but reached impasse around May 30, 204. As a result, Farmers filed the summary judgment motion.

Policy Exclusions And City Ordinances

May 31, 2015 | Mark S. Humphreys

Everman insurance lawyers need to be know this 2015, Texas Supreme Court opinion. It is styled, Jaw The Point, L.L.C. v. Lexington Insurance Company.

This insurance dispute involves losses the insured incurred as a result of city ordinances triggered by damage to an apartment complex during Hurricane Ike. The insurance policy covers the costs of complying with city ordinances, but only if the policy covers the property damage that triggers the enforcement of the ordinances. Here, the property damage that triggered the ordinances resulted from both wind, which the policy covers, and flooding, which the policy expressly excludes. The policy’s anti-concurrent-causation clause excludes coverage “for loss or damage caused directly or indirectly by” flooding, “regardless of any other cause or event that contributes concurrently or in any sequence to the loss.” Because the evidence conclusively establishes that flood damage triggered the enforcement of the city ordinances and thus “directly or indirectly” caused the insured’s losses, the Court concluded the policy excludes coverage for such losses regardless of the fact that wind damage “contribute[d] concurrently or in any sequence to the loss.” Because the Court agreed with the court of appeals that the policy did not cover the insured’s losses and thus the insured cannot recover for the insurer’s bad faith failure to effectuate a prompt and fair settlement of the claim the case was affirmed.

In July 2007, JAW purchased an apartment complex in Galveston for approximately $5.7 million.Fourteen months later, Hurricane Ike struck the Island and caused substantial damage to The Pointe apartments. Lexington provided the primary coverage.

Taking Responsibility For Getting Insurance

February 24, 2015 | Mark S. Humphreys

Texas insurance lawyers will sometimes find themselves in a situation where there was no insurance on a piece of property. When this happens, the next question is why isn’t there insurance. Then, who is responsible for getting the coverage. This was the issue in a 1976, Texas Supreme Court opinion styled, Colonial Savings Association v. Taylor. Here is what happened.

This controversy arose because a house owned by, Mr. Taylor, which was destroyed by fire, was not insured. Mr. Taylor sued Colonial, contending that Colonial had gratuitously assumed responsibility for insuring the house and had negligently failed to do so. Trial was to a jury, which returned a verdict with answers favorable to Mr. Taylor, but the trial court entered judgment Non obstante veredicto for Colonial.

The property involved is located at 846 East 26th Street in Houston. There are two houses at this address, an older house near the street and a newer house behind it. Taylor purchased the property in 1967 from Mr. and Mrs. James E. Reynolds, taking title subject to a prior outstanding lien held by Colonial. In consideration for the conveyance Taylor made four over-due payments to Colonial on the Reynolds note which the property secured. Pursuant to the conveyance, Colonial transferred the mortgage loan to Taylor’s name, and he was made all subsequent payments thereon.

Coverage Or No Coverage

February 5, 2015 | Mark S. Humphreys

Dallas insurance attorneys will tell you that in order to determine coverage or no coverage under an insurance policy that the entire fact situation needs to be examined. In a 2014, Fort Worth Court of Appeals opinion, in a case styled, City of Carrollton v. Fred Loya Insurance Company, reversed a trial court that said there was no issue to be decided. Here is the relevant information from that case.

This case revolves around whether an insured, Danelle Butts, validly added her daughter, Donna, back to her insurance policy so that the daughter’s car accident with a pedestrian was covered by the policy.

Danelle had an automobile insurance policy through Fred Loya Insurance. On August 3, 2007, Danelle amended her policy to exclude her daughter Donna from coverage under the policy because Donna moved out of the family home.

Misrepresentation In Health Insurance Policy Application

January 27, 2015 | Mark S. Humphreys

Fort Worth insurance lawyers will find the 1995, case, Darby v. Jefferson Life, useful in their insurance law practice. It is from the Houston Court of Appeals [1 Dist.].

On October 5, 1987, Jefferson Life’s agent, Charles Sharp, interviewed Darby in her home after she applied for a major medical insurance policy. Sharp read questions from the application and recorded Darby’s answers on the policy application. In one section of the document, Darby’s recorded answers showed one doctor’s visit and one hospital confinement in the previous 24 months but also showed a denial of past health problems. In another section, Darby’s recorded answers indicated she had a complete checkup during the previous month, a blood clot earlier that year, and was on medication for arthritis. Darby signed the application in two places, affirming that each answer was full, true, and complete, and agreeing that any false statement materially affecting Jefferson Life’s acceptance of the risk would render the policy void.

At trial, Darby testified that she also told Sharp, although the application did not so reflect, that she had a computerized axial tomography (CAT) scan and a magnetic resonance image (MRI) the month before her application; she had been hospitalized for a blood clot and continued to see a physician three times a week; and she had rheumatoid arthritis, which was controlled with medication. She also may have told Sharp she saw a physician once a month.

Read Those Title Insurance Policy Exclusions

December 9, 2014 | Mark S. Humphreys

Mineral Wells insurance lawyers will tell you that you have to be aware of “exclusions” in your insurance policies, otherwise, you risk finding out the hard way. A 1999, Austin Court of Appeals case illustrates this. The style of the case is, Zimmerman v. Chicago Title Insurance Company. Here is the relevant information.

In 1988, the Zimmermans purchased residential property in Austin and obtained a policy of insurance from Chicago Title insuring title to that property. The policy obligates Chicago Title to defend the Zimmermans against any action in which a claim adverse to their title is asserted, unless the claim is based on matters excepted by the policy. In the separate litigation underlying this dispute, the Zimmermans were sued by the owners of adjoining property, Mary Joseph and her four daughters, who asserted title by adverse possession to a twelve- to twenty-inch strip of land insured under the Zimmermans’ policy. Chicago Title refused the Zimmermans’ request to defend them against the suit.

The Zimmermans sued Chicago Title for a declaration that it owed a duty under the policy to defend them in the underlying suit. The Zimmermans subsequently moved for partial summary judgment, asserting that Chicago Title had relied on four policy exclusions to refuse their defense, none of which applied. Chicago Title filed its own motion for summary judgment, arguing that each of the claimed exclusions justified its refusal to defend. Following a hearing, the district court rendered an order denying the Zimmermans’ motion and granting summary judgment for Chicago Title.

Exclusions In An Insurance Policy

November 15, 2014 | Mark S. Humphreys

Grand Prairie insurance lawyers need to know how “exclusions” in an insurance policy work. This is partially explained in a 1994, San Antonio Court of Appeals case. The style of the case is, Telepak v. United Service Automobile Association. Here is the relevant information from the case.

The question before the court concerned whether the insured or the insurer has the burden of proof as to the applicability of an exception to an exclusion in an insurance policy. The court held that the applicability of an exception to an exclusion is a question of coverage, on which the insured has the burden of proof.

The insured brought a claim under an all-risk homeowner’s insurance policy for damage to their home. It is undisputed that the damage was incurred by the settling of the foundation. In its answer, the insurer pled the affirmative defense that “exclusion k” of the insurance policy excluded from coverage damage resulting from settling or cracking of the foundation. The insured asserted that the settling was caused by water which leaked from an air conditioner and escaped under the foundation of their home. They asserted that their loss fell under an exception to exclusion k, which stated that exclusion k would not apply to settling caused by accidental leakage from an air conditioning system. The jury charge read as follows:

What Happens When An Insurance Company Denies A Claim

November 13, 2014 | Mark S. Humphreys

The answer to the above question when asked of a Dallas insurance attorney will result in an answer of, “it depends.” There are many factors that come into play when trying to understand the consequences of the denial. The worst result for the claimant and best result for the insurance company might be that the insurance company does not have to pay anything on the claim.

The best result for the claimant and the worst for the insurance company might be what was reported by The Pennsylvania Record in an October 2014 article. The title of the article says it all, “Bad Faith Settlement With Allstate Awards $22 Million To Accident Victim.” Here is what the article tells us.

The rejection of a $250,000 claim has ultimately cost insurance giant Allstate $22 million following a settlement this week with the victim of a 2009 car accident. The agreement is the largest insurance bad faith settlement in Pennsylvania history, and the largest involving a motor vehicle accident in the nation, according to Ross Felley Casey, which represented the victim.

Uninsured Motorist And Vehicles Available For Regular Use

November 2, 2014 | Mark S. Humphreys

Fort Worth insurance lawyers need to know how Texas insurance law applies when presented with a certain set of facts. As it relates to Uninsured Motorist coverage, a San Antonio Court of Appeals case is important to know. It is a 1990, opinion styled, Briones v. State Farm. Here is the relevant information from the case.

Briones appealed a take nothing summary judgment granted in his suit against State Farm seeking recovery on his family automobile insurance policy under the uninsured motorists clause, for bodily injuries suffered in a one vehicle automobile accident. In one point of error Briones contended that:

The Trial Court erred in granting State Farm’s Motion for Summary Judgment because there is a genuine issue as to material facts regarding the one remaining issue to be litigated by the parties, namely whether the tractor-trailer in which Briones was a passenger at the time of his bodily injuries was furnished or available for his regular use.

What If An Adjuster Is Negligent In Handling My Claim?

October 30, 2014 | Mark S. Humphreys

Fort Worth insurance lawyers will often times be asked the above question. The answer is that there are many things an adjuster can do wrong for which they and the insurance company can be held liable if that wrong causes harm to the insured. However, the Texas Courts do not recognize a claim for negligent claim handling. This is told to us in the 2008, Houston Court of Appeals [14th Dist.] case, Justice v. State Farm Lloyds Insurance Company and FTI Consulting. Here is the relevant information taken from that case.

A tree fell on the Justices’ house in 2000, the Justices made a claim under their State Farm homeowner’s insurance policy and State Farm paid the claim. In 2001, the Justices discovered mold in the walls of their house and reported the claim to State Farm. State Farm sent the Justices a reservation of rights letter, hired FTI to conduct an industrial hygiene evaluation, and paid the Justices over $137,000 for remediation of their home, alternative living expenses, and cleaning costs on this claim. Thereafter, the Justices filed suit against State Farm and FTI for additional mold damage. State Farm and FTI each filed a motion for summary judgment, which the trial court granted.

State Farm moved for summary judgment against the Justices’ claim for breach of contract on the ground, among others, that this claim was barred by the mold exclusion in the policy. The Justices contend that the mold exclusion is somehow overcome by a provision of the State Farm Adjuster’s Guide, purportedly stating that if the original claim is covered, such as the damage from a wind blown tree, then any loss that proximately results is therefore covered. However, the Justices’ brief provides no legal authority suggesting that a provision of the Adjusters Guide could be controlling, relevant, or even admissible concerning the meaning or scope of coverage of the policy. Nor does it indicate how such a provision, even if applicable, could overcome an express exclusion in the policy. Therefore, this contention affords no basis for relief, and the Justices’ challenge to the summary judgment against their breach of contract claim was overruled.