Dallas Fort Worth Insurance Lawyer Blog

Co-operating With Insurance Investigation

June 11, 2016 | Mark S. Humphreys

Texas insurance attorneys will tell you that one of your obligations under your insurance policy is to co-operate with the insurance company investigation of your claim. A Houston Division, Southern District case illustrates how difficult matters can be when the co-operation is questionable. The case is styled, Resie’s Chicken & Waffles Restaurant, et al. v. Acceptance Indemnity Company, et al.

This case went to trial and the jury found in favor of Resie’s and against AIC. However, AIC argued that the jury finding in favor of Resie’s should be disregarded due to the jury making findings against Resie’s as it relates to Resie’s turning over financial records that were sought from Resie’s by AIC.

This declaratory judgement action was for breach of contract, violations of Chapters 541 and 542 of the Texas Insurance Code and DTPA violations.

Insurance And Hospital Liens

June 9, 2016 | Mark S. Humphreys

One of the issues Arlington insurance lawyers have to deal with is hospital liens.

Texas public policy strongly supports hospital liens, and it is important to understand that these liens aren’t just applicable to hospitals; they also operate in the benefit of EMS providers and doctors at teaching hospitals whose bills are not already included in the hospital bill. The right of hospitals and certain other medical providers to be paid from settlement proceeds or a judgment begins with the Hospital Lien Statute, found in Chapter 55 of the Texas Property Code. It olds, in pertinent 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 party subsequently transferred for the same injuries. This is found in at Section 55.002(a),(b). These 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 party may have to wrestle with the hospital for first priority, according to the 1985, Texas Supreme Court case styled, Bashara v. Baptist Memorial Hospital System.

The intent of the Hospital Lien statute was to save lives, by “…inducing hospitals to receive a patient, injured by the negligence of others, by giving the hospital a lien on the claims, suit or settlement of the patient.” This is cited in the 1979, Dallas Court of Appeals opinion styled, Baylor University Medical Center v. Travelers.

Life Insurance And Committing A Crime

June 7, 2016 | Mark S. Humphreys

Dallas area life insurance attorneys will occasionally see a situations like this 1997, Dallas Court of Appeals case. The case is styled, Grant v. Group Life & Health Insurance Co.

Grant used a pry bar to break into the residence of Stokes. When Grant entered the residence Stokes shot him five times, killing him. Grant’s wife sued Group Life to recover benefits under an accident policy for the death of her husband. Group Life moved for summary judgement on the basis that Grant died while committing a burglary and, therefore, his death was not accidental. The trial court granted the summary judgment and Grant appealed.

In it’s ruling, the Court said that because Grant’s death was not accidental, the trial court correctly granted Group Life’s motion for summary judgement. Grant argues that because Group Life id not furnish her with a certificate of insurance, it is estopped from relying on undisclosed exclusions. Because the policy in question does not provide coverage for Grant’s death the policy exclusions are irrelevant.

Vacancy Clause In Homeowners Policy

June 5, 2016 | Mark S. Humphreys

Colleyville insurance lawyers should be able to discuss “vacancy” clauses in homeowners policies. A 1997, San Antonio Court of Appeals case discusses the vacancy clause found in a USAA homeowners policy. The style of the case is Lynn v. USAA Casualty Insurance Company.
Mr. and Mrs. Lynn’s country home was insured by USAA. The house was completely destroyed by fire and USAA denied coverage based on vacancy and arson. The Lynn’s brought suit against USAA for breach of contract and breach of duty of good faith and fair dealing. The trial court granted USAA’s Motion for Summary Judgement and this court affirmed the ruling.
Although there were some contents in the house six months before the fire, the testimony established that the house was vacant when it burned. The Court of Appeals stated that the house was “without contents of substantial utility” due to the lack of heating equipment, air conditioning, appliances, sleeping accommodations or efforts to preserve the contents for several months. Therefore, the “vacancy” clause precluded recovery. Furthermore, although the illegal acts (such as arson) of a co-insured do not bar recovery under an insurance policy, the “vacancy” clause, on the other hand, does not have a limitation for who “caused” or was aware of the “vacancy.” The clause excludes coverage regardless of the innocent spouse’s knowledge of the “vacancy.” Finally, a bad faith claim is established by showing that the insurer had no reasonable basis for denying the claim or that the insurer failed to investigate. In this case, USAA was justified in denying the claim under the “vacancy” clause. Therefore, there was no bad faith.

Life Insurance – Intentionally Killing Insured

June 4, 2016 | Mark S. Humphreys

A Texas life insurance lawyer will want to keep this case in his file. It is a 1941, opinion from the Waco Court of Appeals and is styled, National Life & Accident Ins. Co., Inc., et al. v. Thompson.

Velma Thompson instituted this suit for the recovery of $200 and statutory penalties alleged to be due her as beneficiary in a policy of insurance on the life of her husband, Era Thompson. Defendant answered with a plea in abatement on the ground that plaintiff had assigned the policy sued upon to one Braswell, and, subject thereto, with general demurrer and general denial. The brother and sisters of the insured filed their plea of intervention, asserting their right to recover the proceeds due under said policy, by reason of their allegation that plaintiff wilfully brought about the death of her husband. Defendant answered further, alleging that it was unable to determine who was entitled to receive the proceeds due under said policy and that it was paying into the registry of the court the sum of $200 to abide the judgment in the cause, and it prayed that it be dismissed from further liability with its costs.

The case was submitted to a jury on special issues, in response to which they found that plaintiff did not wilfully bring about the death of the insured; that a common-law marriage was in existence between plaintiff and the insured at the time of the latter’s death; and that $100 would be a reasonable attorney’s fee for the legal services rendered in prosecuting plaintiff’s case. Interveners and defendant each presented separate motions for judgment in their favor, respectively, non obstante veredicto. The court rendered judgment in favor of plaintiff and against defendant for the sum of $200, with interest and court costs, and that interveners take nothing. Each of the parties filed separate motions for new trial, all of which were overruled, and to which each duly excepted and gave notice of appeal.

Hail Damage And Prompt Notice Of Claim

June 2, 2016 | Mark S. Humphreys

Lawyers handling hail damage claims will tell you to immediately check for damage after a hail storm and immediately report any damage to your insurance company. The reasons for doing this are illustrated in an opinion from the U.S. District Court, Dallas Division. The style of the case is, Hamilton Properties v. American Insurance Company.

This case arises out of a dispute regarding an insurance company’s decision to disclaim coverage and deny its customer’s claim for property damage following a hailstorm. Plaintiffs are suing for:

(1) breach of contract; (2) violations of the Texas Deceptive Trade Practices Act; (3) violations of the Texas Insurance Code; (4) breach of the duty of good faith and fair dealing; (5) breach of fiduciary duty; (6) misrepresentation; and (7) common law fraud by misrepresentation. Defendant The American Insurance Company (“AIC”) has moved for summary judgment with respect to all of these claims. This Court granted the motion.

Federal Court – Paying Attention To Detail

May 31, 2016 | Mark S. Humphreys

Insurance lawyers in the Dallas and Fort Worth areas can tell you that paying attention to detail is most important. A McAllen Division opinion illustrates this point. The style of the case is, Mark Dizdar et al v. State Farm Lloyds, et al.

Mark Dizdar, et al (Plaintiffs’) claims arise from damage sustained to their property as a result of an alleged March 29, 2012 storm event in Hidalgo County, Texas. Shortly after the storm, Plaintiffs reported an insurance claim to State Farm for the damages sustained to their property.

Thereafter, Mr. Wallis inspected the property on behalf of State Farm on June 22, 2012, estimating the loss to the property at $8,654.13. Consequently, State Farm issued to Plaintiffs a payment of $4,955.60, after applying depreciation and deductible.

ERISA Disability Claims

May 29, 2016 | Mark S. Humphreys

This 5th Circuit Court of Appeals opinion is a must read for ERISA attorneys. The case is styled, Burell v. Prudential Insurance. The facts will be given here. The case needs to be read to understand how the Court affirmed the findings of the lower Court in denying benefits to Burell.

In 1985, Burell began working as an entry-level technician for Methodist Healthcare Systems (“MHS”). After 26 years, he ended his career as Director of Biomedical Services for all San Antonio MHS facilities. As an employee of MHS, Burell participated in the company’s insurance plan (“the Plan”), which is provided through HCA Management Services, L.P. Prudential acts as both administrator and insurer of the Plan. In order to qualify for long-term disability benefits, a claimant must meet the following definition of “disabled”: the claimant must (1) be “unable to perform the material and substantial duties of [his or her] regular occupation due to [his or her] sickness or injury “; (2) be “under the regular care of a doctor “; and (3) suffer “a 20% or more loss in [his or her] monthly earnings due to that sickness or injury.”

Burell was diagnosed with multiple sclerosis (“MS”) in 2008. Citing worsening symptoms of MS, in September 2011, Burell went on medical leave and filed for long-term disability benefits with Prudential, claiming that he qualified for benefits under the Plan due to MS, headaches, depression, and anxiety. In January 2012, he stopped working altogether, ending his employment with MHS. In support of his claim, Burell submitted medical records from his treating physicians and a psychiatrist. Prudential hired Heidi Garcia, a registered nurse, and Dr. Alan Neuren, who is board certified in neurology, to review Burell’s claim. Dr. Neuren found that Burell’s diagnosis of MS was unsupported by his medical records. He also found it unlikely that Burell suffered any cognitive impairments, opining that job stress is “likely the source of his complaints as opposed to a neurological disorder.” Garcia focused her review on Burell’s claim of depression and anxiety, ultimately finding that any cognitive symptoms he was experiencing were not sufficient to prevent him from working. Based on their reports and the medical records submitted, Prudential denied Burell’s claim for long-term disability benefits.

Bad Faith State Farm

May 28, 2016 | Mark S. Humphreys

Here is a case that discusses bad faith accusations against State Farm. Insurance attorneys need to read the case. It is from 14th Court of Appeals. The style of the case is, State Farm Lloyds v. Candelario Fuentes and Maria Fuentes. The facts are set out here.

Hurricane Ike struck the Gulf Coast on September 12 and 13, 2008. The Fuenteses evacuated prior to the storm. When the Fuenteses returned home, they discovered that a tree had fallen through their roof over their master bedroom. Their home sustained exterior damage. According to the Fuenteses, their home also sustained interior damage from water leaking into their bedroom, as well as into their bathroom and laundry room.

On September 22, 2008, the Fuenteses’ daughter reported an insurance claim to State Farm for her primarily Spanish-speaking parents. State Farm assigned adjuster Dustin Namirr, who inspected the Fuenteses’ home on November 12, 2008. Namirr allowed for total replacement of the roof and covered damage to a backyard shed, the fence, a window, and a screen. Namirr inspected the interior of the home with the Fuenteses. The Fuenteses pointed out several areas of interior water damage from Hurricane Ike. Namirr’s log entry and notes do not mention an interior inspection, and he destroyed the two or three photos he took of the home’s interior. Namirr claimed that, based on his inspection, he determined that the interior damage was not caused by Hurricane Ike. He went to his truck, printed out an estimate of damages in English, and provided the Fuenteses with a check for $4988.63 for the exterior damage, as well as a check for $350 in “food loss.” State Farm closed its file on the same day. The Fuenteses did not receive any written explanation for State Farm’s denial of the claim for interior damage.

ERISA And Time Limitations For Appeal

May 26, 2016 | Mark S. Humphreys

ERISA lawyers can tell you that the rules with ERISA claims are pretty tough. This is illustrated by a Dallas Division opinion issued in March 2016. The style of the case is, Sharon Smith v. The Boeing Company.

Sharon sued Boeing seeking spousal pension benefits from her deceased husband’s retirement plan. On January 1, 2008, Henry Smith designated his former spouse, Trinette Smith as his primary beneficiary. Henry and Trinette later divorced, and Henry married Sharon in 2011. Henry attempted in a letter dated May 14, 2012, to change the primary beneficiary to Sharon. The request was denied because Henry had already begun receiving his pension benefit.

After Henry’s death in July 2013, Sharon requested that Boeing recognize her as the beneficiary. In a letter dated October 14, 2013, Boeing informed Sharon her request was being denied because she was not the listed spouse at the time of Henry’s retirement. Sharon was also informed of rights under ERISA and under Section 502(a) she had no later than 180 days to appeal the decision which she did.