Dallas Fort Worth Insurance Lawyer Blog

Health Insurance Attorney

June 6, 2015 | Mark S. Humphreys

Burleson insurance attorneys who handle health insurance situations need to read this 1989 opinion from the Houston Court of Appeals [14th Dist.]. It is styled Paramount National Life Insurance v. Williams.

On March 5, 1981, insurance agent Cliff Cox met with Frankie Williams and her husband Willie and took an application for a hospital insurance policy to be issued by Paramount. Mrs. Williams was sixty-four and had a long history of medical problems which the couple described to Cox. Cox told the Williamses he needed to know only about the preceding five years. He filled out the application and had them read and sign it. Paramount approved the application and issued the policy on March 20, 1981. Mrs. Williams was hospitalized in July 1981 and again in December 1981. She filed two claims totaling over $40,000 in connection with these hospitalizations. Paramount denied the claims and cancelled the policy on the grounds that Mrs. Williams had failed to disclose her full medical history on the insurance application and that the conditions for which she was being treated were preexisting conditions. The company refunded her premiums. Mrs. Williams then sued Paramount for breach of contract, breach of the duty of good faith and fair dealing, fraud and violations of both the Texas Insurance Code and the Texas Deceptive Trade Practices Act.

Paramount denies there was a breach of contract. It alleged that it rejected Mrs. Williams’ two hospital claims on the basis that the conditions for which she was being treated (primarily colon-related) did not comply with the definition of sickness under the policy as well as her failure to disclose preexisting medical conditions. Paramount claims that certain language in the documents relating to the policy puts the applicant on notice that accurate and complete information is required. On her application Mrs. Williams stated she was in good health and free from any physical or mental defects and her only prior medical problems were a kidney stone in 1952 and a cancerous uterus in 1975, both with full recovery. However, the evidence showed Mrs. Williams had experienced numerous physical and mental problems, including the removal of a kidney stone, colitis, possible diverticulitis, recurring pneumonia and schizophrenia. Paramount’s president testified that had the company been aware of Mrs. Williams’ complete medical history, the policy would not have been issued.

Insurance — Who Can Be Sued?

June 4, 2015 | Mark S. Humphreys

Everman insurance attorneys need to be aware of the people and entities that can be liable under the Texas Insurance Code. Section 541.151 provides that a person who has sustained damages caused by another’s engaging in unfair or deceptive insurance practices may sue the person engaging in those acts or practices. Section 541.002(2) defines “person” to mean “an individual, corporation, association, partnership, reciprocal or interinsurance exchange, Lloyd’s plan, fraternal benefit society, or any other legal entity engaged in the business of insurance, including an agent, broker, adjuster or life insurance counselor.”

In 1998, the Texas Supreme Court applied the plain language of the statute to hold that the term “person includes businesses and individuals “engaged in the business of insurance.” However, the statute would not apply to an insurance company employee that was not engaged in the “business of insurance.” The style of the opinion is, Liberty Mutual Insurance Company v. Garrison Contractors, Inc.

Engaging in unfair practices in “the business of insurance” is the key to liability. Those engaged in it may be liable. Those who are not may not be. Thus, when the Texas Supreme Court concluded that contracts of suretyship are not part of the business of insurance, the court also held that a surety could not be liable for unfair insurance practices. This was a 1995 opinion styled, Great American Insurance Company v. North Austin Municipal Utility District No. 1.

Who Can Sue An Insurance Company?

June 2, 2015 | Mark S. Humphreys

Benbrook insurance lawyers need to know who can properly be a plaintiff in a lawsuit against an insurance company. In order to sue an insurance company, the plaintiff must have “standing.”

A 1996, 5th Circuit Court of Appeals opinion states that an intended beneficiary under a policy of insurance has standing to sue under the Texas Insurance Code statutes. After reviewing Texas cases and other 5th Circuit cases, the court concluded that “if the Texas Supreme Court were presented with the question before us it would hold that standing under (Section 541) is satisfied by not only those who can establish privity of contract or reliance on a representation of the insurer, but also by those who can establish that they were an intended third party beneficiary of the insurance contract.” The court set out the standards under Texas law for third party beneficiary status:

(a) the claimant was not privy to the written agreement between the insured and insurer;

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.

Who Has Standing To Sue An Insurance Company

May 30, 2015 | Mark S. Humphreys

Arlington insurance lawyers need to be able to answer the above question when someone comes into their office with a complaint. Simply put, standing means the legal right to be in court on a case.

Texas Insurance Code, Section 541.151 grants a cause of action to a person who sustains actual damages caused by another person engaging in any unfair insurance practice or deceptive trade practices.

The Texas Supreme Court in a 2000, case stated the law that to assert a cause of action a plaintiff must be: (1) a “person” as defined by the statute; or (2) injured by another’s unfair or deceptive acts.

Deceptive Trade Practices Act (DTPA) And Insurance

May 28, 2015 | Mark S. Humphreys

Texas insurance lawyers need to understand the ways the Texas DTPA can help with insurance claims.

Texas Insurance Code, Section 541.151(2) cross-references and prohibits conduct defined in the Texas Business & Commerce Code, Section 17.46(b), commonly known as the Deceptive Trade Practices Act. This latter statute applies to all types of consumer transactions, not just insurance, so many of the provisions are not directly relevant. The most relevant subsections prohibit:

* Causing confusion or misunderstanding as to the source, sponsorship, approval, or certification of goods or services.

Insurance Misrepresentations

May 26, 2015 | Mark S. Humphreys

Fort Worth insurance lawyers know the statutes dealing with insurance misrepresentations can be found in the Texas Insurance Code. Several sections deal with this issue. The different types of misrepresentations that are prohibited by statute are found in sections, 541.051, 541.052, 541.053, 541.055, 541.059, 541.060(a)(1), and 541.061.

These misrepresentations are also against the law under the DTPA, Section 17.46(b), which is incorporated into the Texas Insurance Code. Both the DTPA and Insurance Code prohibit misrepresentation by non-disclosure.

Section 541.051 broadly prohibits making any statement misrepresenting the terms of a policy, or the benefits, advantages, or dividends of a policy, making misrepresentations about the financial condition of an insurer, misrepresenting the true nature of any policy or class or policies, or making any misrepresentation to a policy holder for the purpose of inducing or intending to induce the policy holder to allow an existing policy holder to lapse, forfeit, or to surrender his insurance. This provision is sometimes referred to as the “anti-twisting” provision, because the latter portion is aimed at preventing one insurer stealing away the insureds of another insurer by making misrepresentations.

Delay In Paying Insurance Claim

May 24, 2015 | Mark S. Humphreys

Dallas insurance attorneys know the statutes dealing with the requirements of time within which an insurance company must pay a claim. A 2000, Corpus Christi Court of Appeals case addresses this issue. The style of the case is, Colonial County Mutual Insurance Company v. Hector Valdez.

Hector Valdez bought a 1992 Plymouth Acclaim and arranged insurance for the car with Colonial through the Diego Luna Insurance Agency. An employee of the insurance agency told Hector that the car was insured “against theft, against accidents, against medical expenses, everything concerning the insurance.” A few months after obtaining this insurance, Hector sold the car to his son, Rene Valdez, for $7,000. Rene obtained a loan from Mercantile Bank in order to make the purchase. Hector called the Diego Luna Insurance Agency and told them Mercantile Bank would be calling them to make “changes” and “arrangements” on the insurance. Diego Luna testified that an employee of Mercantile Bank did call, and asked to verify insurance on the car for “a Mr. Valdez.” The bank was told that “Mr. Valdez” had insurance. Hector continued to pay insurance premiums on the car while Rene owned it. It is undisputed that Hector never told Colonial or Diego Luna Insurance Agency that he had sold the car to Rene. It is also undisputed that Hector was never informed, orally or in writing, that he could only insure the car if he owned it.

In November 1995 Hector’s policy was automatically renewed. On January 14, 1996 the car was stolen. Hector reported the theft and Colonial proceeded to investigate. During this investigation, Colonial discovered that Rene was the owner of the car. On March 19, 1996 Colonial sent Hector a letter informing him that “the handling of this claim is being conducted under a Reservation of Rights” because Colonial was investigating whether Hector had an “insurable interest” in the car.

Insurance Company Unfair Settlement Practices

May 23, 2015 | Mark S. Humphreys

Grand Prairie insurance attorneys need to know what insurance company unfair settlement practices are and how to recognize them. The Texas Supreme Court and lower courts have opinions issued describing what has happened in certain situations. However, the Texas Insurance Code has specific statutes that are helpful for insurance lawyers.

The Texas Insurance Code, Section 541.060 lists particular practices to be knowledgeable of. The statute prohibits engaging in any of the following unfair settlement practices with respect to a claim by an insured or beneficiary:

(1) misrepresenting to a claimant a material fact or policy provision relating to coverage at issue;

Life Insurance And Interpleaders

May 21, 2015 | Mark S. Humphreys

Dallas life insurance attorneys will encounter situations where the funds to be recovered from a life insurance policy are “inter-plead” into a court. A Texas Supreme Court opinion issued in 2007, is a must read for lawyers handling interpleader cases. The style of the case is, State Farm Life Insurance Company v. Toni Wasson Martinez.

It has long been the rule in Texas that if an insurer promptly interpleads policy proceeds, it cannot be subjected to statutory penalties for delayed payment even if it missed the statutory deadlines.

After 13 years of marriage, Ed and Linda Martinez divorced in 1994. In their Agreement Incident to Divorce, Ed agreed to pay Linda contractual alimony of $5,000 per month for ten years, with his estate to continue paying if he died earlier. Ed also agreed to name Linda as irrevocable beneficiary on three life insurance policies, providing that he could drop those policies or change beneficiaries so long as the unpaid alimony amount was covered.