Dallas Fort Worth Insurance Lawyer Blog

Home Owners Policy Defininitions

June 14, 2014 | Mark S. Humphreys

Parker County insurance attorneys have to know how courts interpret definitions contained within policies. A recent Houston Court of Appeals [1st Dist.] case helps as it relates to the definition of “you” in a homeowners policy. The case is styled, Hodges v. Safeco. Here is some of the relevant information.

On August 17, 2009, Darrell Lee Hodges, Sr. was assaulted in his home. His son, Darrell Lee Hodges, Jr. [“DJ”], lived at the home with his father. DJ knew the assailants, knew they were looking for his father and that they posed a risk to his safety, but nonetheless failed to warn his father of the men’s presence outside the home and failed to call the police to have the men removed from the premises.

SAFECO had a homeowner’s condominium policy in place at the time of the offense. Mr. Hodges is the named policy holder and DJ is also covered because he lived at the condominium with his father. Mr. Hodges made a claim under the policy for insurance benefits to cover his injuries. SAFECO denied coverage, citing the “homeowner’s exclusion” in the policy, which precludes coverage for “bodily injury to [the named insured] or an insured.”

Wage Replacement Benefits And ERISA

June 12, 2014 | Mark S. Humphreys

Dallas and Fort Worth insurance lawyers need to understand how ERISA policies are different from other types of policies. The difference is that a “plan administrator” makes a decision on a claim and if the claimant disputes that decision and files a lawsuit, the Courts look at the decision and decide whether or not the plan administrator abused their discretion in arriving at their decision.

A decision from the United States 5th Circuit is a good case to read to understand how the courts look at ERISA claims. The style of the case is Patrizia Lalonde v. Christus Health. Here is what we learn.

The facts can be learned by reading the case.

Covered Property

June 10, 2014 | Mark S. Humphreys

Grand Prairie insurance lawyers need to be able to discuss with a client how courts interpret insurance policies. The Houston Court of Appeals [14th Dist] issued an opinion in April 2014, that is worth reading. The style of the case is “ACGS Marine Insurance Company v. Spring Center, Inc.” Here is what the case tells us.

Spring Center owns a business park in the Houston area consisting of eleven buildings, all surrounded by a single fence. It leases space within its eleven buildings to various businesses, including those providing light manufacturing, storage, and light machine repair, among others. Spring Center also has a management office located on the property that is staffed during normal business hours.

A vacant building in the business park was broken into and “completely stripped of electrical wiring.” Major damage was done to the offices and exterior doors were broken. Spring Center timely notified ACGS of the damage and requested coverage under the Policy. During its investigation, ACGS learned from Spring Center’s representative that the building had been vacant for about four months prior to the loss. ACGS informed Spring Center in writing that it would not cover the damage based on the following Policy condition:

Insurance Company Fraud

June 8, 2014 | Mark S. Humphreys

Not very many Texas insurance lawyers really understand what went on in the Farmers fraud case several years ago. The public in general did not know what was going on, only that Farmers was refusing to renew home- owners policy. This was causing the public to be upset. The whole story isn’t that difficult but it is essentially over.

Texas Watch ran an article in April 2014, titled “Judge Concerned About Sweetheart Deal For Farmers Insurance” and the story does not discuss the underlying facts that gave rise to what was discovered but it does talk about some of the repercussions. Here is what the article tells us.

A Texas district court judge refused to allow a sweetheart deal between Farmers Insurance and the State of Texas to move forward today. At a hearing in Judge Scott Jenkins‘ court, lawyers for Farmer Insurance and Attorney General Greg Abbott’s office argued in favor of a deal that allows the insurance giant to avoid paying interest on millions of dollars in excessive premiums.

Insurance Fraud Cases

June 7, 2014 | Mark S. Humphreys

Hudson Oaks insurance attorneys need to be able to distinguish between real insurance claims and fraud claims. The Insurance Journal published an article in April that discussed insurance fraud in Texas. Here is what the article tells us.

Texas Department of Insurance Fraud Unit opened investigations into more than 550 insurance fraud cases in 2013.

More than $10.3 million in insurance fraud was identified in criminal cases referred for prosecution in 2013, the department said. Court-ordered restitution for cases that reached final adjudication during this same period totaled more than $7.5 million.

Deleting Vehicle From Insurance Coverage

June 5, 2014 | Mark S. Humphreys

Insurance attorneys in the Dallas and Fort Worth areas need to know about a recent United States Fifth Circuit Court of Appeals decision. It is styled, Bituminous Casualty Corporation v. The Travelers Indemnity Company; Frontier Mining & Material, L.L.C. Here is the relevant information.

Travelers issued a commercial automobile insurance policy to Big D Concrete, Inc. (“Big D”) with a policy period of November 7, 2010 through November 7, 2011. Bituminous issued a commercial automobile insurance policy to Frontier for a policy period of June 10, 2011 through June 10, 2012. In August 2011, Big D leased a 1999 Mack tractor and a 1999 Vantage trailer (“the Tractor and Trailer”) to Frontier as evidenced by an Equipment Lease (“the Lease”) dated in August 2, 2011 and an Addendum to Equipment Lease dated August 5, 2011. The Equipment Lease required Frontier to insure against the entire risk of loss related to the lease equipment and provided that Frontier’s insurance policy coverage would be primary and non-contributing.

On August 10, 2011, a Policy Change Request was submitted on behalf of Big D to Travelers requesting that 10 units owned by Big D be deleted from its commercial automobile insurance policy with Travelers. The Tractor and Trailer were among the 10 units deleted from the policy with Travelers. The Policy Change Request was ultimately approved and an endorsement change (“the Endorsement”) was issued with an approval date retroactively effective to August 8, 2011. Travelers issued to Big D a refund of $3,847 in premiums for the 10 units once the policy change was approved and in effect.

Proving A Delay In Paying A Claim

June 3, 2014 | Mark S. Humphreys

Dallas insurance lawyers will tell you that when involved in a lawsuit, it is necessary to prove the case. In this regard, a recent opinion from the United States District Court for the Northern District of Texas, Dallas Division, needs to be read and understood. The style of the case is, Robert Bell and Cheryl Bell v. State Farm Lloyds. Here is the relevant information from the opinion.

Plaintiffs Robert and Cheryl Bell (“Plaintiffs”) purchased from Defendant an insurance policy covering property damage to Plaintiffs’ property. On June 22, 2012, after a hail and wind storm, Plaintiffs made a claim to Defendant for damage resulting from the storm. On June 27, 2012, Defendant acknowledged receipt of the claim and commenced an investigation. On July 24, 2012, State Farm adjuster Donald Kimberlin inspected Plaintiffs’ property with Mr. Bell and Plaintiffs’ contractor, Roland Vitullo. Kimberlin determined that Plaintiffs’ roof had been damaged and agreed that replacement was required. On August 21, 2012, Vitullo sent a copy of his estimate to Defendant. Defendant requested additional information.

On September 16, 2012, Defendant received an estimate from a public adjuster hired by Plaintiffs, Steve Whitehood of H&S Claim Recovery, that was lower than both Vitullo’s estimate and Defendant’s adjuster’s estimate. On September 21, 2012, Plaintiffs requested Defendant make a second inspection of their property. On October 6, 2012, Defendant sent another adjuster, Brandon White, who conducted an inspection with public adjuster Elvis Spoon. White estimated $32,907.45 in damages, which exceeded Kimberlin’s estimate. White’s estimate was sent to Plaintiffs. On December 13, 2012, after receiving a purported “final invoice,” for $32,879.33 from the construction firm that did the repair work, State Farm sent a payment for $32,907.45 less Plaintiffs’ deductible.

Insurance And The Workplace

June 1, 2014 | Mark S. Humphreys

Aledo insurance attorneys are already aware of statistics reported recently by the Texas Tribune. An April 22, 2014, article tells us a half million employees in Texas are without workplace insurance. Here is what the article says.

At least a half-million Texas workers have no occupational insurance coverage, either from a state-approved workers’ compensation plan or from a private equivalent, state insurance officials said Tuesday.

The figures, provided by the Texas Department of Insurance, provoked impassioned debate at a legislative hearing about policy solutions in the only state in the country where the decision to carry workers’ compensation insurance or a private equivalent is voluntary for companies of any size.

Pre-Existing Condition And Health Insurance

May 31, 2014 | Mark S. Humphreys

Fort Worth insurance attorneys will get calls from people who have been denied benefits by their insurance company because the insurance company claims the person has a pre-existing condition. KSAT recently posted an article about this practice. Here is what the article tells us.

The KSAT 12 Defenders uncovered a little-known fact that insurance companies consider a person’s weight when awarding settlement monies for accident claims.

Maria Vasquez was in a wreck caused by the other driver in May 2013 and found out State Farm is considering her weight while deciding how much to award her in damages.

Disability Claim And ERISA

May 29, 2014 | Mark S. Humphreys

Attorneys who do not handle ERISA claims often times make the mistake that there is not much difference between an ERISA insurance claim and a regular insurance claim. This is a mistake. The United States Court of Appeals for the Fifth Circuit issued an opinion on April 18, 2014, that discusses how courts looks at ERISA claims. The case is styled Cynthia Spenrath v. The Guardian Life Insurance Company of America. Here is some of the relevant information related to the case. However, for anybody dealing with an ERISA case, it is necessary to read the entire case and other cases dealing with ERISA law and issues.

Spenrath worked at Protect Controls, Inc. as an order entry manager. In 2005, Spenrath started having seizure-like episodes in which she would be non-responsive for about five minutes. She asserted that the episodes were accompanied by swishing in her ears, limb weakness, and an inability to move or speak. Spenrath’s primary care physician, Dr. Michael DiTeresa, referred her to two neurologists, Dr. Balbir Singh and Dr. J. William Lindsey. Neither neurologist made a definitive diagnosis, but they mentioned the possibility of multiple sclerosis based on abnormal MRI results and recommended additional testing. Spenrath did not undergo additional testing. Though she continued to take anticonvulsant medication, Spenrath did not visit the neurologists after 2005. In 2008, Spenrath experienced difficulty doing her job, with a diminished ability to focus and type information into the computer. When she failed to complete several assignments, she was given a negative performance review and a salary reduction. Shortly after the negative review, she ceased working on February 22, 2008. On May 7, Spenrath submitted a claim for long-term disability benefits under the company’s ERISA Plan, and claimed commencement of disability as of February 22, 2008.

The Plan’s administrator, Guardian Life Insurance Company (“Guardian”) began a review of the long-term disability claim. Under the Plan, Guardian has “discretionary authority to determine eligibility for benefits and to construe the terms of the [Plan] with respect to claims.” In order to receive long-term disability payments, the plan sets forth several requirements: