Dallas Fort Worth Insurance Lawyer Blog

Disability Policy Coverage Issues

September 30, 2018 | Mark S. Humphreys

Insurance lawyers who handle disability cases need to know these coverage issues.

Disability policies normally require that any claimed disability occur while the policy is in effect or within a specified time after any claimed accident or injury. As an example, the policy may provide coverage for an illness or injury that “totally and continuously disables the insured within 30 days of the date of the accident so as to prevent him from performing each and every duty pertaining to his occupation.”

Disability insurance policies usually distinguish between disabilities caused by illness and those resulting from accidental injury. This is seen in the 1978, Beaumont Court of Appeals opinion, Lone Star Life Ins. Co. v. Griffin. In this case the policy provided that the insurer would pay the insured $1,000 per month for 60 months for an accidental injury resulting in total disability and that it would pay $1,000 per month for 24 months for total disability resulting from sickness.

Liability Of Insurance Adjusters

September 29, 2018 | Mark S. Humphreys

Insurance attorneys representing the insureds would prefer to fight cases in State Court. One way of doing this is to successfully plead a case against the insurance adjuster. Insurance companies would prefer to fight in Federal Court.

Here is a case wherein the case was filed in State Court against the insurer and the adjuster and removed to Federal Court by the insurance company. The insurance company successfully kept the case in Federal court but expressly allowed the insured to replead the case against the adjuster.

The case was replead and now the insured is seeking to have the case remanded to the State Court. This 2018, opinion is from the Northern District of Texas, Dallas Division and is styled, William W. Caruth, III, et al. v. Chubb Lloyd’s Insurance Company of Texas, et al.

Worker’s Comp. And Subrogation

September 28, 2018 | Mark S. Humphreys

The 14th Court of Appeals issued an opinion recently dealing with Texas Workers Compensation law and subrogation. The opinion is styled, Liberty Mutual Insurance Company v. Buddy J. Trahan.

When as in this case, a person suffers an injury due to the actions of a third party and the injured person is on a job that is covered by Texas Workers Compensation benefits and those benefits as paid, as a general rule the workers compensation carrier has subrogation interests in any recovery made by the injured employee against the responsible third party.

It is important that these subrogation interests are handled properly to keep the injured employee and others from being sued by the workers compensation carrier for monies recovered from the third party.

Delay In Paying Claim And Prompt Pay

September 27, 2018 | Mark S. Humphreys

Here is a case where the Prompt Payment of Claims Act was not violated, even though at first glance it appears it was violated. Knowing how the facts and the law square on these issues is important in evaluating a case. This 2018, case is from the Amarillo Court of Appeals and is styled, Steven Biasatti And Paul Gross D/B/A Topdog Properties v. GuideOne National Insurance Company and John Karl Graves.

TopDog was insured with GuideOne and suffered property damage during a storm. A claim was made and GuideOne adjusted the loss as being $1,896.88. TopDog requested an additional inspection. GuideOne retained an engineer who confirmed the adjuster’s findings. TopDog wished to proceed with an appraisal and GuideOne responded that only they, GuideOne, could invoke the appraisal process.

TopDog filed this lawsuit and then GuideOne invoked the appraisal clause in the insurance contract. The trial court ordered appraisal, the parties designated appraisers, and the court appointed an umpire. The umpire filed the appraisal award, in which the parties’ appraisers and the umpire unanimously set the amount of loss at $168,808.

Insurer Paid – Is There Still Any Liability

September 25, 2018 | Mark S. Humphreys

Insurance lawyers who handle home owner and property claims must know this case. It is a 2018 case from the Northern District of Texas, Dallas Division. It is styled, Meisenheimer v. Safeco Insurance Company of Indiana.

This is a storm damage claim. Plaintiff suffered damage and made a claim. Safeco sent out an adjuster who found total damage that was less than the $7,700 deductible amount. Plaintiff hired a public adjuster who determined the loss to be $129,794. Safeco re-inspected the property and the parties still could not reach a resolution. Plaintiff claims the inspections were substandard.

The insurance contract includes an appraisal provision for resolving disputes over the proper amount of the claim. Safeco invoked the appraisal process and both parties participated. An umpire issued a final appraisal award of $54,535. Safeco timely paid the final appraisal amount.

Removal To Federal Court

September 23, 2018 | Mark S. Humphreys

Anytime an insurance company is sued from conduct arising from insurance policy and the investigation of a claim, the insurance company is going to seek to have the case heard in a federal court. This is seen again in the 2018, opinion from the Western District of Texas, San Antonio Division, styled, Electro Grafix, Corp. D/B/A Aetna Sign Group, LTD., D/B/A Aetna Sign Company, Inc. v. Acadia Insurance Company, and Marlin Douglas Odermatt.

This is a lawsuit filed in State District Court arising out of claim for property damage wherein Acadia claims there was no damage or minimal damage to Aetna’s property. Marlin was an engineer assigned to investigate the claim by Acadia. Aetna claims Acadia has not accepted responsibility for the conduct of Marlin and thus Marlin is being sued in his individual capacity.

Acadia had the case removed to federal court and Aetna is filing this motion remand based on Marlin being improperly joined.

Processes In Adjusting A Claim

September 22, 2018 | Mark S. Humphreys

Insurance lawyers need to know what the policy at issue says and how the courts interpret those policies and make their rulings.

For a homeowners policy, the 2018 Eastern District of Texas, Sherman Division, opinion styled, Rainey Rogers v. Nationwide General Insurance Company, is a good read.

The Rainey case arises out of a dispute between a policyholder and Nationwide regarding the extent of damages and the amount of loss suffered to Rainey’s property. On March 26, 2017, the property suffered damage due to storm-related conditions and Rainey made a claim for benefits.

Home Owners Claims For Insurance Code Violations

September 20, 2018 | Mark S. Humphreys

The Southern District of Texas, McAllen Division issued an opinion in August 2018, for insurance lawyers to read that is styled, Alfredo Murillo Jr., et al v. Allstate Vehicle and Property Insurance Company.

The Murillo’s filed a lawsuit in State court against Allstate after Allstate did not handle a storm damage claim to the satisfaction of the Murillo’s. The Murillos alleged violations of the Texas Insurance Code, the DTPA, and breach of contract. Allstate removed the case to Federal court and filed a motion with the Court seeking dismissal of the Murillos Insurance Code and DTPA violations pursuant to Federal Rule of Civil Procedure 12(b)(6).

Rule 12(b)(6) requires plaintiff to plead “enough facts to state a claim to relief that is plausible on its face.” The pleading requires “more than labels and conclusions” or “a formulaic recitation of the elements of a cause of action.” Conclusory allegations are disregarded.

Reading The Insurance Policy

September 18, 2018 | Mark S. Humphreys

Insurance lawyers will tell their clients to read the insurance policy and then the attorney can discuss with the client how courts interpret the language in the policy. A 2018, opinion from the Southern District of Texas, Corpus Christi Division, styled, Mark Eller V. United Property & Casualty Insurance Company, is a good read for seeing how at least this particular court interprets the policy at issue in this case.

United filed a “Motion to Abate Proceedings to Complete Appraisal Process” and Eller responded.

Eller owns property damaged in Hurricane Harvey on or about August 25, 2017. United was the insurer and provided an estimate of the loss that was far less than what Eller says. A pre-suit demand was made under Texas Insurance Code, Chapter 542A on February 1, 2018.

Disability Coverage And Disability Due To Illness

September 16, 2018 | Mark S. Humphreys

According to the 28 Texas Administrative Code, Section 3.3012(b), in a definition of “total disability” in an individual accident and sickness policy or hospital, medical, and dental service corporation subscriber contract, the inability to perform duties may not be based solely on an individual’s inability to perform “any occupational duty,” but the insurer may specify the requirement of the inability of the insured to perform all of the substantial and material duties pertaining to his or her regular occupation, or words of similar import.

A policy may further provide coverage for “partial disability,” which is typically defined as the insured’s inability to perform one or more but not all of the essential duties of his or her employment or occupation.

Disability policies normally require that any claimed disability occur while the policy is in effect or within a specified time after any claimed accident or injury.