Merlin Law Group has been focusing on practicing insurance law since 1985. The attorneys at Merlin Law Group will choose top industry experts tailored to your specific type of claim and in most cases, the firm fronts all costs for experienced experts in order to build the strongest case for you, the policyholder.
From engineers to contractors, to independent professionals, Merlin Law Group retains qualified experts to adequately assess your insurance claim. The utilization of these professional expert witnesses sets Merlin Law Group apart from other insurance law firms.
The attorneys at our firm perform with due diligence and are determined to assist policyholders in obtaining what they are owed and the initial review of your insurance claim is complimentary. Merlin Law Group is the policyholder’s advocate, representing policyholders nationwide.
Merlin Law Group attorneys typically work on a contingency fee basis, so there is no cost to you unless we win your case. In many cases, Merlin Law Group will hire industry experts, among other resources, to build the ultimate case for you, the policyholder. In these cases, costs can accumulate greatly and quickly. Merlin Law Group attorneys know that these in-depth, unbiased expert analyses can make or break your insurance claim. Merlin Law Group is dedicated to obtaining the maximum settlement for our clients and will advance most costs pre-settlement.
The insurance company must treat its policyholder’s interests with equal regard as it does for its own interests—this is not an adversarial process.
Should assist the policyholder with the claim.
Must disclose to its insured all benefits, coverages, and time limits that may apply to the claim and must conduct a full, fair, and prompt investigation of the claim at its own expense.
May not deny a claim or any part of a claim based upon insufficient information, speculation, or biased information. In the case of a full or partial denial, the insurance carrier must give written explanation, pointing to the facts and policy provisions.
Must not misrepresent facts or policy provisions.
May not make unreasonably low settlement offers.
An insurer must adopt and implement reasonable standards for the prompt evaluation of claims. In evaluating a claim under a replacement cost policy, it is not proper for an insurer to deduct deprecation from the value of the claim.
Failure to fairly and reasonably investigate a claim does not permit the insurance company to deny the claim due to lack of information or one-sided information.
An insurance company may not ignore evidence which supports coverage and if a claim is denied, the insurance company must promptly give the policyholder a reasonable explanation of the basis in the insurance policy in relation to the facts, policy provisions, or applicable law upon which it relies for denial of the claim.
Cannot discriminate in the claim settlement practices based on the claimant’s race, gender, income, religion, sexual orientation, national origin, disability, or the territory of the property or person insured.
An insurer must communicate with its insured to keep it appraised of the status of its claim and the insurer has a duty to disclose all significant facts to its insured while not misrepresent facts or policy provisions relating to coverage of an insurance policy.
An insurance company must not fail to acknowledge and act promptly upon communications regarding a claim arising under an insurance policy should adopt and implement reasonable standards for prompt investigation of claims.
When insureds don’t recognize they are entitled to benefits in a policy, an insurance company’s obligation is to point out those policy benefits to them.
An insurance company may not use the claims department as a profit center and must keep a total claims file that reflects all activity on a file.
In terms of insurance, bad faith this can be ill fulfillment of contractual obligations to the policyholder. Administering misleading information and breaching basic industry standards are just some examples of an insurance company displaying bad faith.
The answer depends on the law of the place that interprets insurance policies and practices. The ability of the insured to file a bad faith lawsuit on their insurance company encourages fair and timely adjustment and payment of claims and provides a proven remedy if the insurance company fails to perform. Bad faith isn’t the type of claim an insured can consider as a guaranteed route to getting a recovery. Bad faith litigation is navigated best when using the court’s prior rulings as a road map. Overall, bad faith actions stem from the withholding of benefits due under a policy or for unreasonable conduct by the insurer.
Policyholders entitled to benefits under an insurance policy may be able to sue for bad faith if those benefits have been wrongfully withheld.
Whether the withholding of benefits rises to the level of bad faith purely depends on if it’s determined that the insurer’s actions are unreasonable. If an insurer has a reason to withhold payment, then there may not be bad faith or breach of contract. Bad faith doesn’t arise in every matter, and the particular facts of each case should be carefully considered before such a claim is made.
There are differences among the various states as to the time limitations by which one can bring an action against an insurance company for bad faith.
The statute of limitations is the time you must file a lawsuit against your carrier after a loss. This varies from policy to policy and state to state. Act promptly and make sure you don’t delay if you want to be properly paid for your claim.
If a policyholder refuses to answer a question at EUO, defense counsel often suspect fraud. The policyholder is violating their duty to cooperate and claims can be denied in this instance. Typically, the insured doesn’t want to answer questions that are too personal but the insurer has the right to delve into areas during the examination that may expose fraud, such as the policyholder’s income.
The court typically rules that the EOU are contractual obligations which must be complied with in order for the insured to garner recovery. It’s common that the policyholder is required to answer questions pertaining to the actual loss itself or circumstances surrounding that loss.
Refusing an EUO is considered a material breach of the policy conditions. An examination under oath can be distinguished from a deposition, since an EUO is a contractual agreement where policyholders have a duty to volunteer information to the insurer, where no such duty exists during a deposition. Depositions are not an adequate substitute for EUOs.
Most property insurance policies include an appraisal provision that may be invoked by either the insurer or the insured to determine the value of a loss. Courts generally agree that “valuation” is the task of an appraisal panel, and “coverage determinations” are the province of courts. Courts are inconsistent as to what falls under “valuation” (which may be decided by appraisal) or falls under “coverage determination” (which must be decided by a court). Policyholders who believe their claims have been undervalued or underpaid often invoke the appraisal provision, hoping to avoid the time and expense of litigation. Unfortunately, insureds may receive one of the following responses from the insurer:
Policyholders who believe their claims have been undervalued or underpaid often invoke the appraisal provision, hoping to avoid the time and expense of litigation. Unfortunately, insureds may receive one of the following responses from the insurer:
“Method of repair is not subject to appraisal.”
“The cause of damage is not subject to appraisal.”
Past cases have shown that policy interpretation is extremely important. The facts determine coverage in first party property insurance claims and policyholders should note the following:
Small factual changes potentially result in drastically different outcomes in a coverage evaluation.
Some property insurance policies may contain an exclusion where an insurer will not cover a loss “to the interior of any building or structure, or the property inside any building or structure, caused by rain…” In this situation, it is important to look at the policy to see if it defines the term “rain” as this may affect whether the loss will be covered. It could be covered if there were windstorm damages to the exterior roof or walls of the structure the water had entered.
This policy limitation/exclusion is often referred to as the wind-driven rain exclusion. It is important for insureds to be aware of this common provision when reporting claims to their insurers or giving statements about the details of a loss.
When evaluating damages and losses to your property, there are several things to be evaluated. One key note to investigate: was there damage before the loss? Does your insurance policy only cover loss and not damage? Can there be loss without damage? Was the damage pre-existing (resulting from wear and tear)?
The property insurance proof of loss usually is typically part of the formal claim, including:
The parties claiming under the policy
Those with an interest
The date and cause of loss
Some supporting documents of the amount of the loss.
The policy usually requires that the proof of loss be sworn to as truthful and a contain a notarized signature by the insured. The time to provide a proof of loss varies from policy to policy and from state to state. It’s important to comply with the time requirements of submitting the proof of loss. In some instances, and in some states, a late-filed proof of loss may provide the insurer with a basis to deny an otherwise valid proof of loss.
The insurance company should send out a licensed insurance adjuster following the claim. Insurance companies should ensure that the insured’s property can be put back to its pre-damage condition. As a policyholder it is important to review the policy and look for provisions of elections of the right to repair, managed repair programs, and to read through the policies to know what their requirements and obligations are when a loss occurs.
Insurance Provider Responsibilities:
Investigate the policyholder’s claim thoroughly, sufficiently and in a timely manner.
Treat the policyholder fairly and without bias.
Compensate policyholder for any covered damages promptly.
Clearly and thoroughly explain in writing to the policyholder why their insurance claim or part of their insurance claim was denied.