Insurance Coverage Claims

You buy insurance to get peace of mind. You want to know that if something unexpected happens to your car, home, or health, you’ll be financially covered.  All too often, simple coverage isn’t the result for policy holders.  Instead, the insurance company delays or denies a valid claim under the policy, or offers to pay less than the full claim amount.  We represent policy holders who deserve to receive what they pay premiums for - fair and honest claims payments – instead of denials and run-arounds.

An insurance policy is a contract. The question as to whether a claim denial is contrary to the terms of the insurance policy is a breach of contract issue. Since policy holders have no ability to change the terms of their insurance policies, any vague language in the policies is interpreted against the insurance company by the courts. When the meaning of a policy term is disputed, it should be interpreted to provide the greatest coverage available. A basis to challenge an insurance claim denial generally falls into two categories:
  • Since there may be multiple interpretations of an insurance policy, the company used one such interpretation to deny an insurance claim.  Since vague policy language is interpreted against the insurance company, if the policy holder can validly interpret the language as providing coverage, there should be coverage.
  • Mistaken facts can be a basis to challenge a coverage denial.  Even when a claim adjuster based the denial on a good faith belief in a fact related to the claim, the insurance company may still be liable later when that belief turns out to be wrong. 

Bad Faith Claims

Depending on the circumstances, the wrongful denial of your insurance claim may only be the start of your legal action against an insurance company.  It may have also been acting in bad faith, which could be the basis for additional legal claims. An insurance policy is not only a written contract where the insurance company promises to recoup your losses covered by the policy, in exchange for your premiums; it’s also a legally recognized promise to act in good faith and in your best interests. If your insurance company handles your claims improperly, contrary to generally recognized standards in the industry and/or Florida law, the insurer acted in "bad faith." This can be a basis for legal action if you prevail in your original coverage denial claim. Even a settlement by the insurer may turn out to be a basis for suing for bad faith. If a claim is denied or disputed for the wrong reasons, that doesn’t necessarily mean bad faith was involved.  An insurer may have a legitimate reason for its actions. However, too often, insurance companies and adjusters put their interests ahead of the interests of their policy holders, causing damage to the insured. Improper claims handling practices can include an insurer's:
  • Failure to thoroughly and/or properly investigate your claim in a timely manner
  • Delay tactics to put off paying your claim, slowing claim adjustment, or making numerous records and information requests without explaining the reasons for or relevance of the material sought,
  • Not paying the full amount of the claim,
  • Unreasonable claim denials,
  • Misrepresenting policy language or coverage when communicating with the insured, and
  • An unreasonable interpretation of the policy language.
An adjuster’s improper handling of a claim may be caused by the claim’s processing guidelines created by the insurer. Their goal may be to decrease costs and increase profits. If the guidelines are improper, adjusters may be unable to fairly process your claim in a timely manner. In this situation, and others where the insurer violates Florida law by using unfair and deceptive claims practices, there could be a claim for punitive damages. Punitive damages are ordered by the court to punish the insurer for egregious actions and create a visible warning for other companies.  This award is in addition to the insured's damages, suffered as a direct result of the insurer's actions. If you feel your insurance company’s claim denial may constitute bad faith activity, contact our office so we can discuss the situation.

Auto Claims

Cars are virtually indispensable for most of us.  We use them every day to get us nearly everywhere we want to go. Most of us will be involved in at least one accident in our lifetime. We rely on our auto insurance to help us when accidents happen, but coverage is not guaranteed. Florida laws require anyone that owns a motor vehicle in the state to have auto insurance. Someone involved in an accident needs to use their own auto insurance to pay the first $10,000 of their own medical bills, no matter who is at fault. This benefit is known as “PIP”(Personal Injury Protection). To receive compensation for pain and suffering, state law requires there to be a “permanent injury,” known as the permanency threshold. As you can imagine, insurance companies will often aggressively argue the injury is not permanent, so there should be no compensation for pain, suffering and loss of enjoyment of life. The treating physician must certify the injury is permanent, so it’s important that your physician is familiar with auto insurance law requirements. There are strict deadlines for filing claims, and failure to comply could result in a complete bar from receiving any compensation for your injuries. Contact us if you have any questions or concerns about an injury due to an auto accident or the denial of an auto insurance claim.

Property Damage Claims

Florida residents are all too familiar with tropical storms, hurricanes, sink holes and the occasional fire as regular instigators of property damage.  Similar, many of us are all too familiar with denied property damage claims as well. Property insurance (including homeowner policies) must cover damage from sinkhole activity. If your property has been damaged by sinkhole activity (such as cracked walls and foundations, damaged flooring and holes beneath your home or business) you may be able to file a claim to repair these damages. Many windstorm claims are denied due to a dual causation defense (damages due to wind should be covered, but not damage due to rainwater so if the wind blew your front door open, you may be denied coverage for the resulting damage from rainwater or flooding). If your claim for insurance-coverage from property-damage has been denied, contact our office so we can discuss your situation and go over your legal options.

Life, Health & Disability Insurance

Consumers buy life insurance to care for their loved ones and business partners when they pass away.  Denial of a life insurance claim could have devastating effects on beneficiaries.  The costs to treat a major illness or injuries from a serious accident can quickly go into the hundreds of thousands and even millions of dollars.  A wrongly denied health insurance claim could destroy a family’s finances and force it into bankruptcy. Disability insurance is bought to protect one in case of a debilitating disease or accident and to provide income for supporting yourself or your family when a pay check can no longer be earned.  A disability-insurance denial claim may come when you need money the most. If you find yourself in any of these situations, reach out to our office to learn about your legal rights to these benefits and ways to fight a benefits denial.

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