Loose Lips Shrink Chips - What NOT to tell your insurance adjuster

by Mark Goldwich

Image courtesy of allposters.com

There are so many great quotes that support this subject – “Silence is golden”, “It’s better to be thought a fool than to open your mouth and remove all doubt”, “Play your cards close to your vest”, and so on.

The point is, as with many things in life, when it comes to insurance claims, you need to watch your Ps and Qs (I couldn’t help throwing in one more). Be mindful of what you say, and how it may affect you later. That could be tricky, especially when you don’t know how what you say now can affect you later as it relates to something as complex as insurance. So, stick to the rules above, and below.

My best advice for when you are talking to any insurance representative (after recommending you consult a professional for representation on your claim) is to say as little as possible, and to keep what you say as factual as possible. Most people, once they get started talking, have difficulty putting on the brakes. Most people are also uncomfortable with “dead air”, or that “awkward silence.” They’ll start off telling you about the pipe that burst, and before you know it, they’ll be rambling on about how their “dog Petey, named after a favorite uncle, doesn’t like a certain neighbor, who’s kid once stole a car and” … you know?

I tell people to just answer questions factually, in as few words as possible, and only if they personally know something to be a fact. For example, if their uncle told them the house was built in 1972, and he explains he knows that for a fact because that was the year the Miami Dolphins went undefeated…and they are asked how old the house is, and they don’t personally know, the answer is “I don’t know.” Or they could say, “I don’t know, but my uncle has said it was built in 1972.” But, “1972” is the wrong answer, even if the uncle was right, and the home happened to be built in 1972.

There is absolutely nothing wrong with saying, “I don’t know”, or “I don’t recall”, especially when that is the truth, but many people feel saying that too many times gives the impression that they are being evasive, or worse, that they are not smart (otherwise, they would know). To me, what’s not smart, is giving an answer to a question when you don’t really know the answer. And to an insurance company, giving an answer that turns out to be proven wrong – can be considered evasive, or even “a material misrepresentation”.

Courtesy of experttextperts.com

I also remind people that terminology counts. I’ve heard many people describe a pipe leak, or a toilet overflow, as “a flood”. That may be what it ended up looking like, but in insurance terminology, “flood” refers to “a general and temporary condition of partial or complete inundation of … normally dry area from overflow of inland or tidal waters or unusual and rapid accumulation or runoff of surface waters from any source…”, and for the most part “flood” is not covered by your homeowners insurance. So, don’t say “flood” unless you are really sure this is what it is.

Another often confused term is “back-up”. Sounds innocent enough, right? There are generally two reasons why water comes up out of a drain, instead of going down a drain. Water is either backing up through the city sewer line or a septic drain field (this is a true “back-up”), or there is a clog in a drain pipe (this is technically a “fill-up”). In both of these cases, the results appear to be exactly the same – water coming up out of a toilet or drain. Why does this matter? Well, one is typically excluded from coverage, and one is typically covered. The problem is, most people, even insurance adjusters, aren’t familiar enough with these terms, and if the wrong term is given, the claim is denied. Now, you can’t just say “fill-up” and expect the claim will be paid, either. You have to be able to demonstrate it was truly a “fill-up”, and you may have to be able to articulate the difference, to someone who is supposed to know the difference, but doesn’t, and will not readily believe they have been “doing it wrong all these years” – You can bet I have heard that response a few times.

From newgeography.com

How about “vacant” versus “unoccupied”? Historically, and generally, when it comes to insurance, the term “vacant” also triggers thoughts of denial by insurance adjusters, especially when related to certain types of losses (theft and vandalism) on certain types of policies (commercial rental or business policies). Here, another seemingly trivial technicality may be the difference between coverage (if unoccupied) and denial (if vacant). The term unoccupied means nobody is living in the property. And the term vacant means there is not only nobody inhabiting the property, but there is no personal property there as well. So if a home is vandalized, and an adjuster learns the home had been empty for 2-3 months before the vandalism occurred, they may deny the claim, despite the fact that the property still contained many personal property items (furniture, dishes, cleaning supplies, etc.). Now, I will say some insurance companies have picked up on this difference, and now take steps to more specifically define what they mean by “vacant”, or they simply exclude for theft or vandalism if the property is either “vacant” or “unoccupied.” 

And then there are words that just scream “not covered!” to most adjusters. You see, most insurance policies have certain things that are universally excluded from coverage. These are things like, “mold”, “rot”, “wear and tear”, “defect”, and just plain “old.” So when an adjuster hears these words coming from a policyholder, the little red light in their head immediately goes off, and sometimes they don’t even bother to verify it for themselves. After all, they were given the “facts” by you, the person who should know best. Case closed.

Mold as a rule is often not covered. But water damage is usually covered. And in most cases, guess what almost always precedes mold? That’s right, water. So in cases where water has damaged property, and then mold sets in, you might want to focus your attention on the water, not the mold if you want to have a better chance of getting paid. Is this being deceptive? An insurance company adjuster might suggest it is, but it absolutely is not, it is being factually correct.

The same is true for rot. Rot is generally not covered. But sometimes the rot that is seen (which may have occurred years ago from an old leak), is simply found in the same area of a new leak. If you just show the adjuster the rot in that area, he or she may assume the rot is related to the “new” leak, believing it is a long-term, on-going leak. A small difference in understanding could change the entire outcome of the claim. We have seen it happen more than once.

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This is just a sample of often confusing and misunderstood terminology related to insurance claims. There are many more, and as we have seen, policies are always evolving to minimize the potential misunderstandings or ambiguities that tend to result in litigation. This is good for the consumer in that lawsuits are reduced, which could (theoretically) keep premiums in check, but on the other hand, it usually resolves the ambiguity in favor of those who write the policies to begin with – the insurance companies.

I hope you have learned from this that when the chips are down, it is best to know your insurance policy, know your terminology, and as Kenny Rogers famously sings, “You gotta know when to hold ‘em.” By that I mean, don’t spill your guts when talking to an insurance adjuster, because words matter, and simple misstatements could mean the difference between a claim’s life and its demise.

Mark Goldwich is president of Gold Star Adjusters, a group of public insurance adjusters dedicated to helping citizens get the maximum settlement for any insurance claim.