Ask The Public Adjuster About Insurance Claims: denied insurance claims

Showing posts with label denied insurance claims. Show all posts

Your Vacation Checklist

by Mark Goldwich

Image courtesy of pixabay.com

Summer break is nearly over, but vacations happen year round, so it is never too late (or too early) to learn a thing or two that could really come in handy should disaster strike while you are away, from the perspective of an insurance claims professional.

First, be sure you have insurance to begin with, and that it is the right insurance for you and your property, with the right coverages, endorsements, and deductible. Whether you are going on vacation or not, you should meet with your insurance agent yearly, or you should review your policy carefully if you don’t have an agent. Why? As you might imagine, insurance policies differ from company to company, and each insurance company may also have policies that differ. Some policies are actual cash value only, meaning they will deduct for depreciation in the event of a loss, while other policies are replacement cost value, meaning they will not deduct for depreciation, but fully pay whatever it costs to replace what you had that was damaged, lost, or destroyed. Even this is not consistent, in that some policies say they are replacement cost, but will only pay the full replacement value if you replace the item, and they will not pay actual cash value until or unless you actually replace the property first.

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Another consideration that needs to be made when researching insurance options is what I call “internal limits”. Most people understand their policies have overall policy limits for which their property is covered, like a limit for all items related to the structure, and another limit for all of their personal belongings. However, some don’t realize there are usually internal or sub-limits for items, usually for personal property. For example, all your personal property may be insured for $50,000, but your policy may have multiple sub-limits for items like jewelry, cash, antiques, camera equipment, business property, stamps, firearms, silverware and goldware, watercraft, trailers, expensive rugs or tapestries, and even computers. Sometimes these limits apply only if the property is damaged under certain circumstances (like theft), and sometimes these limits apply regardless of what caused the damage.

In short, it’s important to have an idea of what these limits and circumstances are, and whether or not you can buy additional insurance to cover your property. Oftentimes you can, but unless you know what the limits are, how can you know whether you need to buy more insurance or a better policy? Early in my career as an insurance company adjuster, an associate and I inspected a claim for a theft loss that highlights this well. As we interviewed the homeowner, he explained that while he was out of town, thieves broke into his home and stole a number of items, including jewelry, cash, and designer clothing from his wife’s boutique. Other items were stolen and damaged as well, but the items listed above were all subject to relatively low internal limits.

The cash limit was $200, the jewelry limit was $2,500, and the limit for clothing used in his wife’s

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business was $1,000. Normally, this wouldn’t be so dramatic, but in this case, the amounts he was claiming were extraordinarily high. You see, he was claiming the amount of cash stolen exceeded $200,000, the amount of jewelry exceeded $100,000, and the clothing exceeded $50,000 in value. We were shocked, he could probably sense in our questions that we doubted his story, but he assured us he could document and prove all the items and quantities being claimed. He even noted the money was still in the U.S. Marshall’s bags from when the money was recently returned to him. A strange claim, indeed! And to say he was upset about the shortcomings of his policy sub-limits would be an understatement – I was glad to make it back to the office alive! No doubt most people will never experience a loss of this magnitude, but it well illustrates the point of internal policy sub-limits, and the importance of being familiar with those in your policies.

And for similar reasons, it is crucial to have at least a basic understanding of all other aspects of the policy. Without this basic knowledge, it is impossible to know whether or not you have the right policy and endorsements for your needs. Once you are confident of your policy, you can be a bit more at ease when you leave for vacation.

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But just having the right policy is not enough. You need to have a plan as well. This can include how to prepare your home to make it less attractive to thieves, to be less susceptible to electrical and plumbing losses, and general life and home protection ideas, including a contact list to use in the event of some disaster, and a step by step strategy for beginning to deal with the claim remotely. I actually found some very good ideas and tips on insurance websites for www.Nationwide.com and www.Travelers.com (hey, just because I don’t trust those guys to help you after a loss doesn’t mean I won’t recognize any of their good works).

With a comfortable knowledge of your policy, a plan in place, and your home prepared, it’s time to pack your bags and enjoy your trip!

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.

Public Adjusting Takes a Vacation

by Mark Goldwich

Image courtesy of flickr.com

Like many other Americans, this week the family and I are on our last vacation of the summer. Vacation is a bit different for me as a business owner versus my decades as an employee for a large national insurance company. Back when I worked as an employee of the insurance company, I could just go. My job and the office would be there when I returned, but I didn’t have to worry about work while I was away on vacation. Now when I go on vacation, I have to be sure to take my phone and laptop (and chargers) with me, both of which allow me to communicate in various ways with coworkers, insureds, and others. With the systems we use, I can work virtually from anywhere, as long as I can connect to a network, or get Wi-Fi, without missing a beat.

In fact, just yesterday, as I was completing the last driving leg of our trip to Williamsburg, Virginia, I got a call from an adjuster I was expecting to hear from the day before, and in just less than 10 minutes at highway speeds, we were able to settle the claim. My insured, Ms. “P”, will be very happy. Ms. “P” suffered a water leak in April when the shower valve in her daughter’s bathroom sprang a leak in the wall cavity between the bathroom and the laundry room. They immediately shut off the water and called a plumber, who located and repaired the source of the leak. She then called a contractor who extracted the water and dried the structure. In the meantime, Ms. “P” got a closet-full of shoes out of her daughter’s room, and began drying and cleaning them. A few days later, the insurance adjuster showed up, and Ms. “P” said she could tell it was not going to go well from the start. The adjuster began by saying he needed photos of odd things, like the mailbox, and the exterior of the home (none of which had any damage or were related to the claim in any way). The adjuster suggested the water was leaking for “quite some time” and questioned the insured’s truthfulness regarding certain aspects of the claim.

Image courtesy of flickr.com

Sure enough, about a week later, the insured was officially told her claim would be denied because the insurance company felt the water leak was an ongoing maintenance issue that occurred for weeks or months, and not just hours or days as the insured had claimed. Fortunately for Ms. “P”, her water restoration contractor told her about me, and one month after the leak was discovered, she hired me to help recover on the claim. As soon as I saw the damages, exactly as the insurance company adjuster saw them, I knew with certainty the loss should have been covered. I took my photos, made some notes, and had an estimate prepared. The estimate was sent in to the insurance company with a request to meet with an adjuster (either the same one, or a new one). They sent a new one, about a month later. When we met back at the house, the adjuster acknowledged he was not familiar with the claim, or why it was not covered, but assured us he would consider it with “fresh eyes”. I remained sure the claim would be paid. Ms. “P” was encouraged, but not yet convinced. Until today, when I communicated (via email from 3 states away), the general terms of the agreement the adjuster and I came to in the car yesterday. He confirmed they agreed to fully cover the claim, and even agreed to the vast majority of my estimate, plus something to compensate the insured for saving and cleaning her daughter’s shoes.

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While on vacation, the TVs where we are staying are programmed to have the weather channel appear when the TVs are turned on. For most guests, I imagine this is so the visiting tourists can check the weather and plan their days. Of course, for me, I get to see where the storms are, and remain in “work-mode”. Today, for example, I see Tropical Storm Earl is heading for Mexico’s Yucatan Peninsula, and that Maryland is recovering from recent heavy flooding. So, while my family is at a local theme park, I am taking the day off from vacationing to catch up on some emails and write this blog. Tomorrow, though, it is back to family vacation fun, I promise – but I may need to take a work call or two, and check email and text every few hours. And I wouldn’t have it any other way. I love that I can help people any day of the week, no matter where I am!

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.

Collateral Damage - Can your insurance policy become a casualty of war?

by Mark Goldwich

Image courtesy of en.wikipedia.org

While just about everyone in America is talking (if not listening) about the racial problems facing the nation, and all the theoretical reasons for the discord, as well as the perceived solutions, I was also thinking about the real life property damage consequences from the Dallas attack and other demonstrations that sometimes begin peacefully, but don’t always end peacefully, as well as events such as the Orlando and San Bernardino attacks.

After giving the obvious due consideration for the loss of life, and everything that goes along with that loss of life, and the acts that led to the loss of life, I couldn’t help but think about the property damage involved in these types of events. Often, the property that is damaged does not belong to either the victims, or the perpetrators. Instead, the owners of the property that is collaterally damaged or destroyed are additional innocent victims of the various types of mayhem that seem to be more and more common. In fact, in Dallas, the explosive that ended the event, was introduced and detonated by the police, not the assailant. Should this make a difference? I thought, “If I’m wondering about this, maybe other people are as well.”

So what about it? Is property damaged like this covered? First, we’d need to break down the causes of the property damage, because determining coverage always begins with the cause of the damage. And as you might imagine, the cause might depend on who you are asking. Was the event a riot, a civil commotion, civil unrest, looting, arson, terrorism…?

Image courtesy of YouTube

Because we are talking about insurance, these terms are usually defined in either the policy, or in case

law (a legal ruling or judicial interpretation based on a past case, usually with similar facts). Still, what one person interprets as “riot”, another may consider “terrorism”. Without even getting into this very deeply, you can probably see that what should be clear cut, with just a little wordsmithing can be made to be as confusing as which bathroom should be used by someone born with male parts. Some will say, “that’s easy”, while others will promptly chime in, “not so fast.”

To illustrate how quickly and easily key terms can be interchanged, Brendan McKenna in a 2006 article found at Insure.com noted, “At 9:30 a.m. on Sept. 11, 2001, shortly after learning about the crash of a second airplane into the World Trade Center in New York City, President George W. Bush called the events an "apparent act of terrorism." Standard property/casualty insurance contract forms provided to the industry by the Insurance Services Office contain clauses excluding "war, including undeclared or civil war" and "warlike action by a military force, including action in hindering or defending against an actual or expected attack, by any government, sovereign, or other authority using military personnel or other agents." Just over a day later, Bush said that "the deliberate and deadly attacks which were carried out yesterday against our country were more than acts of terror.

They were acts of war." While the President’s words have unequivocally stated the position of the United States, they may have muddied the waters concerning the insurance issues around the attacks on the World Trade Center and the Pentagon. Many property/casualty insurance policies are written to exclude coverage for acts of war, but not for acts of terrorism. If the act-of-war exclusion clause of the insurance contracts is invoked, insurance companies can refuse to pay the benefits on the policies, including payments on businesses, homes, and cars that were damaged or destroyed.” That would have been ruinous to countless Americans who suffered tens of billions of dollars in direct and consequential damages.

Most standard Homeowner’s or Business insurance policies exclude damage caused by war, and most do cover damage caused by riot or civil commotion, but so far, I have not seen or heard of many policies having specific coverages for, or exclusions against, terrorism (especially on the Homeowner’s policies – some Business policies already exclude terrorism, but allow terrorism coverage to be purchased). So far, at least, this trend benefits policyholders, as most of the events we are referring to here would not be considered “war”, even though we generally talk about “war on terrorism”, or note that radical jihadis have declared “war” on America. As far as I know, no insurance company would consider any of the cases above to be “war”.

According to an article by Gwen Moran in HouseLogic.com, “Several states, including Florida, Massachusetts, New York, Ohio, Pennsylvania, and Texas, forbid terrorism exclusions, according to a report on terrorism’s impact on homeowners insurance from the Missouri Bar Association.”

On the topic of terrorism insurance, according to the Insurance Information Institute (www.iii.org), most personal policies cover terrorism, and most commercial/business policies do not, and even if a business did have a terrorism policy or endorsement, some losses associated with terrorism could still not be covered (fire, nuclear, biological, chemical, radiological, and cyber-terrorism), so it is increasingly important to sit down with your insurance agent to consider these threats, especially if you own a business. While talking with an agent, it may be worthwhile to see how your various insurance policies (home, condo, rental, auto, business, life, health) would react to the scenarios mentioned above.

In conclusion, there are still many questions left unanswered with regard to the insurance coverage of these types of events, and changes continue to be made as additional events occur and more data is gathered by underwriters. That said, you can be pretty sure insurance executives everywhere are meeting at conferences and other industry events to consider how to address the seemingly growing costs associated with paying claims from these types of events. Whether they will adjust policy definitions, limit exposure to these types of losses, or exclude more of these events altogether, remains to be seen, but I have a hunch they will eventually determine a strategy for maximizing profits. They always do.

ps: As I write this I am reminded that terror is an international scourge. This morning's news is filled with the tragic terror attack in Nice, France that claimed at least 50 lives, 2 of whom are American.

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.

Collateral Damage - Can your insurance policy become a casualty of war?

by Mark Goldwich

Image courtesy of en.wikipedia.org

Image courtesy of YouTube

Because we are talking about insurance, these terms are usually defined in either the policy, or in case

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.

Seems Absurd, But It Must Work

by Mark Goldwich

Today I wanted to highlight a pair of recent claims that provide great insight into the strategies employed by property insurance companies (I could do a lot more than two, but for the sake of brevity I’ll just use the two). As we go through these together, you will note a few things both have in common, even though they are being handled by different adjusters at different insurance companies. And one thing is for sure, you don’t want to be treated like any of these people.

Image from en.wikipedia.org

In the first claim, a family experienced a failed supply line to an upstairs commode. This is fairly common, as all toilets have supply lines that remain under pressure, just waiting for the next flush, and these supply lines tend to be made of fairly inexpensive material with very simple connections. These lines can easily go unnoticed for decades (until they fail). When they do fail, the water does not usually drip out. Rather it pours out at a rate that can be measured in gallons per hour. And I’m not sure how these plastic lines know, but they seem to prefer to rupture in the middle of the night, or when people are away on vacation. Devious little suckers, right?

In this case, the line failed during the night, and spewed water for hours until the next morning, when both the upstairs and downstairs were inundated with water. And wouldn’t you know it; the upstairs bathroom where the line broke was right above the kitchen, where all the cabinets became soaked as well.

Sounds pretty straightforward - and it should be. But for some reason in this case, the insurance adjuster who initially inspected the loss only estimated about $18,000 in damages, and the insured wanted a second opinion after we were recommended to her by a co-worker of hers. It turns out her co-worker friend was right, and our estimate was more than double that of the insurance company.

Weeks turned into months as the carrier dragged its feet at every turn. First they wanted the adjuster to go back out to try to correct the estimate; then they wanted a national contractor to complete what they call a “peer review” estimate. The idea is the national contractor will write a fair estimate for what they would do the work for. In reality, the contractor knows they are usually not getting the job, and even if they do get the job, they know they can always submit a “supplemental” invoice to their pals at the insurance company so they can make a good profit. In this case, the national contractor rep told me before coming out that they will never do a job when a public adjuster is involved. Company policy. So, what do you think that does to the value of their estimate? If you guessed, “they write a low estimate”, then your intuition matches my experience. The rep was there for less than 20 minutes, mainly taking photos, and rarely measuring the room sizes, since we were giving him our estimate as a reference.

Image courtesy of flickr.com

Low and behold, the national firm generated an estimate that was much higher than the insurance company adjuster’s estimate, but it was still $12,000 less than our estimate. It is now 4 months since this loss took place, the insurance company has paid less than half of the contractor’s estimate, which is still $12,000 less than our estimate, and the insured is seriously considering accepting their offer, as they are tired of the claim dragging on. And trust me, if we were not helping her, she would have already accepted much less, just to get on with her life. Absurd, but it works.

In the next case, someone I have known for years recently asked me to look at his insurance settlement, admitting he had no idea whether it was fair or not. He had suffered wind damage to his roof, and the insurance company quickly paid to repair the damage, which totaled about half of his entire roof. So far he (and the insurance company) was lucky, as no water had leaked inside despite a number of severe rainstorms.

Immediately upon inspection of the roof and the paperwork he had received from his insurance company, I could see they were not just off on the amount being offered, they had failed to bring to his attention key facts which clearly warranted their paying for his whole roof to be replaced. They must have made a mistake, I thought, and this should be easy for them to fix. I told the insured I would let the insurance company know of their mistake, and if they simply corrected it and paid him in full, I would charge him nothing.

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So I wrote the insurance company a half page letter, clearly explaining what their error was, why it was an error, and I even provided them with an estimate for the proper amount. After days of no response, I called the carrier, and was told the adjuster no longer worked for the insurance company. OK, I said, but didn’t you get my paperwork? Isn’t someone else going to handle this now? The rep politely said the claim was closed. I understand, I answered, but when you received my paperwork asking for the claim to be reevaluated, why wasn’t it reopened and given to someone else to handle. I could tell that if I never called them, they certainly were never going to call me. She then stammered a bit and suggested they just received my paperwork the day before(this had in fact been faxed and emailed to them about 10 days prior). Then she said she would get the claim to a manager to review it. When I asked how long it would take for someone to contact me, she admitted she had no idea. You could hear the embarrassment in her voice.

A few days later, I received an email from the new claim handler. It was very brief, and simply said he wanted to offer an initial compromise settlement of about $4,000 more than what was previously

Image courtesy of pixabay.com

paid. A compromise?, I thought, this was very straightforward. They completely ignored their own policy and state statutes calling for a full roof replacement, which meant they owed about $10,000 more. What was there to compromise? So I responded in considerable detail, showing my math for exactly how I reached the amount I claimed was due, and asking him to point out any error in my math or in my reasoning. He responded by suggesting I was inflating my measurements, and overestimating the costs. He did so by misrepresenting actual numbers presented by myself, the original adjuster, and our local property tax appraiser’s website. His misrepresentations were clear and obvious. If he thought he was being tricky, he was quite mistaken. So I factually pointed out each and every misrepresentation that he made, and again offered him the opportunity to do the right thing.

You would think at this point, seeing that I was not falling for any of his tricks, let alone all of them, that he would just give up and pay the claim in full. No, he simply dusted himself off, and in another very brief email, offered another $1,000 to settle the claim. He was still about $5,000 short. I am certain here too, that if I were not involved, this insured would in all likelihood have accepted the additional money. This would have forced the homeowner to take out a loan to get the roof replaced. Another absurd attempt to get an insured to settle for less than what was owed. I can’t help but believe that it must work on the vast majority of insureds, or they wouldn't resort to these tactics so often.

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.

When Things Go Wrong and Then Right

by Mark Goldwich

Last week I wrote about an insurance claim that actually went right from start to finish (a fairly rare occurrence in my experience). This past week I was reminded of the awful reality of how rare that is, and how terrible it can be when things go wrong (at least until they go right).

Image courtesy of flickr.com

Imagine you are the grandmother of 5 children, and you are their sole caretaker and guardian. That sounds pretty tough enough, doesn’t it? Now imagine that the home the 6 of you live in is completely destroyed in a fire…2 days before Thanksgiving! Are you crying, yet? If not, just wait.

Now imagine you contact your insurance company of many years, and they assure you (on the phone) that everything will be alright, and they will send an adjuster out right away. An adjuster does come, but instead of paying you for the loss, or even advancing you some money for a place to live, or for clothes to wear (other than those on your backs), or for your next meal, you are told they will be sending an expert to investigate and determine the cause of the fire, and that you will have to make yourself available for a recorded statement.

During that recorded interview, you are asked about your finances, your medical history, your relationships, if you have a criminal history, whether you are taking prescription medications, where you were and what you were doing when the fire broke out, whether you or anyone you know had anything to do with the fire starting, and just enough other questions to make you feel like a suspect in the arson of your own home (when it wasn’t even caused by arson to begin with).

Image courtesy of en.wikipedia,org

Weeks pass as adjusters and investigators inspect the home and consider whether or not to pay any part of your claim. All the while you are forced to live with a relative who has 3 children of their own (that’s now a household of 8 kids for those of you with rusty math skills!). Weeks turn into months, and you don’t hear anything from your insurance company well into January (certainly you have a tear at this point, right?).

It is easy to understand how anyone could begin to lose hope at this point, but fortunately one of the fire restoration companies that came around looking to bid on the job told you about a public insurance adjuster that might be able to help get the claim processed. You contact them, agree to hire them, and finally things start to go right. Within days you get a $5,000 advance so you can move into your own place while your home is being repaired. The mere sight of the check causes you to completely break down. And not long after that, your public adjuster calls to say another $235,000 is on the way.

This is what countless numbers of people go through every year in dealing with their insurance companies. And it is what gives me great pride and satisfaction in my chosen career. I was at a networking event with the adjuster that handled this claim recently, and we told the story of this claim. When we were done, the woman sitting next to me (vice president of a local credit union) was staring at me, with a mixed look of shock and disgust, and said, “I don’t get it, why wouldn’t they just pay her?” to which I replied, “Why would they want to do that?” “Isn’t that the whole reason for insurance?” she asked. “Yes” I said, “but if they paid her, their profits would be less, wouldn’t they?”

Image courtesy of Pixabay.com

Obviously, I was toying with her a bit, but she soon realized what I have been saying for years – the smiling faces you see on TV and the catchy jingles you hear on the radio for insurance companies are not what you will likely be faced with when you actually file a claim. You will go from loyal customer to financial adversary. Every penny they pay out in claims is money taken from their bottom line. And they don’t like that.

This story illustrates that things can go very wrong in the course of an insurance claim. But as we have seen, things can also go right, either straight from the beginning or after they started going wrong. Unfortunately, most people will never be told they have the option of hiring a professional adjuster to assist them on their claim. For them, the ending to the story could be just as heart-wrenching as the beginning.

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And this is why I network, promote, talk to people, and use social media blogs. I want everyone to know they don’t have to settle for less than everything they are entitled to. I want them to know they have options, and they don’t have to simply accept poor treatment from an insurance company. They don’t have to hire me. They don’t have to hire anyone. I just want them to know they have the right. I really just want them to know, because people who know make better decisions that lead to happier endings.

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.

When Things Go right

by Mark Goldwich

My blogs typically expose the tendency of insurance companies to either reduce claim payments, or avoid claim payments altogether. And today will be no different. But today I want to focus on what happens when claims are handled well by an insurance company. It does happen, even if far too seldom (in my opinion … based on decades of experience).

Image courtesy of commons.wikipedia.org

Recently, I was referred to an insured by a contractor who felt the insured’s roof was damaged by wind, and who also felt some of the screens on the pool enclosure were damaged as well. But before suggesting the insured submit a claim, the contractor recommended I take a look at the roof and screens, and confirm the contractor’s opinion.

I believe the first thing to go right for this insured was to have a contractor who was truly looking out for the insured’s best interest, rather than simply the contractor’s own best interest. The contractor knew if the insurance company did not agree to pay the claim, it would still count on the insured’s claim history, and could even result in the insured losing his insurance with this company, and he would be forced to find insurance elsewhere – and in Florida, that is not always easy.

Once I determined this particular claim should be valid, the insured signed an agreement with me to handle his claim, and the claim was submitted. We provided his insurance company with our contract, a letter of representation, and within just a few days we also submitted our estimate.

Less than a week later, we were meeting with a representative of the insurance company at the insured’s home. This was another thing that went right. Typically, we are lucky to hear from an insurance company within a week of submitting a claim, let alone meeting with them. Often, we don’t hear anything back from insurance companies, especially if the claim was previously submitted and closed with little or no payment prior to our involvement. And when we follow-up with the insurance companies, we often get the impression that if we never called them, they would never have called us, even though we send written correspondence requesting they contact us to schedule an inspection.

Image courtesy of commons.wikimedia.org

When we met with the adjuster, she noted that she was not told the insured was represented by a public adjuster, so she was not aware of my contract, letter of representation, or estimate. She then apologized for speaking to the insured prior to my arrival, explaining again that she was not aware of my involvement at the time. This was probably the only thing that did not go “right”, but for me, it was not a big deal. I can understand the insurance company did not get her the information quick enough, especially since it had only been a few days since submitting the claim. I showed her the original contract that I had in my file with me, allowed her to take a photo of it, and I gave her a copy of my estimate.

With that, we proceeded with the inspection. She quickly agreed the roof was sufficiently damaged to warrant a full replacement. Whether or not she would have made that same determination if I was not involved, we will never know for sure. But my experience tells me, probably not. When we discussed the screens, she stated that she did not agree with me on my scope of the extent of the damage to the screens, and she told me why. She also asked me to clarify my position, which I did.

She then did something few adjusters do on a regular basis in this area. She got in her car, and instead of leaving in a huff, she told me she would write her estimate on the spot, taking my estimate into consideration, and see if we could settle the claim right there and then. This is something I did hundreds of times as an adjuster for State Farm, but that was a long, long time ago, and except in storm situations (which this was not), we rarely see this happen today. In fact, most adjusters we meet are independent adjusters, who are third party administrators for the insurance companies (not employees), and they often tell us they are simply acting as the eyes and ears of a “claim examiner” or “claim processor” who will be settling the claim, and that they don’t have the authority to settle the claim or even say what they think is covered (even most of the employed staff adjusters we meet do not settle claims on the spot, and don’t always have the authority to detail what the carrier will and won’t pay for). So this was not only another something that went right, it was quite a refreshing change of pace.

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In the end, she prepared an estimate that while less than mine (they almost always are), the contractor agreed was quite adequate, so the insured accepted it, and we were all able to shake on the agreement. The check arrived about a week later - this was the final thing to go right! It’s great when things go right, but especially when it comes to insurance claims, you can’t expect things to go right, or hope things will go right, you have to intentionally plan for things to go right.

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.

Sliding Down the Slippery Slope

by Mark Goldwich

Snow Moon image courtesy of pixabay.com

Last week brought us the “Full Snow Moon”, also known as the “Full Hunger Moon”. Maybe I simply wasn’t paying close attention in the past, but this was the first time I heard each moon came with its own name, based on the month, dating back to Native Americans. With February being known as having heavy snow falls which makes hunting more difficult, it is easy to see how “Snow” and “Hunger” was connected to the name for the February moon.

Anyway, today’s forecast once again featured a weekend warning for strong winter storms, sure to bring huge amounts of the cold, wet, white stuff. Sure, it looks beautiful as it is falling, but man does it ever wreak some havoc when it lands!

So in the spirit of all the heavy snow, I wanted to point out a few ways those cute and fluffy flakes can be dangerous to all kinds of property, and how insurance companies might try to slide out from covering the damage.

Image courtesy of en.wikipedia.org

While it looks a bit like whipped marshmallow topping, snow is actually quite heavy. Accumulated snow and ice (we usually only see the snow on top, but there is usually ice underneath) can topple trees, or at least break large branches. These trees and branches may harmlessly fall to the ground, or they can smash anything they land on…roofs, fences, pools, walkways, power lines, cars, outdoor furniture and swing sets…whatever gets in the way. Trees being heavy and dense, they can really pack a wallop. I once handled a claim where a large tree basically split a 2-story apartment building in half, causing over $400,000 in damages.

Even without involving trees, heavy snow can collapse roofs. And what do you suppose happens to the tons of snow once it gets inside the warm building whose roof just caved in? If you guessed, “melts into hundreds of gallons of freezing water and soas every last nook and cranny of a home,” you’re right!

The snow and ice can also bring down power lines that are sparked from falling trees. When damaged by trees or just the weight of ice and snow, once the power lines come down, the damage totals rise. Food spoils, electrical components get spikes and surges (before or after the outage), and temperatures inside homes drop drastically. This often makes for frozen pipes, and in many cases, as the water inside the pipes freeze, the water expands, causing the pipes to rupture. Since these ruptures take place inside of walls, they can’t be seen – until, that is, the frozen pipes thaw out and water pours from the ruptured section of pipe.

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Snow falling on roadways create other hazards, such as reduced visibility, black ice, snow drifts, and generally slippery conditions that are prime for auto accidents. Cars then slide into other cars, or other property, making for colossal collisions costing copious quantities of cash.

As you can see, when it comes down to it, snow (in one form or another) has the ability to damage pretty much anything it comes into contact with. Naturally, the heavier the snow even, the greater the potential for damage. But that is why you buy insurance, right? Of course, it is.

But if you’ve been following my blogs at all, even an insurance novice can probably begin to formulate some of the slippery excuses some insurance companies might try to give in order to slide out from paying these claims:

“Wear and tear”

“Negligent maintenance”

“Faulty construction, defective materials, or poor design”

“Failure to maintain heat”

“Failure to drain plumbing pipes”

“Continuous and repeated seepage of water”

“Excluded power surge”

“Abandonment”

“Failure to mitigate damages”

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Heck, some might even claim you misrepresented some obscure and completely unrelated answer on your insurance application form when you initially purchased the policy many years ago. If so, they could declare the entire policy to be void, regardless of whether or not this particular loss is covered. I call this phenomenon, “Denial by rescission”, and yes, it really happens.

Even if they can’t find a way to deny the claim completely, there are always plenty of icy obstacles they can use to delay, deflect, reduce and defend their actions and your payments. All of these can frustrate weary policyholders to the breaking point, where walking away from a fair settlement seems better than continuing to engage in the mental torture an insurance claim can inflict.

Well, that got cold and gloomy in a hurry! So let’s come back around and end on a nice note, with the names of all the full moons for the entire year (according to www.farmersalmanac.com):

– January - Full Wolf Moon

– February - Full Snow Moon

– March - Full Worm Moon

– April - Full Pink Moon

– May - Full Flower Moon

– June - Full Strawberry Moon

– July - The Full Buck Moon

– August - Full Sturgeon Moon

– September - Full Corn Moon or Full Harvest Moon

– October - Full Hunter’s Moon or Full Harvest Moon

– November - Full Beaver Moon

– December - The Full Cold Moon; or the Full Long Nights Moon

And if you ever find yourself sliding down the slippery slope of insurance company denial, remember to call your friendly pubic claims adjuster. He knows how to cut Frosty down to size.

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.

Has your Homeowner's Policy Sprung a Leak?

by Mark Goldwich

At our weekly team meeting this morning, we talked about claims we are currently handling, and how various insurance companies are using everything at their disposal to minimize claim payments, or avoid paying altogether – and what we can do about it. It’s one of the main reasons we meet each week. This week, it just so happened that a few of the claims involved water damage, and we talked about a few of the technicalities involved in these types of losses.

In one case, the insurance company sent out an engineer to inspect the claim. That in and of itself was not so unusual, but my adjuster knew an engineer was not typically sent out for this particular type of water loss. So, when my adjuster met with the engineer (as we usually meet with anyone an insurance company sends out), he asked enough questions to learn exactly why the insurance company picked him (a certified mold specialist) to inspect this claim. The engineer explained there are known types of molds that only grow after a certain number of days. Right away, this told my adjuster more than it would ever tell even the most savvy property owner. The insurance company was hoping the engineer could identify a species of mold that could only grow after an extended period of time. Why? We are convinced it is so they could try to deny the claim under a technical policy exclusion that precludes coverage (theoretically) for “repeated leakage or seepage of water from a plumbing system” – most property policies have an exclusion that reads something along those lines.

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Some policies go on to say there is no coverage if the leak goes on for at least 14 days, some exclude good neighbors on your street, odds are at least 1 of them are insured by this huge national company with a catchy jingle and endless ads on TV) doesn’t always take full advantage of this exclusion. After all, if they did, they could deny every single plumbing leak claim that is ever presented, since all leaks and seepages, by definition, occur over “a period of time”. You have a sudden and accidental pipe burst, and water goes everywhere, causing a lot of damage to your home and belongings. That should be covered, right? Not so fast according to the wording of this particular insurance company policy. Even if you were home, and awake, and standing right where the pipe burst, how long would it take you to get to the main water shut-off valve and turn the water off? I guarantee the answer is “a period of time”. Now, I will say this particular insurance company (I won’t say who it is, but if you have at least 5 good neighbors on your street, odds are at least 1 of them are insured by this huge national company with a catchy jingle and endless ads on TV) doesn’t always take full advantage of this exclusion – after all, if they did, they could deny every single plumbing leak claim that is ever presented, since all leaks and seepages, by definition, occur over “a period of time”.

Instead, they simply pick and choose which they want to cover, and which they don’t. To be honest, I don’t know how they have been able to get away with this for so long. A good public relations team, and good lobbyists, are probably a good start. These leaks, if they result in rot or mold, and one just says the loss is not covered if the leak “occurs over a period of time”. Think about that for a minute (or any period of time). You have a sudden and accidental pipe burst, and water goes everywhere, causing a lot of damage to your home and belongings. That should be covered, right? Not so fast according to the wording of this particular insurance policy. Even if you were home, and awake, and standing right where the pipe burst, how long would it take you to get to the main water shut-off valve and turn the water off? I guarantee the answer is “a period of time”. Now, I will say this particular insurance company (I won’t say who it is, but if you have at least 5

I will say this though – regardless of the language they use, and the resources they employ to have the scenario appear to fit the exclusionary policy language, we are usually able to get these claims paid. How? Because we use technicalities too. When the carrier says the leak went on for more than 14 days, we simply address the damages that occurred during the first 13 days (and we usually find it is not much different than the damages that took place from day 14 on. If they find mold that only grows after an extended period of time, we can find other mold present that only takes 72 hours to grow. If they claim this leak resulted in rot, we may be able to establish that the rot they are referring to resulted from a completely different leak several years ago, and is therefore unrelated.

Image courtesy of en.wikimedia.org

Not all leaks come from pipes. Another common leak source we deal with frequently comes from roofs. Roofs can leak for a number of reasons, some are covered, and some are not. Generally, if the leak occurred due to storm damage, falling object, vandalism, or some other sudden and accidental cause, the roof repair is usually covered; but if the leak was due to a lack of maintenance, faulty construction or design, the roof repair is usually excluded. What about the damage done inside the home as a result of the roof leak? This again may depend on the specific policy language. Some policies cover this interior “resulting damage” regardless of whether or not the roof itself is covered, and some policies specifically say a covered event must create an opening in the roof (or wall) before they will pay for the interior water damages. When pressed on what constitutes an “opening” that the water enters through, adjusters vary. Some will pay if roof shingles are damaged in any way, and others insist the word “opening” means, “if you are standing inside the home and can look up and see the sky.” We eat those guys for lunch!

And I recently wrote about two other water claims that were vehemently denied. In one case a covered source of rainwater was improperly denied as being “flood” or “surface water”, when in fact it was neither. And in another case, an extensive water loss was strongly denied because the carrier erroneously believed the loss occurred after the property was left vacant for more than 30 days, when it was not. In both cases, a more technical investigation of facts and policies led to payments exceeding $50,000.

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As you can imagine, in a voluminous insurance policy, rife with legalese containing coverages, conditions, exclusions, exceptions, and exceptions to exclusions, there is plenty of room for technicalities, and for debate over said technicalities. This is all the more reason to have an insurance claim expert on your side, just as the insurance companies have experts on their side.

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.

Tis the Season for Home Fires

by Mark Goldwich

Although we’re thankfully past hurricane season, and once again, we (especially those of us in Florida and other hurricane prone regions of the U.S.) have again fared better than predicted. We had a close call or two, but no hits to the State. Still, we can not afford to let our guard down.

Image courtesy of eletunk.com

As temperatures drop, a new disaster season begins – that of home fires. Whether from space heaters, fireplaces, holiday candles, Christmas tree lights, cooking accidents, or a variety of other sources, the end of hurricane season on November 30 each year seems to mark the beginning of home fire season.

I’ve talked about home fires before, but with incidents involving home fires on the rise, it’s worth pointing out a few important items to reinforce some key concepts.

Just as you did for hurricane season, make sure you have a plan for fire season. Have a plan for detecting fires (replacing batteries), putting out fires (fire extinguishers), escape routes, alternative meeting locations, calling assignments, disaster kits (for people and animals), temporary living, disaster cash, and of course, plans for documenting your claim to your insurance company (this begins with having insurance to begin with, and keeping your insurance up-to-date based on your changing needs.

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Did you know that it’s your responsibility to prove to the insurance company what you owned when your home burns to the ground? You may pay for $100,000 (or much more) in personal property coverage, but you may only receive payment for what you can both remember and prove that you owned.

I once had a client that lost well over $100,000 worth of belongings when her 2-story home of over 40 years burned to the ground. Tragically, her husband perished in the fire. Would you believe her “top-notch” insurance company would only pay her for about $40,000 in property because that is all she could remember in her traumatized state of mind?

This is why I highly recommend you consider photographing, filming and listing all your possessions, or at least your most valuable ones, and keep copies (with receipts, owners manuals, and appraisals) in more than one location and/or in a fire and waterproof safe.

A fire at this time of year can really ruin your holidays, and let’s face it, no matter how well you plan for the disaster, or how well you can handle the insurance claim, your holidays will be forever marred by the fire. Your home will not be rebuilt in time to host family, and you may not be able to purchase all the gifts you would like to for the family, but surviving the fire is step 1, and dealing with the aftermath is step 2. Rather than dwell on what was lost, make the best of what you have, and look forward to what can once again be possible.

Image courtesy of flickr.com

I have a family I am working with right now, that suffered a fire very early in the season. It seems an

electrical fire began without warning in the garage, and quickly spread to the rest of the home. The home, and most of the contents, were badly damaged. This family will be without their home for the holidays, but they found a similar rental home just a few blocks away, and this is covered by most insurance policies (don’t let them stick you in a cheap hotel for an extended period of time).

And while they got out of the home safely, they escaped with little more than the clothes on their backs. Fortunately in this case, the insurance company gave them an advance on their claim for personal property, so they can buy needed clothing and other essentials without having to overextend themselves on credit cards. If you ever found yourself in a similar situation, and your insurance company refused to give you such an advance, I would take that as a bad sign of things to come. You should ask for an explanation in writing, and consider complaining to a higher level of management at the insurance company, if not the Department of Insurance in your State. You should also consider getting professional assistance on your claim.

What did happen in this case, once I was hired, was the insurance company immediately called the insured, questioned them for hiring me, and told them to check their agreement with me as they may still be able to cancel that agreement (in Florida, insureds have 3 days to cancel a Public Adjuster agreement). While highly unethical, it is not uncommon for insurance company representatives to try to prevent insureds from getting profession help (care to guess why?).

The other thing they did immediately upon notice of my representation, was agree the home was a total loss, so I would not be entitled to any fee based on that payment, which was fine with me. I was confident there would be other ways for me to assist the insured.

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Remember, not all disasters come with names and media coverage – or warning – like hurricanes do. The best time to be prepared is always…now! Also keep in mind you have rights, as well as responsibilities, that come with your insurance policy. If you are ever unsure of what those rights might be, all you have to do is ask. You can start by asking the insurance company, but if questions remain, I highly recommend you ask a true advocate, not someone hired by the insurance company to protect their interests.

Fires and other disasters can really put a damper on your holiday plans, but they don’t have to ruin your life.

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.