Ask The Public Adjuster About Insurance Claims: flood insurance

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The Calm After the Storm

by Mark Goldwich

Everyone talks about the calm before the storm when what they really should be forcused on is the calm AFTER the storm. In the wake of Hurricane Hermine last week, I wanted to talk about some storm insurance basics. First, a little about myself, just so you know I’m qualified to speak on the subject. I’m a Florida native, and have seen my share of tropical storms and hurricanes over the past 50 (or so) years. I have a Bachelor of Science degree in Insurance from the University of Florida, and my diploma is hanging on the wall behind me. I’ve been a licensed insurance adjuster in Florida since 1987. I spent 17 years with one of the country’s largest insurance companies, and personally handled or managed the handling of hundreds of thousands of claims, in many states across the country. In 2004, I decided to leave my job at the insurance company, start Gold Star Adjusters, and adjust claims for policyholders, not insurance companies. A few years later, after seeing too many terrible things happening to so many insurance claim victims, I wrote and self-published my first book, “UNCOVERED: What Really Happens After The Storm, Flood, Earthquake or Fire”.

So with that out of the way, here are some little-known facts about property insurance:

First, how do you think about your relationship to your insurance company? How many of you think of yourselves as a “customer”? Do you want to know what you really are? – You are a financial and legal adversary. That’s right. Now, if you have an insurance agent, especially an independent insurance agent, you may feel like a customer to them, and to be honest, they probably feel the same way about you. But to the claims department of the insurance company, as soon as you file that insurance claim, you are asking the insurance company to share their profits with you. To get an idea of how well that goes over with them, think about asking Microsoft to share profits with you the next time you buy a computer. Good luck.

Image courtesy of flickr.com

Did you know that although insurance is generally marketed as a “product”, your insurance policy is actually a legal contract? The insurance company writes the contract, and when you buy the insurance, you are accepting the contract. Did you also know that while you can’t negotiate how the contract is written, you can negotiate the settlement of a claim? The catch is, even if you knew you could negotiate the settlement, who do you suppose knows more about insurance? - the insurance company, or you, the policyholder?

Not only can you negotiate an insurance claim, but did you know you can re-negotiate a claim after it has been paid (or denied), or that you can re-open a claim years after it has been closed, or even after it has been denied? You can. In Florida, you have 5 years to pursue your claim...except after a windstorm or hurricane like Hermine. You see, while you weren’t looking, your insurance company, their lobbyists, and your state representatives quietly changed that a few years back. Now you only have 3 years to pursue your hurricane claim. Two years, gone, just like that. But again, even if you know this, how well are you going to do against the insurance company’s experts?

Did you know that just because your insurance company sends an official letter, complete with policy language or other legalese, stating your claim has been closed or denied, that doesn’t make it so? We get many of these denied claims paid every year.

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OK, now that you’ve learned a little more about the insurance industry than you probably wanted to know, let’s talk a little about how you can make the best of it, should you ever need to file an insurance claim (a lot of this comes from a section in my book, UNCOVERED, detailing my “10 commandments of claims”):

Know your insurance policy. Meet with your agent and have them explain it to you, and make sure you have the proper coverages, endorsements, limits, and deductibles, based on your individual needs.

Fill out the form below for your free copy.

Flood is not covered by homeowner’s insurance, so consider buying a flood policy.

Just because you’re not in a designated flood zone, doesn’t mean you won’t get flooded. Flood zone maps are created and updated by the federal government. If you trust their accuracy now, you may be one of 1000s filing for government assistance later. Think about it, we (especially in Florida) are surrounded by water. I don’t care what the flood map says, if you live in Florida, you stand a real chance of flooding.

Take photos or video of your property and valuable possessions, and store important documents where they can’t be damaged (the cloud, family, safe deposit box, etc.). These photos and videos could prove to be invaluable when it comes time to documenting your loss.

Don’t try to pull one over on your insurance company – be thorough, but honest. Many of their best adjusters work in their “fraud” units. It would be nice if their best and brightest adjusters were the ones paying claims, instead of being the ones denying claims, but that’s another story, and a testament to the priorities of the insurance companies. Inflating a claim is just not worth risking a felony conviction.

Take notes of everything that’s damaged and keep a detailed log of all conversations with your insurance company, your contractor, and everyone else. Show the adjuster all the damage and be as thorough as possible. If the adjuster doesn’t want to spend to time to review it all, make a note in your log, and have them (or someone else) come back when they have more time. Review the adjuster’s estimate in detail, until you understand it completely. Request a licensed contractor or other professional review the insurance company estimate and provide an independent quote.

If the insurance company refuses to pay for anything at all, demand they explain why – in writing. Even if they explain why in writing, get a second opinion. I can’t tell you the number of times we have gotten claims fully paid after the insurance company initially denied the claims, in writing, including the exact policy language they relied upon to deny the claim to begin with. My motto is, “the claim is covered until I say it is not”.

Be persistent and don’t give up. Appeal up the chain of command. Too many policyholders give up too easily, and as a result, I am convinced they leave many tens (if not hundreds) of millions of dollars in the insurance companies’ bank accounts every year.

And, lastly, seek professional assistance when needed. Whether from a public adjuster, attorney, contractor, engineer, politician, consumer reporter, or anyone else you think can help.

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.

The Calm After the Storm

by Mark Goldwich

Image courtesy of commons.wikimedia.org

So with that out of the way, here are some little-known facts about property insurance:

First, how do you think about your relationship to your insurance company? How many of you think of yourselves as a “customer”? Do you want to know what you really are? – You are a financial and legal adversary. That’s right. Now, if you have an insurance agent, especially and independent insurance agent, you may feel like a customer to them, and to be honest, they probably feel the same way about you. But to the claims department of the insurance company, as soon as you file that insurance claim, you are asking the insurance company to share their profits with you. To get an idea of how well that goes over with them, think about asking Microsoft to share profits with you the next time you buy a computer. Good luck.

Image courtesy of flickr.com

Not only can you negotiate an insurance claim, but did you know you can re-negotiate a claim after it has been paid (or denied), or that you can re-open a claim years after it has been closed, or even after it has been denied? You can. In Florida, you have 5 years to pursue your claim (except after a windstorm or hurricane like Hermine). But again, even if you know this, how well are you going to do against the insurance company’s experts? You see, while you weren’t looking, your insurance company, their lobbyists, and your state representatives changed that a few years back. Now you only have 3 years to pursue your hurricane claim. Two years, gone, just like that.

Get a free copy of my book.

Know your insurance policy. Meet with your agent and have them explain it to you, and make sure you have the proper coverages, endorsements, limits, and deductibles, based on your individual needs.

Fill out the form below for your free copy.

Flood is not covered by homeowner’s insurance, so consider buying a flood policy.

And, lastly, seek professional assistance when needed. Whether from a public adjuster, attorney, contractor, engineer, politician, consumer reporter, or anyone else you think can help.

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.

There Goes the Neighborhood

by Mark Goldwich

I can’t remember the last time I heard about an extreme weather event in West Virgina, but I sure did today. And if you were on any major news network, you probably saw it too. Video footage of an entire home, floating down a swollen river while ON FIRE! It was absolutely remarkable to watch - the power of the water, and the contrast of water and fire. It was just spectacular, but in the worst possible way.

Image courtesy of en.wikipedia.org

Now imagine you are the owner of that home. When you can finally return to your former neighborhood, which could be in just a few days, or it might not be for several weeks, it will be almost impossible to recognize. Street signs could be gone, major landmarks might be missing, and if you can find where your home used to be, we already know the home will not be there. Just a clean slab, next to several other clean slabs. It must be absolutely devastating to the mental state of the family.

For younger children, it might have been the only home they have ever known. For older kids, it might represent their childhood and friends. For the parents, it was where they started their family, and built their lives. And for older folks, it may literally be their entire world. But for all of them, it is time to start over, ready or not, but definitely not by choice.

So where do you start when that is not just something happening on the news, but it is your reality? My suggestion would be to start by reaching out to loved ones. Get help, if at all possible, because you are going to need it. And then, in no particular order, take pictures or video. Grab a pad of paper and start taking notes. List your activities and your expenses. Call your insurance agent and report the claim. Go online and learn what you can about what just happened to you, and what you can expect to go through in the coming months and years (note – I did not bother to include “days” or “weeks”, because that is simply not how you are going to be measuring this journey – sorry, trust me). Figure out what assistance is available to you (Red Cross, FEMA, etc.).

Image courtesy of flickr.com

And I would always recommend professional insurance claim assistance, but especially in this case, where you have damage caused by flood AND fire. Maybe you have insurance that protects against both flood and fire – it would be great if you did, but you could still use help to determine which policy you would want to use to cover which of the items damaged. Just knowing that could make a significant difference as to what damages you attributed to which policy. This alone could more than pay for the fee charged by the insurance adjuster.

But what if you only had insurance that would protect you against one of the two events (flood and fire)? Then you really are going to need help, because imagine this scenario: you have fire insurance, but your insurance company tells you ALL the damage to your property is caused by flood – even though there is plenty of news footage showing your home floating down the river, fully engulfed in flames. While I don’t think there would be an argument for the slab, or maybe even the flooring, or even the baseboards, I would certainly argue a lot of other items were damaged by fire alone. They could still argue if not for the flooding, there would have been no fire. They could also argue that even if the home never caught fire at all, the home and everything in it, would have eventually been destroyed by the flood. As you might guess, I would take on that fight every day of the week.

Conversely, if you only had a flood policy, but no insurance to cover your home for fire, they could argue the majority of the damage to your home, and the belongings inside, were damaged by fire and not flood. If so, I would simply argue the opposite. Is it wrong that I changed my position just like that? I would say no. My job is to fight for the insurance coverage you paid for, not to accept the exclusions they raise. You paid good money for that insurance coverage, and you certainly did not intend any of your premium to be spent on policy exclusions – those just seem to come free with the policy. So yes, quite plainly and openly, I will fight to find any applicable coverage I can, based on the facts of the loss. In other words, if two homes were floating down the river on fire, and one of them only had flood insurance while the other only had fire insurance, I would argue both should be covered, for opposite reasons. And if that sounds like I “want my cake and eat it too”, I’d counter that cliché with “what’s good for the goose is good for the gander!” Anyone who has ever had to wrestle with an insurance company over a claim knows exactly from where I speak.

Once coverage is secured, it is time to start proving your loss. This is going to be difficult as well, since there would be little left to identify, making it difficult to assign a value to it. But it has all been done before. It’s a step by step process, and it does take time, but with the right assistance, you can get back on your feet again. And one day (too long for most people to imagine), you are relocated to a new neighborhood, or your old neighborhood starts to slowly return. Here comes the neighborhood!

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.

Miracle March Means Madness For Many

by Mark Goldwich

Forecasters predicted El Nino storms could drench the Western US in general, and California in particular, calling for a “Miracle March” that could ease the current drought conditions there. And halfway through March, it looks like they might be – predictably – partially correct.

"This is going to put a dent into some of the drought, but it's not going to take it away by any stretch," San Diego-based meteorologist Mark Moede told NBC News earlier this month. But according to Erik Ortiz of www.nbcnews.com, “the return of the storms this month in parts of California has drawn parallels to 1991, when a "miracle March" that brought record rains staved off a water shortage. It was also credited with saving the ski season.”

Image courtesy of en.wikipedia.org

In the first week of March, heavy rainstorms struck California and flooded some low-lying areas, but much more rain would be needed throughout the state to counter years of dry weather. In the second week of March, another round of rains helped replenish water reservoirs, and above-average snowfall has extended California’s expected ski season beyond any of the last several years, but it is still too soon to tell if this will be enough.

And while rain and snow is certainly good for California as a whole with regards to drought relief and snow-related industries, each storm brings disaster to many individuals. During any significant rainstorm event, low-lying areas tend to flood rather quickly. It may be that only 100 homes and businesses are affected, and this may not even make local news, let alone the national news (especially in the midst of a wild presidential election cycle), but for those 100 families, their entire world has turned to mud.

Keep in mind, also, that during most severe rainstorms, there are high winds, hail, and even tornados that come with the many inches of rainfall. Throw in a few mudslides on California hillsides, and you have the makings of a disastrous “Miracle March” for many unsuspecting property owners. The storms so far have not been devastating, but streets have been washed out by floods, highways closed by mudslides – one such slide toppled a dump truck in the process – and homes have also been flooded or damaged by mudslides. The uncomfortable paradox is that much more rain is needed to make an appreciable impact on the drought conditions, but such rains would also bring misery to ever-increasing numbers of people.

Image courtesy of en.wikipedia.org

Having dealt with so many individuals and families suffering through property insurance claims from rainstorms and flooding, I know how difficult it is to recover. Homes are damaged or destroyed, personal belongings are ruined, people are separated and displaced from their homes, and dealing with all the insurance hoops, exclusions, loopholes, and delays can bring a whole new meaning to the phrase “March Madness”.

As always, it’s important to know they can recover, and they will recover. The question is, at what cost? How much aggravation will they have to endure? How much money will they recover – or how much debt will they have to take on? Typically, the answers to those questions depend on what they know, and how well prepared are they are to take on this challenge. I always say, the better prepared you are before disaster strikes, the better you will emerge from the disaster. This goes from having a disaster plan (before it happens), to having a recovery plan (after it happens).

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One thing is for sure, the insurance companies all have plans. And systems. And strategies. And resources. For you to compete, you need to have these plans in place as well, even if it just means knowing who has the plans, systems, strategies and resources to help you.

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.

Time to Break Out the Shovel

by Mark Goldwich

Image courtesy of pixabay.com

I’ve been seeing a lot of shoveling lately. Waves of major winter storm systems bring millions of tons

of snow, blanketing streets, cities, and even entire states. With news reports and headlines calling for “Snowmageddon” and “Snowpocalypse”, followed by images of snowplows, snowblowers, and plenty of snow shovels, the piles of snow seem to be never-ending.

“So how does insurance fit in with all the snow?” you might be asking. Actually, there are two ways.

Image courtesy of flickr.com

First, all that snow (and ice) causes extraordinary amounts of property damage in the form of auto accidents, trees and power lines downed by the weight of ice and snow, frozen pipes that rupture and cause extensive water damage, ice dams create roof leaks, the weight of ice and snow can actually collapse roofs, and so much melting snow causes flooding – I actually saw a 5 foot high ice flow move down a New Jersey street.

And secondly, the heaping mounds of snow is analogous to the mountains of red tape, hoops, delays and other slush insurance companies use to drown insurance victims in their time of need.

Water (that stuff snow eventually turns into) is one of the most powerful and destructive forces on earth (think Grand Canyon, Niagara Falls, and glaciers). I know it seems fairly harmless when portrayed as fluffy little flakes floating down from the heavens, but in accumulations large enough, and depending on variations in temperature, snow melts into water, freezes to ice, and melts into water again.

image courtesy of en.wikipedia.org

In the air, the thawing and freezing cycle can produce damaging hail. On roofs, this thawing and freezing can produce ice dams, allowing water to penetrate roof systems. Sometimes this damages the roof itself as well as the interior of the structure, and sometimes only damaging the interior, while leaving no trace whatsoever on the roof. This makes for an interesting “who-done-it” for insurance adjusters – after all, without proof, why should they believe the damage was caused by an ice dam, and not simply a matter of “wear and tear”? In pipes, the cycle is usually reversed – first freezing, and then thawing, which can inundate an entire home (just don’t call it “a flood” as that is not covered unless it meets the definition of “flood”, and you actually have a flood insurance policy). And outside on the ground, this thawing and freezing and thawing again cycle can lead to actual flooding, sometimes including large chunks of ice and accumulated debris rushing along in a torrent, destroying pretty much anything in it’s path.

By now you get the idea. Water can be very destructive, even when it starts out gently. And after you plow, dig, blow, and shovel your way out from the snow, you should also be prepared to shovel your way out from the ensuing insurance claim.

As I alluded to earlier, snow, ice, and water can be tricky substances. Think of all the riddles involving water in its various properties:

- Power enough to smash ships and crush roofs. Yet it still must fear the sun. (Ice)

- This old one runs forever, but never moves at all. No lungs nor throat, but still a mighty roaring call. (waterfall)

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Because water can take on 3 physical properties (solid, liquid, and gas) in relatively short order, it can appear to be here one day, and gone the next. So unless you have photos of it, it’s very existence can be difficult to prove (especially if the one you are trying to prove it to is not inclined to believe you to begin with).

As you might imagine, some insurance adjusters might use the elusiveness of water to minimize your claim of damages. Hailstones beating down on your roof like 10 million marbles (or golf balls) are almost always gone long before an adjuster ever sets foot on your roof. Depending on the size of the hail, the damage can be anything from excessive loss of roofing granules (tiny bits of “rock”) which protect the water-shedding shingle matting, to bruising of the shingle matting, to actual holes in the shingles. Naturally, the less obvious the damage, the more an adjuster may resist paying.

Image courtesy of commons.wikimedia.org

In the case of frozen pipe claims, many policies have exclusionary clauses requiring property owners to maintain sufficient heat at all times, or to drain the entire plumbing system. For some adjusters, the simple fact that you suffered a frozen pipe is evidence enough that you failed to perform your duties.

And as indicated above, in the case of ice dams, adjusters can claim there is no evidence to prove there ever was an ice dam (since it melted away). They could also claim the roof workmanship or maintenance was faulty. Think about it, exclusions weren’t put into insurance policies to be ignored. They are there to be used. And some like using them more than others. Even if they agree to pay for the inside water damage, they may not agree to pay for damage done to the roofing system when ice built up and crept ever-higher under shingles, causing creases, removing granules, or loosening nails.

Just be ready to dig yourself out from under a drift of insurance legalese, skeptical adjusters, and carrier-dependent engineers. Or, you may want to consider hiring an experienced consumer advocate. Like a dependable snow shovel, we can plow the way for your return to normalcy.

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.

Image courtesy of commons.wikipedia.org

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.

All is Right With the World of Claims

by Mark Goldwich

Recently I wrote posts about two claims I was handling. They were similar in that both cases

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involved strict denials, meaning that the insurance companies were saying the claims were not covered at all, in any way, for any amount, and they had very specific reasons, using verbiage selected from the insurance policies, detailing why the claims weren’t covered. They were also similar in that from my very first consultation with the insured, I could understand exactly why the insurance company would reach the conclusion they did, yet I did not agree with the insurance company in either case. Additionally, they were different in that the two claims were the result of completely different causes of loss, and the two claims were denied for completely different reasons.

In one case, the insureds suffered damage from a pipe breaking inside a home they recently purchased, but before they actually moved into the home. The insurance company could not see a way to otherwise deny the claim, until the insured mentioned they had not moved into the home, and it had been over a month between the date the home was insured, and the date the claim was reported. You see, there was some obscure (to most people, but not to the insurance company) language in the policy that said there would be no coverage for water damage if the home was vacant or unoccupied for over 30 days (heads up for anyone that has any home, rental property, business, or other property).

image courtesy of en.wikipedia.org

To most people, hearing the bit about there being a month between buying the home and reporting the claim would have been meaningless. After all, what is a month in the scheme of home ownership? And besides, it’s not really that uncommon to purchase a home, but not move in right away because you haven’t sold your prior home yet, and sometimes the new home is not “move-in ready”. That’s how most people think, anyway. But to most insurance adjusters, the mere mention of that month is like waving a red cape in front of a bull. It triggers some pleasure receptor in their brain, instantly bringing them back to a day in claim training when an instructor said something about a policy exclusion for losses to properties vacant or unoccupied for at least 30 days. They are suddenly curious, but only inasmuch as the answers continue to trigger those pleasure receptors.

So once the adjuster’s “investigation” confirmed the sale date of the new property, the fact that they did not move into the new property right away, and the approximate date of loss being beyond 30 days from the sale date, they had all they needed to keep those receptors firing in their brain, and their sense of curiosity quickly fades away. Their work is done. They can close that file with a form denial letter, and move to the next claim in a tall stack of claims.

image courtesy of pixabay.com

Until, that is, until they get my letter, explaining that they overlooked a key piece of information in

their “investigation.” What they missed was the fact that the insureds did not just purchase the home and not move in, the husband stayed in the home after the purchase for a few weeks to work on it and prepare to move in, while the wife returned to the prior home to prepare it to move out. With just those few weeks taken into account, the time the home was unoccupied was reduced to about 3 weeks. Initially, the carrier simply replied that they were standing by their decision to deny the claim.

After another letter explaining their error, they re-opened their investigation, and requested proof of when the loss actually occurred. Fortunately, this loss was discovered by the local utility company at the new home when they went out to read the meter, so we knew the leak occurred on or before the date the meter was read. Once we got that information in writing from the utility company to the carrier, they agreed to pay the claim, which totaled over $35,000.

In the other case, extremely heavy rains caused water to enter the insureds’ home as they slept, by filling up a unique atrium room within the home. The water could not escape the holes built into the exterior wall of the atrium fast enough, and the water rose until it was able to pass under the French doors leading from the family room to the atrium.

In this case, multiple triggers starting firing on those receptors. Words and phrases like, “flood”, “surface water”, “subsurface water”, “rising water”, “design defect” and “no opening created” overwhelmed their pleasure receptors and once again, true curiosity failed to take root. This one was easy, they no doubt thought, it’s simply not covered. The form letter went out, and the claim was closed.

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Again, that is, until the insurance company got my letter explaining they had misinterpreted their own insurance policy, whether as an innocent mistake, or something more nefarious. As the coverage question in this case was more complicated, it took more letters, and phone calls, and a demand the matter be mediated via a State mediation program, and frank discussions about attorneys getting involved and how other similar cases were ultimately ruled on by various courts – but we eventually settled this case as well. While the dollar amount on this claim was less than the other, I was happier about this resolution because the coverage issue was more contested. It took more research, and more negotiation efforts, but I felt strongly that we were right, and they were wrong. Now, the settlement agreement will say the insurance company does not admit they were wrong… but I know.

Being passionate about what I do for a living makes it worthwhile, even when things don’t always go my way. Fortunately, that doesn’t happen often. But when the stars align and multiple cases go our way, as they usually do, it feels even better! For now, all is right with the world (of claims).

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.

Not Ready for Prime Time (viewer discretion advised)

by Marc Goldwich

I was reviewing the headlines this morning which were chock full of mayhem. Everything from the aftermath of catastrophic flooding which resulted in numerous drowning deaths in the South Carolina, to more school shootings, along with a smattering of auto-related fatalities vied for my attention. This combined with Halloween being just around the corner was enough to cause my mind to entertain the dark side of life. So I began thinking about the job of cleaning up after a catastrophe.

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In case you're not aware, there is an entire industry set up for handling these kinds of events. Typically called “Biohazard Clean-up” or “Crime Scene Clean-up”, these companies are e an offshoot of emergency restoration companies. Whether the hazard you need gone consists of toxic waste, deadly mold, body fluids or most any other kind of nasty stuff that crop up after an emergency, there are trained professionals who are only too happy to roll up their sleeves and dive right in.

The hit Discovery TV show “Dirty Jobs” is a favorite of mine, but I doubt you will ever see Mike Rowe tackling this type of job. While certainly “dirty” enough, my guess is it would simply be too disrespectful to find any humor in this line of work, and for his show, humor plays a major role.

There are other shows which depict and deal with death, usually CSI or homicide, but I have never seen one address the clean-up aspect that invariably needs to take place after the police finish their investigation. Since you can now watch shows on just about any occupation imaginable, I would not be surprised to find a show following biohazard clean-up teams around.

So what would that entail? First let’s think about the types of situations these companies and their crews might deal with. Things like:

- Sewage backups

From commons.wikimedia.org

- Crime scene residue

- Suicide

- Homicide cleanup

- Blood cleanup

- Accidental death cleanup

- MRSA and H1N1 decontamination

- Hoarding scenes

- Animal waste/remains

- Chemical spills

- Tear gas cleanup

- Meth lab cleanup

- Radiological hazards

None of these events should be taken lightly, or undertaken by anyone except certified biohazard professionals. Not that most people would want to deal with any of these problems

These companies need to be well versed in applicable state and federal regulations, they need to be licensed and certified (where required), they need to use appropriate transportation and/or disposal protocols, and they may need to be registered with the states’ Department of Health. These companies can also expect to be regulated by governing and advisory bodies such as OSHA (Occupational Safety and Health Administration), NIOSH (National Institute for Occupational Safety and Health), DOT (Department of Transportation), and EPA (Environmental Protection Agency).

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The dirty work of these professionals usually begins when the coroner’s office, or other governmental entity officially releases the scene to the property owner or other responsible party. Depending on the type and severity of the “event”, the clean-up teams are required to wear protective clothing, may seal off rooms to prevent or minimize the spread of airborne or physical elements of the bio-hazard scene, and follow specified methods and practices to decontaminate such scenes.

The scenes must be meticulously cleaned of all harmful material, which typically includes the removal of any porous materials (whether personal belongings like clothing and sheets, or building materials such as carpeting, wood subfloor, or drywall) – which must all be properly disposed of, and then sanitized. You can only imagine the mess that will be left, even after the mess that was the biohazard is removed.

And many people are so distraught after dealing with such a loss, that they overlook the fact that insurance may cover the expense of the clean-up efforts. Just remember this rule of thumb, if property is damaged as a result, it is probably covered by insurance (either yours, or someone else’s).

ServPro.com provided the following bio-hazard and sewage emergency tips:

After any biohazard or sewage contamination in your home or business, your primary focus should be safety:

- Is it safe to stay in the house?

- Exposure to biological and chemical contaminants can pose serious health consequences.

- Flood water can contain sewage, pesticides, and other contaminants.

- Only do activities that are safe for you to perform.

Image courtesy of aftermath.com

What to Do After a Contamination

- Stay out of affected areas.

- Call emergency service personnel if the situation is life-threatening.

- Treat all bodily fluids as if they are contaminated.

- Turn off the HVAC system if there is sewage damage.

What Not to Do After a Contamination

- Don’t leave wet fabrics in place. Hang furs and leather goods.

- Don’t leave books, magazines, or other colored items on wet carpet or floors.

- Don’t use your household vacuum to remove water.

- Don’t use television or other household appliances.

- Don’t turn on ceiling fixtures if ceiling is wet, and keep out of rooms where ceilings are sagging.

Let’s all hope we never need these tips, but as we can plainly see from watching the news, the fact is, biohazard clean-up is a grim reality for many families. As with anything else, the more you know in advance of an emergency, the better equipped you will be in handling that situation.

In this article I discussed the subject of biohazard clean-up, and the professionals that are trained to perform what just might be the dirtiest job of all. I mentioned some of the types of events this might involve, and included tips for dealing with such an event.

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.