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