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Insurance Coverage

Gherman Law Practices
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Insurance Coverage

Do not let your insurance company betray you when you need them most. After you pay your premiums months after months and after months, your insurance company undervalues or denies your claim claim? It is unfair and adds an insult to an injury. This firm's lawyers recovered hundreds of thousands dollars for their clients: experience matters.

The Top 10 Worst Insurance Companies: how they raise premiums, deny claims, and refuse insurance to those who need it most, as found by the American Association for Justice: 1. Allstate     2. Unum     3. AIG       4. State Farm       5. Conseco       6. WellPoint        7. Farmers  8. UnitedHealth          9. Torchmark           10. Liberty Mutual
The U.S. insurance industry has $3.8 trillion in assets -- more than the GDPs of all but two countries in the world (U.S. and Japan). Over the last 10 years, the property/casualty insurance industry averaged over $30 billion a year in profits. So did life and health insurance industry.

Our present-day environment and the governmental shift in policy as to the distribution of risk in our society present insurers and insureds with unique challenges.  Our office works closely with clients to minimize exposure and to achieve rational solutions to difficult legal questions in the insurance area.

We litigate the issues of coverage in substantive areas such as:

  • Auto
  • Homeowners & Windstorm
  • Accident and Health
  • Life
  • Title
  • Directors’ and officers’ insurance
  • Commercial general liability
  • Long-term care
  • Excess and umbrella policies

Our office resolves disputes based on “bad faith” claims, including Coblentz and Cunningham agreements associated with “bad faith” litigation.

We analyze the issues of insurance contract formation, its terms, and its enforcement.  Our analysis spans everything from the triggers of coverage to allocation of losses among policies, to uninsured or underinsured parties.

Homeowners' and Windstorm

Homeowners' insurance is a specific type of property insurance, that covers both damage to the insured's residence and liability claims made against the insured, such as arising from the insured's negligence. Homeowners' insurance covers damage or loss by theft and against perils which can include fire, and storm damage. It also may insure the owner for accidental injury or death for which the owner may be legally responsible. Mortgage lenders usually require homeowners' insurance as part of the mortgage terms. Homeowners' insurance can specifically refer to the insurance of a house, but also encompasses the insurance of other types of structures associated with personal residences including tenants (renters) and condominium unit owners. The courts reviewing a homeowners insurance dispute generally agree that “insurance contracts must be read in light of the skill and experience of ordinary people, and given their everyday meaning as understood by the ‘man on the street’.”

Not all storms are created equal. Depending on the type of storm—and when it occurs—different elements of the damage wrought may be covered. If the windstorm is a named hurricane or tropical storm, the insurer will pay for virtually any exterior damage, other than paint, caused by the hurricane's winds. Internal damage undergoes a different analysis. If the windstorm is a named hurricane or tropical storm, then any structural damage caused by elements driven into the inside of the home is covered, regardless of how it entered the property. However, the wind insurer will only pay for personal property damaged by the named storm if the wind damaged the outside of the home, causing an opening through which the wind or wind driven rain and debris entered.

Windstorm and homeowners policies exclude “flood” as a covered peril. Terrestrial forms of water are also excluded, regardless that the wind blew such water onto the insured's property. “Flood” is covered through policies issued from the National Flood Insurance Program run by the federal government.

Auto

The auto coverage can include loss or damage to the vehicle itself, which is evaluated at replacement or repair damage cost, actual cash value, or agreed value. It can also include loss, liability, or expense as a result of ownership, maintenance or use of any such vehicle. The auto coverage also includes medical, hospital and surgical benefits to injured persons, funeral and death benefits to survivors irrespective of legal liability if incurred while in, upon, entering into, alighting from, or being struck by a vehicle if such coverage is issued as part of a liability insurance contract.

There are several types of automobile insurance for private passenger automobile coverage. There are auto policies for businesses. These include policies insuring vehicles with load capacities over 1,500 pounds, insuring more than four vehicles, garages, automobile dealers, repair shops, service stations and public parking places.

Accident and Health

Accident & Health insurance must provide benefits to the insured for treatment as the result of illness or injuries. Accident & Health insurance varies significantly by coverage. Basic Medical Coverage usually includes coverage for hospital stays (a portion of room and board), and surgical and medical costs associated with treatment. Basic coverage usually pays a fixed amount to providers based on a "usual, reasonable and customary" standard. In addition to the basic benefits, Major Medical Coverage may pay for a portion of blood transfusions, prescription drugs, and out-of-hospital costs, including doctor's visits.

Accident & Health insurance can also vary by delivery method. Traditional Health (or indemnity coverage) typically allows the insured to select any doctor or hospital and reimburses a portion of these costs. Managed Care plans usually involve a network of doctors and hospitals, and provide financial incentives to utilize the network; each plan has different reimbursement and costs schedules for "out-of-network" providers. Some managed care arrangements include: Health Maintenance Organizations (HMOs), Exclusive Provider Organizations (EPOs), Preferred Provider Organizations (PPOs), and Point-of-Service Plans.

In the context of health insurance disputes, potential causes of action may include breach of contract, intentional or negligent misrepresentation, intentional infliction of emotional distress, bad faith, breach of fiduciary duty, vicarious liability, and other statutory actions. One must consider the ERISA, FEHBA and PPACA preemption as well.

Life

Life insurance is an agreement between an insurance company and the policyholder to pay a specified amount to a designated beneficiary on the insured's death. Life insurance provides a death benefit for an individual's beneficiaries. It allows survivors to pay off debts and other expenses; it can also provide a source of income to replace that lost by the death of the insured. There are two primary types of life insurance: term, which provides insurance for a specified period of time at a lower cost; and permanent, which provides a certain amount of coverage at variable rates. Term life covers the insured for only a specified period, and pays a fixed benefit to a named beneficiary upon the insured's death but is not redeemable for a cash value during the insured's life. Whole life covers an insured for life, during which the insured pays fixed premiums, accumulates savings from an invested portion of the premiums, and receives a guaranteed benefit upon death, to be paid to a named beneficiary. Whole life policy may also provide that at a stated time, premiums will end or benefits will increase. There are other variations, including universal life, which builds cash value and is widely marketed by life insurance companies.

Title

Title insurance is an agreement to indemnify against loss arising from a defect in title to real property, usually issued to the buyer of the property by the title company that conducted the title search. Title insurance is peculiar since there is only one premium payment, the policy protects the owner theoretically forever against claims asserted by others, and the insurers normally exclude known risks from coverage under the policy. Title insurance insures owners of real property, or lenders using real property as collateral, against loss arising out of defective or invalid titles and the existence of other liens or other legal claims against titles to real property. Title insurance can provide similar coverage regarding personal property. 

Long-term care

Long-Term Care Insurance is purchased in advanced of a persons disability or infirmity, which leaves a person unable to perform some or all of the Activities of Daily Living (walking, eating, dressing, bathroom needs, or mobility).

Long-Term care covers the cost of day-to-day care and treatment at home, in an assisted-care living facility or in a full-time nursing facility, and includes a wide range of medical, personal and social services. Long-Term Care includes services provided by home health care agencies, adult day care centers, traditional nursing homes, and continuing care retirement communities. These policies vary in coverage, but will normally pay a fixed-dollar amount or the actual costs of care up to a specified dollar amount, for a specified length of time and kind of care.