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Last Post 01/05/2008 6:12 PM by HuskerCat
Christmas time claims handling
32 Replies
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Leland Advanced Member Posts:741  
| 12/21/2007 2:44 PM |
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Risk location is a two story residence with 25 yr asphalt comp roof. Insured claims that a big fat man yelling "ho ho ho" somehow landed a sleigh with 12 reindeer on the roof, damaging it. The reindeer hooves dislodged several shingles. At the time the weather was calm with no wind. A neighbor witnessed the fat man trying to enter the chimney. He was unsuccesful, but the blocking of the chimney caused smoke to fill the entire interior. The actual sleigh did not cause any damage to the roof. The sleigh fell off the roof, landing in the no parking zone in front of the dwelling. When the police arrived they placed a ticket on the front seat of the sleigh for parking in a no parking zone, not having working lights, not having current vehicle registration, and hit and run. The fat man subsequently jumped back in the sleigh and took off through the air. As he flew back over the roof, a sudden gust of wind pushed the sleigh into a television antenna, tearing it off. During the recored interview with the insured it was revealed that the insured had written a letter to a Mr. Santa Claus, ordering him to come to the home and deliver a lump of coal to the insured's minor child. The insured admitted that he had also made a $100 payment for the requested lump of coal.
Coverage is provided under the DP1 (named peril) policy form.
What part, if any, of this claim would you cover, and why?
What part, if any, of this claim would you deny, and why?
I will post the relevant policy sections- just ask.
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| 12/21/2007 3:02 PM |
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Send it to SIU
JWG
I know the voices aren't real, but sometimes they're right!
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Ray Hall Senior Member Posts:2443
| 12/21/2007 8:37 PM |
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The DP1 is an ACV policy. The VEHICLE damage to the roof would be covered. The smoke damage to the interior smoke damage to the rooms would be covered as the heating device was connected to a chimney. No coverage for the parking and vehicle fine's as this is not a named peril. Do not recall if the DP1 has a Ded. on all perils or just windstorm, hurricane and hail. So probably no Deductible. The TV antenna is excluded for windstorm and this was the proximate cause of its distruction. Santa would be a third party vendor as he charged $100.00 for the lump of coal, and none of his property is covered as he was not an "insured". What did I leave out ?
back soon.... I,m back, but I think I missed a hidden question in this post.
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| 12/22/2007 8:59 AM |
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Looks like the public adjusters in South Florida have a new seasonal scam! Heck, beats cracked floor tile claims! |
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| 12/22/2007 10:16 AM |
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This would raise several questions that probably could not be answered here. Would the sleigh be considered an automobile or aircraft or falling object. The lawyer for the insured will obviously argue that the damage was caused by the sleigh and not the reindeer. Is this a condo, hence the "no parking" zone. Since the fat man and reindeer are unavailable for the foreseeable future, and unwilling to give a recored statement, (also considered by some in the neighborhood to be "mythical"), could this damage be self inflicted? And really, who has an antenna these days? Are the photos available for review? Obviously not a Texas claim, hence no mention of one of the deer being mounted and on display in the insureds home. Another question I would have is if the alleged sleigh magically flew away, how and why would it just fall off the roof?
Just a few questions, but I'm like that,
JWG
BTW, my wife would like to point out that most fat men in sleighs are pulled by 8 or possibly 9 tiny reindeer, depending on th weather of course, not 12. She even has their names if needed for verification. I know the voices aren't real, but sometimes they're right!
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LelandAdvanced Member Posts:741
| 12/22/2007 12:44 PM |
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I mentioned the ticket placed by the police because I think that detail is relevant to determining whether the sleigh is a vehicle. Since the policy does not define "vehicle" but a law enforcement agency clearly believes it to be a vehicle, I think it would be smart for the adjuster to agree that it is in fact a vehicle. Certainly the case could be made that it is an aircraft, but as long as it can also be reasonably considered a vehicle, I think a good faith analysis of the facts requires the benefit of the doubt be given and the sleigh be considered a vehicle, which might trigger coverage for the peril of "vehicle damage". Are the reindeer, which pull the sleigh, also part of the vehicle? In other words, should damage caused by the reindeer be considered "vehicle damage"?
On a named peril policy like the DP1 there is often coverage for vehicle damage but not for damage from animals. It is rare nowdays but you can still see Clydesdales running around with beer wagons or horse pulled carriages in New York Central Park. The Amish also come to mind. If a horse, connected to a carriage, damages the dwelling, would that be covered? What if the impact is from the horse only, and the actual carriage does not hit the house?
There is, however,another issue here which I think might result in a total denial of the claim, regardless of whether the reindeer damage is determined to be "vehicle damage". I will mention this issue later, maybe someone else will post it first. A key factor in this particular issue (in my opinion) might revolve around whether Mr. Claus was bringing any unsolicited presents in addition to the lump of coal. It might also be helpful to verify if he was visiting other homes in the area, perhaps on a route, rather than making a detour to this one particular house.
On another note it is interesting that Ray Hall points out that the wind was the proximate cause of the damage to the antenna, triggering a denial for that portion of the claim. It is true that "but for" the wind, the sleigh would not have hit the antenna, but couldn't it be considered vehicle damage anyway? Or would that matter? Is antenna damage excluded no matter what the cause, or just for wind. I need to look that part up. I will post the wording. If the antenna is in fact excluded, would you cover the repairs to the shingles where the antenna ripped out of the roof, or would that also be denied?
Also this brings up the issue of wind vs. windstorm. I believe the policy covers "windstorm", not plain ordinary wind. If anyone has experience with claims on a named peril policy where wind damage wasn't covered because it wasn't a "windstorm" I would really like to hear about it.
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Ray HallSenior Member Posts:2443
| 12/22/2007 1:46 PM |
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Any visable wind damage has always been the criteria for windstorm as its too hard to disprove if you can see damage from wind on the building. |
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HuskerCat Veteran Member Posts:762
| 12/22/2007 3:50 PM |
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"When out on the lawn there arose such a clatter,"
Here's your covered named-peril... It's a civil commotion!
In the spirit of giving, everything would be covered except the TV antenna which is specifically excluded property. |
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LelandAdvanced Member Posts:741
| 12/22/2007 5:02 PM |
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DP001
“2.) Windstorm or Hail
This Peril does not include loss:…..
b) to the following when outside the building:
1)Awnings, signs or radio or television antennas or aerials, including lead-in
Wiring, masts or towers….
It appears that the antenna would not be covered under the wind peril.
However, it does appear that the antenna could be covered under the “Vehicle” peril. The vehicle peril has only two exclusions: for vehicles owned by the insured or a resident or for damage to fences and walkways. It seems to me that since the antenna was hit by a vehicle, regardless of whether the wind was a contributing factor, the antenna damage should be covered. After all, “vehicle” is a peril all by itself, whether or not wind was also involved.
I would also tend to consider the reindeer hoof damage as covered under “vehicle”, since the reindeer were connected to the sleigh which was technically a vehicle.
Ray- you posted: “The smoke damage to the interior smoke damage to the rooms would be covered as the heating device was connected to a chimney.”
“Smoke” is a peril in my DP1 but it says:
“Smoke, meaning sudden and accidental damage from smoke. This peril does not include loss caused by smoke from fireplaces or from agricultural smudging or industrial operations.”
Therefore it appears that the smoke damage can not be covered under the peril of "smoke" as it came from a fireplace.
Another peril we might consider is Vandalism & Malicious Mischief. In California, this peril is often interpreted very generously. Some strange guy landing on your roof to deliver a lump of coal would likely be covered as VM&M. Even if a visit from Santa is a beloved historical tradition, why would it not be VM&M just as if teenagers threw toilet paper all over the house? Also, in this case he was there to bring a lump of coal, which is not a very nice thing for the recipient.
If VM&M applies, then the smoke damage can be covered under the VM&M peril, even if it doesn’t get coverage under the “Smoke” peril. (The “smoke” peril excludes fireplace smoke but the VM&M peril does not exclude smoke for any reason. For example: water pipes bursting is specifically excluded. If however, the pipes burst due to a vehicle, a vandal, a riot, a burglar etc, the water damage is routinely covered. If anyone disagrees, please post)
But now I have drifted very close to the reason I think the whole claim would be denied, regardless if the damage was cause by one or more covered perils. I think the answer is under “General Exclusions”. In my opinion the entire claim could be denied under one of the “General Exclusions”.
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LelandAdvanced Member Posts:741
| 12/23/2007 12:41 AM |
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I enjoy starting these kinds of topics because I end up learning so much myself. One subtopic here is "wind" vs. "windstorm". Ray Hall says "Any visable wind damage has always been the criteria for windstorm as its too hard to disprove if you can see damage from wind on the building." I suppose thats always true for most storms but I can think of 3 claims here in California where it wasn't so clear cut. One of mine was a tree that had some rot and fell over in the wind. There was a very localized "windstorm" that never hit the news. I documented it by getting a printout from some weather website, and the fact that other items were also blown over by the same strong wind. Another claim I heard about was from an agent I've known many years. His insured had the wind blow in his front picture window but again, it was a very localized wind gust. The claim was denied for not being a "windstorm". The insured went to small claims. Here's a defintion from an insurance company that sounds surprisingly similar to the defintion of "flood": "Note that the wind must reach sufficient velocity to have caused direct damage at more than one location to establish a "windstorm" loss. However, leakage through an aging roof during heavy rain is not a basis for a windstorm claim. The windstorm peril does not cover loss to the following property when located outside of the insured building: awnings, signs, radio or television antennas or aerials including wiring, masts or towers; canoes and rowboats; lawns, plants, shrubs or trees. Back to More Information " Here's an interesting Wyoming case where it apprears the appeals court ruled against the insurance company for denying a wind claim for not being strong enough to be a "windstorm". http://wyomcases.courts.state.wy.us...iteID=1629 cited by the court: In the case of a policy against damage by tornado, hurricane, or windstorm, the words 'tornado' and 'hurricane' are synonymous and mean a violent storm distinguished by the vehemence of the wind and its sudden changes. The word 'windstorm' partially takes its meaning from 'tornado' and 'hurricane,' and indicates wind of unusual violence. A 'windstorm' need not have either the cyclonic or the whirling features which usually accompany tornadoes or cyclones, but it must assume the aspect of a storm, that is, an outburst of tumultuous force." noted but disregarded by the court: "an ordinary gust of wind, no matter how prolonged, is not a windstorm." The courts conclusion re windstorm: We think the correct standard and applicable to the instant situation is stated in Gerhard v. Travelers Fire Ins. Co., 246 Wis. 625, 18 N.W.2d 336, as follows: "In the absence of definition or limitation in the policy, we think that a windstorm must be taken to be a wind of sufficient violence to be capable of damaging the insured property either by its own unaided action or by projecting some object against it. This is especially true where, as here, the more violent forms of windstorm are specifically named as something different from a mere windstorm. Any other view would work an imposition upon the insured. If defendant wishes to adopt some scale which establishes the velocity of wind necessary for a windstorm, or if it desires to limit its liability beyond the point that we have indicated, it should incorporate its proposed standard in the policy by clear terms and such ambiguities as are left in this policy should be resolved against it." ¶7 Considering the purpose of the coverage and the field of the risk, it would seem that any wind that is of such extraordinary force and violence as to thereby injuriously disturb the ordinary condition of the things insured is tumultuous in character, and is to be deemed a windstorm within the purview of the policy, in absence of a provision therein to the contrary. ¶8 An example of judging the quality of the wind by its effect is to be found in Atlas Assur. Co., Ltd., v. Lies, 70 Ga. App. 162, 27 S.E.2d 791, where the court approved an instruction of the trial court wherein it is declared "if you find that the wind blew hard enough to blow a tree down, then that would be the same as a windstorm, if the wind was that hard." We do not hold that the blowing down of the plum tree above referred to establishes the fact of a windstorm as a matter of law, but we do hold that fact to be competent evidence touching the force and violence of the wind and that same together with other matters herein recited were sufficient to sustain the finding of the jury that a windstorm was the proximate cause of the falling of the roof. ------ So it really isn't that clear cut that wind always equals windstorm but this Wyoming court seemed to think so. Anybody else have experience on this topic, "wind" vs. "windstorm"?? |
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| 12/24/2007 4:17 AM |
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Dennis Mclure appears to have a problem with Public Adjusters. The way I look at it, if you have a problem with cracked floor tiles claims, then have the company exclude them or limit them. However, until then, pay the claim and quit your japping!
There would be no need for Public Adjusters if Independant Adjusters, COmpany Adjusters, and Examiners would all do thier jobs correctly. I have been doing clean-up duty for many cat-adjusters since Hurricane Wilma hit in Florida Especially from Texas Adjusters.
Besides, the business is big enough for all of us. We all have to work together so...in the elegant and subtle words of Rodney King, "Can't we all just get along?"
Can't answer the question. I have yet to handle a DP1 claim and until I do, don't care to look at the policy.
MERRY CHRISTMAS to all!!!
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Ray HallSenior Member Posts:2443
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HuskerCatVeteran Member Posts:762
| 12/24/2007 7:16 PM |
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I think Mr Santos missed the entire point of Dennis' remark about the cracked tile flooring (a topic of discussion either here or on Claimspages). If it's the one I'm thinking about, it had to do with cracked & missing tiles in a rental under a DP. There was no consistency in the areas of cracking, and the landlord wanted to attribute it to vandalism when it was obviously hard use or neglect on the part of the tenant(s) over a period of months/years. Mr Santos' suggests that the insured in question was cheated, without even knowing what the facts of the loss are or what the policy language is.
DP's are the most basic of any HO coverage, and if you haven't seen or heard of them prior to handling any claims...one wonders. This whole thread was, I believe, intended as a fun little exercise by Leland...but once again a PA has taken undue offense and then also showed why some statements are made toward the PA field. Please don't tell us how bad someone did their job, and then admit that you've never even seen a particular coverage form, nor care to see it.
Merry Xmas to all, and to all a good night! |
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Tom TollModerator & Life Member Senior Member Posts:1865 
| 12/25/2007 7:31 AM |
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quote from gustavo santos:
[Besides, the business is big enough for all of us. We all have to work together so...in the elegant and subtle words of Rodney King, "Can't we all just get along?" Can't answer the question. I have yet to handle a DP1 claim and until I do, don't care to look at the policy. ]
Mr. Santos, I suggest you review Rodney Kings past since his first encounter with the law. You will find his words a little deceitful, as he has been arrested on numerous occasions since his first public outcry. As far a being critical of PA's, I believe you misunderstood what was being said. I did not realize that PA's did clean up duty behind cat adjusters. By the way, I have done, for many years, estimate clean up duty behind PA's.
Yes, we all have to live and work together, but lets keep the arena clean and fair.
Success is not final, failure is not fatal: it is the courage to continue that counts.
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Tom TollModerator & Life Member Senior Member Posts:1865
| 12/25/2007 7:34 AM |
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To All My Secular Progressive Friends:
Please accept with no obligation, implied or explicit, my best wishes for an environmentally conscious, socially responsible, low-stress, non-addictive, gender-neutral celebration of the winter solstice holiday, practiced within the most enjoyable traditions of the religious persuasion of your choice, or secular practices of your choice, with respect for the religious/secular persuasion and/or traditions of others, or their choice not to practice religious or secular traditions at all. I also wish you a fiscally successful, personally fulfilling and medically uncomplicated recognition of the onset of the generally accepted calendar year 2008, but not without due respect for the calendars of choice of other cultures whose cont ributions to society have helped make America great. Not to imply that America is necessarily greater than any other country nor the only America in the Western Hemisphere . Also, this wish is made without regard to the race, creed, color, age, physical ability, religious faith or sexual preference of the wishee.
To All My Christian Friends:
Merry Christmas and a Happy New Year! Success is not final, failure is not fatal: it is the courage to continue that counts.
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LelandAdvanced Member Posts:741
| 12/26/2007 3:16 PM |
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Let’s get this forum back on track.
Sure my scenario was a bit light-hearted but it’s not that different from a daily claim any of us could be assigned.
Just to make clear I didn’t write up the post with a pre-conceived answer already thought out. I’m thinking this one through myself, and learning as I go.
I think these are the relevant issues:
Causation & Coverage
As this is a named peril policy, we need to determine if the loss is covered under one or more of the named perils including: (partial list)
1) Fire or lightning
2) Windstorm or Hail
3) Aircraft
4) Vehicles
5) Smoke
6) Vandalism or Malicious Mischief
Just reviewing this list I realize I made an error in not considering the possibility of “aircraft” as a peril.
We have established that the sleigh can be considered a vehicle, but it could also be considered an aircraft. Certainly there do exist a very few amphibious cars which are both vehicles and boats. Santa’s sleigh could be considered both an “aircraft” and a “vehicle”, at least under this fact scenario. It might not make much difference in this particular case but damage to fences is not covered under the “vehicle” peril but would be under the “aircraft” peril.
Another peril I failed to consider is “fire or lightning”. The dwelling suffered smoke damage but there was an actual fire in the fire place. Obviously the “smoke” peril covers smoke damage even when there is no flame but could smoke damage also be covered under the “fire” peril? If so it would avoid the “smoke” exclusion “this peril does not include loss caused by smoke form fireplaces…”
The “vandalism or malicious mischief” peril definitely is a possibility for coverage.
The issue I was thinking might trigger a denial for the whole claim is this:
General Exclusions
Intentional Loss, meaning any loss arising out of any act committed:
a) by or at the direction of you or any person or organization named as an additional insured; and
b) with the intent to cause a loss.
I realize now I didn’t read that real carefully- I missed the “AND” between “a” and “b”. Clause “a” is true but “b” is not, so this exclusion does not apply.
As I said I’m thinking this one through as I go.
So here’s my tentative conclusions:
The roof damage falls under the peril of “vehicle” and/or “aircraft”. I am considering the reindeer to be part of the “aircraft” or “vehicle”.
I would probably submit the damage to the antenna as a question to the company- can this be paid under “windstorm” or not?
The smoke damage might be covered under “Fire” or VM&M, but not under the peril of “smoke” due to the fireplace exclusion. I am going to think about three questions: 1) Does the peril of “fire” also cover smoke damage in this hypothetical? 2) Does Santa Claus, entering the chimney as an “invitee”/hired vendor constitute VM&M? 3) Can all of the damages (antenna, smoke, roof) be paid under VM&M?
I would love to see responses from adjusters that have had similar issues such as these on previous claims.
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LelandAdvanced Member Posts:741
| 12/26/2007 3:20 PM |
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Another mistake on my part I just noticed- if the sleigh is an "aircraft" it doesn't matter if there was a "windstorm"- the antenna damage is covered. Also I forgot that antennas are excluded anyway under "windstorm", so the "windstorm question is moot.
Another question relating very closely to which peril(s) applies- would you apply more than one deductible to this claim??
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HuskerCatVeteran Member Posts:762
| 12/26/2007 6:40 PM |
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Xmas is now over, so there are no gifts for the insured any longer. The only coverage that exists is for "vehicle" damage to the antenna, if we disregard the possibility of wind as the proximate cause. And, this is assuming that the antenna was struck by the sleigh, and not the reindeer.
Smoke from a fireplace is specifically excluded, and the intervening cause of Santa's rotundness plugging the chimney doesn't matter because it does not fit any named peril. The scenario doesn't state "fire" damage, just smoke from the friendly fire after the intervening event.
Shingle damage from reindeer hooves...no coverage, again not a named peril. They are not a vehicle in and/of themselves. Think of them as having been there without a sleigh.
The intentional act exclusion has no bearing. The only intent was for Santa to arrive, not to cause damage. The exclusion is pointed at "intended loss".
The DP1 edit 01/88 I'm looking at doesn't even mention the word deductible, so you have to look at accompanying forms to reach a conclusion on whether concurrent events require separate deductibles.
V&MM is an additional coverage on this same edition only by endorsement and payment of additional payment as shown on the declarations. But with Santa being a "jolly ol' soul", V&MM can also be ruled out. His status as an invitee would only come into play had he fallen down and broken his crown (oops, wrong fairy tale) and filed a liability claim against the insured. But, alas, the DP1 does not offer any liabilty or med pay coverage in its singular form.
Next year, leave a key under the mat for Santa. |
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LelandAdvanced Member Posts:741
| 12/27/2007 6:28 PM |
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Mike Kunze has made some good points and raised some additional issues.
I’m not sure, however, about this line:
“The only coverage that exists is for "vehicle" damage to the antenna, if we disregard the possibility of wind as the proximate cause”
Two points: First, I don’t think we have to “disregard the possibility of wind as the proximate cause” to allow coverage for vehicle damage.
The policy wording is: “….We insure for direct physical loss to the property caused by:…Vehicles…”
In my opinion the direct damage caused by the vehicle should be covered regardless of what caused the vehicle to impact the antenna. In other words: if Santa drove his Sleigh into the antenna on purpose or if somebody dropped the sleigh from a construction crane it wouldn’t make any difference.
(from a lawyer website):
Principles of Insurance : Proximate Cause
The efficient cause which brings about a loss with no other intervening cause which breaks the chain of events.
Example:
Firemen remove undamaged stock from a burning building to avoid its involvement in the fire. It is stacked in the open yard and subsequently damaged by rain. Was the proximate cause of the damage the fire or the rain ?
If the rain damage occurred before the Insured had an opportunity to protect it then the proximate cause of the damage would be the fire and fire is covered under a fire policy. However, if the stock was left unprotected for an unreasonably long period, the rain would be a new and independent cause of damage and damage caused by rain may not be covered under a policy.
My comment on the article above-. Identifying fire as the proximate cause is only important in the example above when 1) rain is not also a covered peril AND 2) there is a delay which can be considered “an intervening cause which breaks the chain of events”. If rain is a covered peril all by itself then it wouldn’t matter whether fire was the proximate cause or not.
So in our Santa example it doesn’t matter whether wind is the proximate cause or even if wind is a covered peril because “vehicle” is also a covered peril.
My second issue is that “aircraft” is also a named peril.
Anyway, thanks for mentioning “proximate cause” because I had to look it up and think about it, which is why I posted this scenario in the first place, as a learning exercise.
I think I have to agree with the next comment, the smoke is not covered:
Smoke from a fireplace is specifically excluded, and the intervening cause of Santa's rotundness plugging the chimney doesn't matter because it does not fit any named peril. The scenario doesn't state "fire" damage, just smoke from the friendly fire after the intervening event.
I also appreciate the use of the term “intervening cause” which was also part of the “proximate cause” definition. Certainly this is an example where “Fire” is not the proximate cause, because of the “intervening cause” which, as Mr. Kunze says, is not a named peril.
I’m not so sure about excluding the reindeer damage by deciding it’s not from the “vehicle” or the “aircraft” peril. The reindeer are attached to the sleigh and it doesn’t fly without them. I would be careful denying this straight out. I would want to ask the company if they wanted to allow coverage or not. That way I’m not sticking my neck out. Also I mentioned it was only a few shingles which migh affect the carrier’s decision on how strictly they should interpret the policy. I’d let them make the call.
"The intentional act exclusion has no bearing. The only intent was for Santa to arrive, not to cause damage. The exclusion is pointed at "intended loss".
V&MM is an additional coverage on this same edition only by endorsement and payment of additional payment as shown on the declarations. But with Santa being a "jolly ol' soul", V&MM can also be ruled out. His status as an invitee would only come into play had he fallen down and broken his crown (oops, wrong fairy tale) and filed a liability claim against the insured. But, alas, the DP1 does not offer any liabilty or med pay coverage in its singular form."
I agree with Mr. Kunze’s analysis about intentional acts. The reason I used the word invitee is I was thinking about “invitees” such as delivery people who are coming onto the insured’s property at the insured’s request. I can’t imagine a carrier denying a claim when the UPS delivery person accidentally breaks some dwellin property because the UPS person was there at the “ insured’s direction”, but the policy wording could be misunderstood. Mr. Kunze put a much better explanation on it.
I also appreciate Mr. Kunze’s point about liability and med pay. I never adjust those kinds of claims but it’s good to be aware of another area of coverage that is covered by the HO policy but not covered by the DP.
As far as VM&M goes, I still think it might be applicable. I’ve seen it paid on all kinds of claims, and it doesn’t always seem to require malicious intent although maybe it’s being interpreted incorrectly.
I’m going to read up on VM&M and post what I learn.
"Next year, leave a key under the mat for Santa."
What, and forget the milk and cookies?
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| 12/27/2007 7:21 PM |
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Wow... just "wow".
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Ray HallSenior Member Posts:2443
| 12/29/2007 2:21 PM |
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Leland the house I inspected had a DP 1. It also had an cast iron oil fired heating stove connected to the brick chimney with a horizontal metal stove pipe; therefore I argue the smoke damage is covered as the vented smoke is traveling in the intended confine escaped. |
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LelandAdvanced Member Posts:741
| 12/29/2007 2:41 PM |
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Here's what my DP1 (o1/05) says:
"PERILS INSURED AGAINST... 7) Smoke, meaning sudden and accidental damage from smoke. This peril does not include loss caused by smoke from fireplaces...."
Ray-
1) Was it smoke?
2) Was it sudden and accidental?
3) Was it FROM the fireplace?
If the smoke came out FROM the vent pipe FROM the furnace that happened to be connceted to the chimeny that is connected to the fireplace, then the smoke is not FROM THE FIREPLACE. It is FROM THE VENT PIPE or FROM THE FURNACE.
(I don't mean to SHOUT, I can't make the italics work)
So I would agree with you, the smoke in your example should be covered.
Where I see a big problem is if you had a basement furnace catch on fire, sending smoke up the vent and then out through the fireplace into the living room.
You could say the smoke was FROM THE FURNACE and you could also say the SMOKE WAS FROM THE FIREPLACE.
Would a claim like that be covered or denied?
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| 01/01/2008 1:53 PM |
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If you use the dictionary definition of "from" you might determine the origin or starting point of the fire was "from" the furnace....then through the fireplace. If the fire was totaly contained, intentional and within the intended area of its useful purpose it would be friendly fire. However once the fire "suddenly" left it's intended place to an unintended place it would be hostile. Then smoke leaving a hostile fire should be covered. If it traveled through the fireplace, I 'd opine that it was covered.
I think this "from fireplace" language intends to exclude slow escaping smoke from a lazy fire of poor combustion and weak draft. That damage would occur slowly over a period of time and properly be a maintenance issue. If the fire grows out of control and the flames lap out of the firebox charring the wood mantel which might allow "hostile' smoke to damage covered property, I'd try to get that covered on the basis of it being hostile. One could say the charring wood mantel is part of the fireplace, but I think it would be outside of the intended fire area and covered the same as when a furnace catches fire where it is not supposed to catch fire.
As usual the adjuster recommends, the carrier decides, the homeowner negotiates, the insurance commish pressures, and a hierarchy of courts review the whole process.
Of all those levels of authority....my opinion is subject to adjustment.
Randy Cox
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Ray HallSenior Member Posts:2443
| 01/01/2008 6:17 PM |
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Very well thought out response to friendly & hostile fire.
In Texas which has always had a lot of open gas heaters, that is the type that is connect to the shut off valve coming out of the wall or floor without any type chimney, this was the standard 163 line policy (NY163 line) exclusion. SPECIFIC COVERAGE CONDITIONS
Conditions Applicable only to Smoke:loss by smoke shall be limited to loss caused by a sudden, unusual and faulty operation of any heating, disposal or cooking unit, only when such unit is connected to a chimney by a smoke pipe, and while in or on the premises described herein, excluding, however, smoke from fireplaces or industral apparatus.
Bath rooms use to have a small heater in the wall..( no smoke pipe) .that would smoke up a whole whole house with low pressure on a very cold day.
*** I will scan the old Texas Standard 163 line Fire and Lightning Policy which is three pages. If you read ever line on ever page you will never have a problem reading any fire insurance form...... ever..Homeowners, BOP, CP etc. Please send me a email and I will attached and send back. |
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HuskerCatVeteran Member Posts:762
| 01/01/2008 8:57 PM |
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Just 3 pages, Ray? Can't find that anymore, can you?...try 15 to 50 plus endorsements. Irregardless, my mentors always preached "RTFP". How many of you have heard that before? |
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sbeau4014Founding Member  Member Posts:427
| 01/02/2008 4:44 PM |
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As in " Read The Friggin policy" or something similiar to that
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Ray HallSenior Member Posts:2443
| 01/02/2008 5:49 PM |
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Yep I think thats what I have drummed into my head also. Well I guess my offer had no value is I did not charge for the policy; therefore; I will charge $5.00 for it and all who request a copy can put $5.00 in the Salvation Pot the next time they pass a bell ringer. |
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HuskerCatVeteran Member Posts:762
| 01/02/2008 8:15 PM |
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Sounds like the same school!!
Ray, can you really scan that old 3 page policy? Last I checked, stone tablets don't feed thru a scanner all that well. Justifies the extra 5 bucks, I suppose, for wear & tear.  |
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| 01/03/2008 3:58 PM |
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In addition to the previous comments there is definately subrogation potential in this claim due to the fact that there was a paid contract between the insured and Mr Clause I would be sure to send all known information about the contractor (Mr Clause) so that the insurance company can persue legal actions against the contractor to rcoup moneys owed.
Wes |
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Ray HallSenior Member Posts:2443
| 01/04/2008 3:04 PM |
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The subrogation was not covered by the first adjuster, but when the 2nd adjuster inspected for the cause and origin he noticed a contract on white paper with red and green ink and ask the insured if he could read it. When reading the HOLD HARMLESS & INDEMNITY AGREEMENT the adjuster read about some risk of damage to property or person in the method of delivery in foul weather conditions signed by Mr. Insured and Mr. Clause on Thanksgiven day. The adjuster suggested subrogation not be pursued as the insurer would have to defend Mr. Clause under the HH&IA any only the lawyers would come out on top.
It seems the inside adjuster not up to speed on HH&IA and sent it to outside council for an opinion, which confirmed what the second adjuster had recommended and the opine cost $2,000. The claims manager was upset and chewed the inside adjuster out who was PO'd at the 2nd adjuster and cut the firm off from further assignments. This resulted in the IA chasing off the old 2nd adjuster who was let go at christmas time and no storms to go on on a very slow time for old IA who spend idle hours on the internet. Happy new year all and going to be good for me , don,t fret. |
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| 01/05/2008 11:02 AM |
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Okay, the holidays are over, time to get serious! The world changed forever on 9-11. Did anyone check this guys identification? Did he have a green card? Eye witness descriptions say he was a big man. Was that really all man under that large red suit or something more sinister? Was it really a little round belly that shook like a bowl full of jelly...or something more plasitic. Did he file a proper flight plan. If not, how did he get in under the radar; what kind of technology are we dealing with here? Without disclosing classified information, can anyone tell me the difference between waterboarding and snowboarding?
Happy New Year to all, especially those guys in the red suits that will be unemployed until next year and other individuals known to hop from roof to roof in the course of their employment.
RandyC
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Ray HallSenior Member Posts:2443
| 01/05/2008 3:49 PM |
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When some of the large metro cities have some roof claims this spring I think Homeland Security should be required to keep track of all the adjuster reports of bullet holes and slugs found during the roof inspection to determine if the crack down on the border security is working effectivly.
The vendors should also require the adjuster to do a complete investigation for subrogation purposes. Fines will be imposed on both for non compliance. Each vendor must have a certified mold police chief to report the non compliance violations . The bullet hole certification can only be offered by the Texas or other states reputable license schools who can meet the filing dateline of January 31, 2008 by sending a notorized letter of application to National Zhar of three day wonder schools in Costa Rica. This certification will be required to work any roof claims between February 1, 2008 and November 30, 2008; however, it will expire on January 1, 2010 and require recertification.
This certification will assure you of work this spring as many of the old crusty adjusters, who think "certifications" from the three day wonder schools are worthless will be sitting at home while you are out working.
*** Side note the fees for the certification should be very competive and I advise you to shop around for the correct credentials and be wary of mail order or online presentations as you will be acting as a quasia federal agent. |
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HuskerCatVeteran Member Posts:762
| 01/05/2008 6:12 PM |
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Great idea, Ray! Pretty soon, you can run a banner promoting all of the services you have suggested and/or offered. Maybe it could be called "Hallmark", or something similar. Select members of CADO could buy stock in your company, and sit back reaping in the cashflow that comes from the 3-day wonders. I will offer my services to help tutor from my barcalounger, and also help issue the certificates to those that pay the class fees. We will build a list of those that paid, and put them on permanent standby status. As additional ideas come up, they can enroll in those classes too. To avoid discrimation, new students would also be accepted for a modest late enrollment fee and completion/payment of prior sessions offered. It may be necessary, though, to rename the the mold police certification to mold enforcement regulator to avoid any legal problems such as impersonating an officer. |
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