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CCarr
Canada
1200 Posts |
 Posted - 11/24/2003 : 17:41:02
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In the "Safety & Roofs" thread, recently in the General forum, Steve made the comment, ".... make it a requirement for the insured .... under the terms of their policy for them to prove their claim ....". Ghost eluded agreement to that suggestion, with his comment, ".... just like in claims where the customer has to prove their loss ....". Kile also says, ".... the burden of proof lies with the insured ....".
But, it is Kile's statement, ".... no one has ever tried to prove that they owed ME money. The one receiving the money is the one who always has to prove that he is owed it", is the catch all assertion that I would like to try and relate to a policy wording, and show that in fact; the opposite seems true.
First, agreed, no objection, with regards to personal property, the policy clearly spells out in its own language, how the insured must prove their personal property loss.
However, with regards to a structure loss, and lets stick with a roof, I suggest there is no such requirement for an insured to prove anything to do with a structure / roof loss.
Whether the insured really knows he has a roof loss from an insured peril, or like many claims reported, the insured simply calls the claims center or his agent and says there was a lot of wind here last night and I'd like someone to check for damage; an adjuster will get a new claim for an insured showing "possible roof / shingle damage from wind".
Reviewing an HO3, what must an insured do to "prove" his structure loss?
Again, if it was a personal property loss, Section I - Conditions goes to great lengths to spell out under "Your Duties After Loss" what an insured must do.
But, what about a structure loss?
Yes, the insured "must" give prompt notice, protect the property from further damage, keep an accurate record of repair expenses, and show the damaged property; but that has nothing to do with "proving" a loss.
If the insured is asked ("after our request"), he must do the Proof of Loss thing.
However, no where in the policy is the insured asked to acquire repair estimates (prior to the PofL demand), or substantiate anything regarding his reported structure claim.
This is in total contrast to the insured's requirements regarding a personal property loss.
Therefore, while I agree with Kile's comment as it may apply to our everyday life in the real world outside of insurance claims, ".... no one has ever tried to prove that they owed ME money ...."; I don't think that applies to claims settlements on a structure loss.
The "drill" seems pretty well carved in stone. We get the new claims notice, we communicate with the insured, we set an appointment, we attend and we inspect, then we determine if an insured peril damaged the insured roof and what the cost of that damage may be; all while the insured sits and waits at the kitchen table for the adjusters conclusion - "Yes, I have proved that your insurer owes you money".
I agree, that IF an insurer requests a Proof of Loss, the "rules" of the game change; but that affects a small percentage of the claims handled. |
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KileAnderson
USA
875 Posts |
Posted - 11/24/2003 : 18:04:12
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In practice a "Proof of Loss" to most cat adjusters is a form you have to submit in a flood file, and that's it.
I've never had to deal with one on any other type of claim besides flood. But I still believe that it is the insured's duty to provide proof that a loss has occurred. That proof may be in the form of allowing a representative of the insurance company (an adjuster) to inspect the property for the damage being claimed.
Maybe we are looking at the same fence from different sides but to me I don't see how anyone would prove their loss other than to allow an inspection. Even if they submitted a proof of loss in writing and accompanied that with a labled and measured diagram of the damaged property along with a repair estimate I still think they would have to actually prove that said property was damaged by a loss insured (i.e. allow an inspection).
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Type R 1090
Canada
14 Posts |
Posted - 11/24/2003 : 23:02:28
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CCarr (my fellow Canadian [:)]),
I've always had it in my head that when it comes to an All-Risk policy, it is up to the insurer to show that the peril does not fall within coverage, while in a Specified Peril policy, it is the insured that must prove the loss is caused by an insured peril and bring themselves within coverage.
I'm not sure where I picked up this idea, but I get the distinct feeling it's through one of the CIP classes I took. |
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Steve_One
USA
22 Posts |
Posted - 11/25/2003 : 07:42:28
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I might suggest that the policy does instruct the insured to prove their loss under coverage "A", using Claytons words from above "...show the damaged property....."
After that it seems the only thing to be resolved is how much value to place on said damaged property. Clearly that is where the adjuster becomes very important to the claims process.
My suggestion from the other thread was focused on keeping the adjuster safe while in the process of his/her duties to that end. My suggestion was one of specifically putting more of a duty upon the insured regarding a roof claim only.
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sbeau4014
USA
53 Posts |
Posted - 11/25/2003 : 08:54:16
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| At one point in the insurance claim history there was a belief that it is the duty of the policy holder that to prove their loss. The language of the policy along those lines hasn't changed in the 24 yrs I've been doing this, but the state statutes have in the bad faith areas (IE Texas HB2) A lot of them now require the insurance carrier to prove the claim isn't covered, or any part thereof. If the insd submits a claim for hail damage to their roof, there is nothing in the policy that I know of that would require anything more then the filing of the properly executed proof of loss timely. If so required and the insd does that, it is the carriers duty to show or prove that it isn't a covered loss in whole or part and the reasons why. Can't say driving up to a 12/12 pitch or greater gives me any warm fuzzy feelings, but I never have or never would ask an insd to get me a diagram or estimate on the roof. Not that I don't trust roofers etc, but I do trust my own diagrams and measurements |
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Steve_One
USA
22 Posts |
Posted - 11/25/2003 : 09:25:36
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I'm not advocating that an insured climb their roof and diagram same, of course not. My only suggestion was that based on slumping fees for our services, why should we risk potential injury from a process that might better be accomplished through a differant avenue of determination.
Clearly there's no contractual or statutory requirement for adjusters to climb, diagram, etc. every roof claim. Further, I'm only speaking to those few roofs that one might better access from a helicopter.
While no adjuster is going to blindly trust the insureds roofer, I think we're all skilled and experienced enough to, from the ground, review the roofers diagram and spot damages that said insured is claiming. If damages and diagram and measurements appear to be in line, then the only conversation is cost, and we don't negotiate that from the top of the roof anyway, so I see no harm for those few claims that are just too unsafe to climb.
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CCarr
Canada
1200 Posts |
Posted - 11/25/2003 : 09:38:05
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TR, as I look out the window at a 2" blanket of new snow, I do hope you are still enjoying green fairways. Note the very distinct contrast between the "Requirements After Loss" Statutory Condition, of a HO policy on your desk; versus the "Your Duties After Loss" Condition of an HO3 policy. Clearly a Canuck HO policy establishes the burden of proof on an insured to prove their claim, if the claim is pursued by the insurer according to the policy language requirements. I don't see that as the situation with an HO3 policy involving a structure loss.
Steve K, the requirement in an HO3 for an insured to "show the damaged property", I suggest in no way establishes a burden of proof on the insured to prove their claim. This merely allows "access" to the insurer for presumably an adjuster to examine or inspect. That "access" function is played out repeatedly in claims with a carrier representative meeting the insured at the door of their home, then the representative saying they are going to climb up to the roof to examine it; and the insured either expressly or through implied jesture agreeing and returning to his kitchen table to sit and await the conclusion.
Steve B, while I agree that the ingrained concept has always been that the insured must prove their loss, I don't see where an HO policy wording creates this 'duty' for a structure loss; nor am I aware of the application of that concept on the thousands and thousands of hail or wind damage claims reported for roofs each year. |
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Newt
USA
657 Posts |
Posted - 12/12/2003 : 18:28:42
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I am trying to prove a a loss on a 14:12, my photos don't reveal damage, yet there is hail damage. I will now have to revisit and get underneath the shingles to find the evidence. These are very heavy shingles and some fractures were noted with a clear round hit, however this was not good enough. ( The roof has started leaking)
Proving this claim is my job, delegated to me by the carrier, and they want it yesterday. I always thought the proof fell on the adjuster and like CC I never read otherwise in the policy where the structure is involved.
The only thing we have a problem with is getting claims to see the damage we see in the photos. If you are looking at a photo, someone else took you may not see what the other person did.
I wish I had one of you pro's around to give me some tips on how to get the proof on this puppy. Maybe I will find it under the shingles. |
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Admin
547 Posts |
Posted - 12/12/2003 : 20:22:13
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Newt,
If your photo documentation of the roof damage does not clearly support the damage that you found then if possible you could also support with hail damage to other items on the dwelling, like roof vents, patio covers, gutters, screens and so on. You could also add additional support by indicating in your log notes that your close inspection of the shingles found impact damage or bruises that did not show clearly in the photos. I also have some concerns about the leaking as a result of hail damage to a heavy shingle. Unless the hail damaged the felt or decking which should show in photos typically a roof will not leak as a result recent hail damage.
Adjusters always need to support their position. Often on Cats we rely on the insured to support their claim, for example when it comes to appliances we will request that they get them inspected. |
Roy Cupps -
CatAdjuster.org :: Contact\Feedback :: Adjuster Roster :: Current Forum |
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Newt
USA
657 Posts |
Posted - 12/13/2003 : 09:33:13
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I have tried most of the items you mentioned, I noted the visible hail damage and can see it, however I know what and where the hits are. About eight dwellings on this street are having the roofs replaced as we speak. The roof leak is in an area of transition to a flat bitumineum, torch attached to the decking. In some places this roof has hits that actually cracked the shingles. I might mention that the insured is also the insurer, or at least high up on the totem pole. The roofer is one of the best and I have a high regard for his opinion,( he agrees with me). I am going to re-shoot the photos and see if I can't bring out a little more detail.
I am going to use my machette and try to look under the shingles, with extreme caution. Sometimes the hits show up there. The valleys have very little exposure, and the turtle vents are heavy plastic, the hail came straight down so I didn't find other damaged property.
Thanks for the feed-back, I need all the help I can get. I will take your suggestions and re-trace the steps I took.
I sure wish this was a flat roof. A 14:12 roof doesn't show hail damage as well. The roofer was surprised that I got up there at all, but you gotta do what you gotta do. I took about 35 pictures, and need to go back this morning and try again.
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Edited by - Newt on 12/13/2003 09:56:42 |
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CCarr
Canada
1200 Posts |
Posted - 12/13/2003 : 10:20:26
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Newt, following your 1st post on your roof situation (hail), and Roy's cautionary comment relative to leakage vs hail, and now in your last post the one sentence related to the leakage; that generally is a maintenance or deterioration (wear and tear) issue at transition points like you mention.
There is no doubt that you found hail damage on the shingles, and your extra efforts to document it for the carrier are noble. However, the leakage and any resulting water damage, based on what you have noted, may fall outside the peril of hail; and that is not all that uncommon. |
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Newt
USA
657 Posts |
Posted - 12/13/2003 : 10:46:11
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| CC, There were cracks in the shingles, which looked like hail hits were the cause at the transition, or I should say near the transition. This is a flat area below the shingles which are 14:12. I have to prove this damage was caused by hail, I don't have a choice. With all the hail damage in the area, eight dwellings around this one and many more in a five mile radius. |
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CCarr
Canada
1200 Posts |
Posted - 12/13/2003 : 12:20:32
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Certainly you have a choice!
Your job is to prove what did or did not happen. |
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trader
USA
236 Posts |
Posted - 12/13/2003 : 18:52:44
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| I have looked at thousands of roofs, and if your good 35 MM camera or your good digital will not show the hits, some thing is out of wack. Did you see any splatter marks on the oxidized paint on the AC condenser or the meter box. Is it possible the other houses on this street were not inspected by a "trained person"? When a steep roof runs out onto a flat roof a very very high percentage leak at the transition. I will say a charcoal roof less than 18 months old is very very trickey. Dont look at the auto in the driveway either. They move about. |
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KileAnderson
USA
875 Posts |
Posted - 12/14/2003 : 22:06:07
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If the roof is that steep and the hail came straight down, it may not be damaged at all.
You say there are cracks in the shingles. What do these cracks look like are they vertical or horizontal? Do they run the length of the shingle? I've never seen hail leave cracks in shingles. What kind of shingles are you talking about? The description of cracks with a round impact mark sounds like you are describing hail damage to a wood roof. But when you say you are going to use a machette to look under the shingle it sounds like you are talking about a comp roof. It seems if you have hail large enough to crack and leave an impact mark on a wood shingle it would be pretty easy to see in a 35mm photo, but it also seems that straight down hail would have to be as big as a watermellon to damage a 14/12 wood roof.
Please give us more info on the material we are talking about. |
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Newt
USA
657 Posts |
Posted - 12/15/2003 : 13:42:24
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This is arch. shingles, of a type I have never seen. The cracks all the way down on some and others have chipped out areas along the edge, with a visable round hit above the chip and the same with the cracks. On the bottom edge ther is fiber glass which looks like cotton (very white) sticking out which is sandwiched between the composites. This is a new one on me and I felt I had the evidence, but no cigar. I have an olympus camera and took over 60 shots. I have some very closeups and some that are normal. I couldn't find any thing on the structure to help, gutters (none) awnings etc.The turtle shell vents did not reveal any damage, they are heavy. With all the roofs being replaced in the area, one would think I would find more compelling evidence, no doubt this claim will be approved. It nags at me that the person reviewing the file is having a problem identifying the hits with the cracks.
Except for the cracks and chips this roof has a heavy coating of granuals and looks "almost" new. One other thing this hail storm occured over seven months ago. I think a more recent storm would have shown more hits. The only known is the date of the storm.(5-6-03). |
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Who "proves" an insured's claim?
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