MedulusModerator  Veteran Member Posts:786  
| 01/25/2013 7:56 AM |
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When handling a fire, it is my experience that insurance carriers generally consider damage done to a structure by the firefighters to be part of the fire loss. My question is similar, but much more complex. I would be especially interested in hearing from those who have encountered scenarios like the one I am about to describe while working on Hurricanes Katrina or Sandy. This is a hypothetical, though I have no doubt that there are many actual claims out there that would fit the scenario.
Standard ISO HO3 policy form with backup through sewers and drains endorsement. Two story house above grade and finished basement floor walkout below grade on three sides. The insureds have decided to stay in their home initially, but as the storm approaches water starts rising like fountains out of the commodes and sinks. Insured looks in the basement and see that water is about two feet high down in the basement. The family grabs their dog, jumps in the car and gets out, heading inland before an 8 foot storm surge hits their neighborhood. Two days later they are allowed back in the neighborhood. This is what they find:
Many missing shingles on the roof. Some of the siding on two elevations missing. Warped siding near the bottom of the same elevations. A water line in the finished basement just below the ceiling. Water damage throughout the first level (above grade) floor. Broken door jambs and evidence the dented doors were kicked in. Muddy/sandy footprints throughout the house on the first and second stories. Muddy carpets on the second story. Drywall separation at the tape joints on first and second stories. A few water stains on the second story ceilings. Mud scraped across the walls in several rooms on the first and second floors. Nothing is missing. No evidence of theft or vandalism.
You determine that the causes of loss are: 1. Flood (excluded) 2. Sewer Backup (covered to a $5,000 limit) 3. Wind and 4. Damage done by the Search and Rescue Operation. How do you handle the Search and Rescue Damage? Is it covered? Is it excluded? Is it a separate claim with a separate deductible? What is your reasoning for your answer? There are several ways to go with this. Does anyone have a real life example of how a carrier with which they were working handled a scenario like this?
Steve Ebner CPCU AIC AMIM
"With great power comes great responsibility." (Stanley Martin Lieber, Amazing Fantasy # 15 August 1962)
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CatAdjusterXVeteran Member Posts:964
| 01/25/2013 10:02 PM |
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Steve,
I have had a few of these scenarios albeit not the exact same, but does address the pertinent question of your post about search and rescue damage. Initial estimate from Liberty Mutual in Arabi, Louisiana (Katrina) denied the damage caused by search and rescue teams extracting folks out of the attic of said risk through the roof. On this specific risk, initial adjuster replaced the front slope of roof and excluded everything else. Problem was said "experienced" adjuster did NOT go inside the risk whatsoever and thus provided NO documentation/no photos of interior damage. Documented/photos of roof and a 7 foot water line. Now the insured is rep'd by a PA and at the re-inspection, risk was already gutted. Of course the PA asked for the moon and strangely provided a comprehensive stick built estimate
(I didn't know they knew how to do that!!LOL)
In the end, I bought the whole roof (which took care of the search and rescue damage 96 SF plywood decking) bought the attic contents, bought all ceilings/vents, minimal wall repair, paint, mask/tape flooring. The PA wrote to replace the entire roof yet even though they did that, they included the search and rescue damage as a separate line item. Why? They allege rafters damaged. Sorry but no, rafters were exposed with zero damage. I didn't write the S&R damage as a separate line item. I simply labeled the damage S&R in pics of the roof. LM agreed on scope and paid additional monies.
It should be noted that Liberty Mutual took a hardline stance early (much like SF) and was attributing most damage from flood and thus excluded. Nevertheless, on the 2nd go around with PA rep'd or litigated claims, they essentially did a 180* and allowed me and others to write below the flood line provided we could document ceiling failure (holes/openings/etc..) With no indications of failure but stained ceilings/etc.. replace ceilings minimal wall repair paint mask/etc..
Had a few claims with kicked in doors as well. LM paid for all attributed to S&R regardless of water line (on PA rep'd and litigated claims)
"A good leader leads.....
..... but a great leader is followed !!"
CatAdjusterX@gmail.com
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MedulusModerator Veteran Member Posts:786
| 01/26/2013 8:07 AM |
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Was there also wind damage on either of those claims, Robbie, or only flood damage? I can't quite tell from your description. Is the rest of the roof being bought due to wind damage(as well as the interior items)?
Just to be a little more explicit is what I identify as issues to be considered when determining coverage for this, here are some of the issues:
1. Is the search and rescue happening because of the wind, because of the flood, or because of the sewer backup? If the search and rescue is because of the flooding, why would it be covered? If it is because of the sewer backup, why would it not be subject to the $5,000 limit? If there were only wind associated with the storm, would there even be a search and rescue operation in this neighborhood?
2. Is the search and rescue a separate cause of loss that would be considered a separate claim with a separate deductible? It is not actually part of the mitigation of damages as the efforts of firefighters would be in a fire claim.
3. If it is a separate claim, is it excluded under the "government action" clause? It is not vandalism because there is no malicious intent.
4. Can you really handle a single event of a uniform character such as a single search and rescue operation as being due to flood below the water line and wind above the water line? How can a single event of a uniform character be treated as partly covered and partly not covered simply because of the elevation at which it takes place? Robbie brings this issue up in his post above.
5. What are the pitfalls of not covering the damage from the search and rescue operation? Might a decision to cover it be made by a carrier as a purely business decision to avoid excessive court costs? Robbie brings up this issue as well. We have had a prime example of insurance carriers making such a business decision with Hurricane Sandy and use of the "catastrophic wind" deductible.
Steve Ebner CPCU AIC AMIM
"With great power comes great responsibility." (Stanley Martin Lieber, Amazing Fantasy # 15 August 1962)
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Leland Advanced Member Posts:741
| 01/26/2013 10:05 AM |
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Imagine if the insured had a $30,000.00 diamond ring inside the home that was expected to wash away the next day after being knocked over by wind. The insured pays $2000.00 to have someone with a 4 wheel drive telehandler place a worker on the roof and cut through the sheathing to the bedroom below, and rescue the ring. That would clearly be considered a reasonable expense to mitigate damage to covered property (the ring).
Now consider if the item was a pet, or even a child. The difference is the pet is not covered property, nor is the child. So rescuing the pet or child would not be mitigating damage to a covered item. But should an insurance company really take the position that it is not reasonable to pay for the damage to property necessary to allow humans or even pets to escape?
Consider a situation where there is a fire in a kitchen, and the insured breaks a bedroom window to escape the burning house. Clearly the window damage ensues from the proximate cause, fire. How is a rescue different?
The rescue is different in two ways: the damage is done by a thrid party, not directly by the insured, and the third party may be fulfilling a public service and be independent of the insured's direction and control (the government rescuers are not hired by the insured). The second difference is a possible intervening time period, ie. the damage happened Monday and the rescue happens Wednesday.
But neither of these factors make any difference, in my opinion. If doesn't make any difference if a window is broken to escape a fire while it is burning, or a roof is cut open by the fire department two days after a covered loss. That damage is simply ensuing damage from the covered loss, and should be covered even if it wouldn't be covered if it had been a separate incident.
This goes to case law- there was a famous case where merchandise was left out in the rain, and the insurance carrier denied coverage. The only problem was that the insured had moved it out of a fire damaged warehouse one day prior to the rain. The fire was a covered loss, so the court ruled that the rain damage was related to the fire and should be covered even though it wouldn't be covered if there had been no fire. One of the key points was that there was no "intervening time period". It wasn't like the insured had a fire and then left there stuff outside for six months.
So if you apply the logic from this case, some roof damage from a rescue occuring shortly after the covered loss would also be covered.
Consider a hypothetical where Mr. Bippo moves into his attic with six months of water and food supplies, then a windstorm hits and damages his home so he can't get out. He sends text messages to friends and family explaining that he is perfectly happy stuck in his attic and doesn't want to be rescued. Six months later the fire department and social services decide he needs to be removed for his own safety, and a hole is cut in the roof. I suppose the insurance company could say that there was an intervening time period so long that the hole cutting was not damage due to the proximate cause of the fire. But the difference here is that in the warehouse case, the insured could have used alternatives to store his merchandise. In the hypothetical Bippo case, what would be the alternative? Eventually the home will have to be damaged to get the guy out, even if just to pull out his corpse.
Ask the question another way- is it reasonable to leave someone stuck inside a house? Since the answer is no, then it must be reasonable ensuing damage to remove them.
There are all kinds of things that are "not covered" that get covered when they ensue from a covered loss. Again, it's that whole proximate cause issue.
After Katrina the carrier I worked for routinely paid for repainting of the rescue marks painted on walls - remember the big "X"s with codes to indicate whether a body was found? The carrier also paid for damage due to rescuers kicking in doors to look for people.
This type of damage also brings up public policy issues. I think even if the carrier thinks its not covered they often want to pay it anyway from a customer service and public relations perspective.
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ChuckDeatonLife Member  Senior Member Posts:1110 
| 01/26/2013 10:03 PM |
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An HO-3 is an open perils/all risk policy written on ACV basis with Replacement cost provisions with Limitations and Exclusions as regards the Building. The Contents are covered by Named Peril at ACV. Generally there will be endorsements. Sewer Backup is generally provided by endorsement. As is Replacement cost for Contents.
The main thing to remember is that if the causation is not excluded or limited coverage exists. The most quoted exclusion in Super Storm Sandy is the water exclusion which includes flood. Sewer backup, I doubt it. NY city had less than a 100 sewer backups prior to the storm and then, Super Storm Sandy approached and suddenly there were thousands of sewer backup claims.
Remember that if the insured makes a claim under an all risk/open perils policy, files a Proof of Loss, it becomes the insurers responsibility to reject the Proof and deny the claim.
Leland, you must be back on the Left coast with Robby.
"Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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MedulusModerator Veteran Member Posts:786
| 01/28/2013 7:54 AM |
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The following are potential ways to look at the search and rescue:
1. It is part of the wind claim and, therefore, covered. Unless the wind is an F4 or F5 hurricane or tornado, it is unlikely that the search and rescue operation is the result of wind. So this probably doesn't fit the facts if one is honestly assessing the situation.
2. It is part of the flood claim, so it is excluded. This is probably the closest to fitting the actual scenario.
3. It is part of the sewer backup claim. The limit was already reached without any search and rescue damage included, so there is coverage but no additional moneys can be paid over the limit.
4. The search and rescue is due to a number of causes of loss and somehow they have to be split out. This is highly problematic. Again, I think there is no case law that allows exclusion of damage due to the elevation of that damage.
5. It is a separate claim with a separate deductible. This is probably excluded under the government action clause.
And, when all is said and done, many carriers are going to do exactly what Leland suggests and what Robbie has experienced - cover the loss.
If presented with this scenario, the best way to handle it, in my opinion, is to submit the facts to the carrier without analysis of the coverage issues and let the carrier tell you how they want it handled. Then, with the carrier's official answer documented, one can proceed to follow their instructions. Steve Ebner CPCU AIC AMIM
"With great power comes great responsibility." (Stanley Martin Lieber, Amazing Fantasy # 15 August 1962)
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LelandAdvanced Member Posts:741
| 01/28/2013 11:18 AM |
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Chuck- you make a very good point and I am guilty of muddled thinking, at least a bit. Your point that "if it's not excluded, its covered" (on an HO3) is well taken. I should have outlined that principle.
However in my defense, we were also discussing flood polices, which have more limited coverage, and I am always handling named peril Dwelling policies, so often my instinct is to think about what is covered, rather than what is excluded.
Although I should have mentioned the principle "if it's not excluded, its covered" I did have some HO3 exclusions in the back of my mind:
1) Exclusion for Governmental action
2) exclusion for intentional acts of the insured
For example, when the police break down doors looking for a criminal, that damage is usually excluded under an HO3. What makes search and rescue damage different is that it ensues from a covered loss, ie. its not a stand alone act of government action but a government action taken in response to damage that is covered. This is the same reasoning why damage from the fire department is covered, even on a named peril policy.
I think it would be accurate to say that on an HO3 policy you could deny coverage for police smashing in a door to to serve a warrant, but you would need to cover that same damage if it was done by the fire department while putting out a fire.
The other issue Chuck brings up is really important- the use of a POL to shift the burden of proof to the carrier. I think this is a big issue that is easily overlooked. A related question is "what is a proof of loss- does it have to have the words "Proof of Loss". The reason this is so important is that the insured could file a POL for the police damage to the door, and the insurance company might have to pay it if they haven't dotted their "i"s and crossed their "t"s.
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CatAdjusterXVeteran Member Posts:964
| 01/28/2013 11:12 PM |
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Posted By Medulus on 26 Jan 2013 08:07 AM
Was there also wind damage on either of those claims, Robbie, or only flood damage? I can't quite tell from your description. Is the rest of the roof being bought due to wind damage(as well as the interior items)? Steve, I actually answered this question last night and with a particular lengthy response(even for me). Unfortunately I guess I took to long and when I hit submit, it took me back to the login page and hence....zero zip nada!
So here we go...again
Yes there was wind damage on all claims discussed. I was only there (Liberty Mutual) to assess wind damage on PA rep'd or litigated claims that were either underpaid (according to the PA or a plaintiff attorney or outright denied (due to flood damage)
As stated above, the original adjuster on the claim in Lakeview, Louisiana (I thought this one was Arabi but no ) paid for one slope (approx. 6 or 7 squares) and 32 SF of plywood decking. He excluded the back slope (even with probably a dozen missing shingles in addition to an approx. 64sf opening created by S&R to extract the insured and family. Additionally on the rear slope,( the roof was a simply gable roof with 30 yr architectural asphalt composition shingles) the power mast was ripped out and laying on it's side (as a result of a tree falling across the lines coming into the risk. He again paid for the front slope and excluded everything else as attributed to flood. His photos were comprised of maybe 5 or 5 pics of said slope and a pic to document the waterline (7ft.) He did NOT enter the risk nor did he take any pictures to substantiate a no damage claim.
As stated above LM initially took a hard line stance on flood damage and almost without exception excluded everything under that water line . On the second go around, LM essentially walked away from that stance and advised me (and dozens of others) to not give away the farm but clear concise instruction (IF ceilings show evidence of failure (opening) and you can establish a sequence, shingle failure leads to decking failure/etc....) buy that room to the floor. ANY gray area is to error upon the side of the insured. It's obvious they made the decision that they would rather pay some now as opposed to more later whether through mediation/litigation.
On this claim, the front slope had significant damage, almost 75 % of shingles and paper were...gone and multiple rather large openings (impact damage) The rear slope had maybe a total of around a square of assorted missing shingles as well as the 64 sf opening (Search and Rescue) and the power mast torn down. I bought the whole roof to include electrical (power mast). I was questioned on that by the LM examiner and he kicked that back to me. I advised that this was NOT attributed to flood (IMHO) but by Katrina's wind speeds. Atleast in this example, yes the risk was inundated with 7 ft. of flood water, however the onset of flood water was akin to filling a bathtub as risk was some distance from either the London or the 17th street canal/levee and as such, tree coming down was a result of wind.
The risk had been gutted and because the original adjuster did NOT document anything inside the risk, I was not in a strong position to deny interior damage. The PA wanted everything to the floors. We compromised, I bought the roof the attic contents, all ceilings, minimal wall repair paint/texture. In the end, I bought the power mast (the LM examiner agreed with my opinion) I did NOT add the S&R damage as a separate cause of loss nor as a separate coverage. I (when I bought the roof) added an additional 64 sf of decking and simply labeled those S&R pics and hence was contained within schedule (A)
The other risks that had the kicked in doors were in Arabi and Violet respectively (these areas for the most part had flood waters that exceeded 15 to 20+ ft) In these examples, I believe I bought one roof and denied the other. Nevertheless, I bought the doors and framing, jambs R/Reset the hardware. LM examiner only asked for pics to document the S&R hallmark (the spray painted X). If that was present I could pay for the S&R damage (even though these risks were obviously destroyed from an excluded peril) In BOTH examples, the S&R damage was contained within schedule A
We did give the insured $500.00 for mandatory evac/food spoilage from loss of power. That was separate from schedule A
Just to be a little more explicit is what I identify as issues to be considered when determining coverage for this, here are some of the issues:
1. Is the search and rescue happening because of the wind, because of the flood, or because of the sewer backup? If the search and rescue is because of the flooding, why would it be covered? If it is because of the sewer backup, why would it not be subject to the $5,000 limit? If there were only wind associated with the storm, would there even be a search and rescue operation in this neighborhood?
2. Is the search and rescue a separate cause of loss that would be considered a separate claim with a separate deductible? It is not actually part of the mitigation of damages as the efforts of firefighters would be in a fire claim.
3. If it is a separate claim, is it excluded under the "government action" clause? It is not vandalism because there is no malicious intent.
4. Can you really handle a single event of a uniform character such as a single search and rescue operation as being due to flood below the water line and wind above the water line? How can a single event of a uniform character be treated as partly covered and partly not covered simply because of the elevation at which it takes place? Robbie brings this issue up in his post above.
5. What are the pitfalls of not covering the damage from the search and rescue operation? Might a decision to cover it be made by a carrier as a purely business decision to avoid excessive court costs? Robbie brings up this issue as well. We have had a prime example of insurance carriers making such a business decision with Hurricane Sandy and use of the "catastrophic wind" deductible. As LM's original stance (to exclude S&R damage) the pitfall is one of animosity (whether warranted or not) with the insureds.
YES! I firmly believe adding the S&R even on risks where the risk was destroyed from an excluded peril was a calculated business decision to avoid a slew of additional monies awarded in mediation/litigation
"A good leader leads.....
..... but a great leader is followed !!"
CatAdjusterX@gmail.com
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ChuckDeatonLife Member Senior Member Posts:1110
| 01/29/2013 12:45 PM |
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Other than as a matter of curiosity what does it matter what Liberty Mutual did in S. Louisiana post Hurricane Katrina.
Any reference to Liberty Mutual, New Orleans or Katrina as an explanation for action taken in NY are dangerous. Dangerous and should be avoided. Even references made on this board might carry unpleasant consequences.
Determining causation is the first step in handling any insurance loss/claim. Preserving evidence, scoping damage and writing an estimate are next in line. Applying coverage is the next step.
My suggestion, in an area, like NY, that is famous for litigation, that the field adjuster do a stellar job of determining causation, preserving evidence, scoping the damage and writing an estimate and report. In order to protect your interests and avoid being subject to a judgement it is prudent to put the application of coverage and any denial off on to the company.
"Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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Tim Wieneke Member Posts:92 
| 01/29/2013 6:30 PM |
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I had a claim similar to this in Massapequa on an HO3. There was a basement fire limited to a few outlets and some soot/smoke, but there was a foot of flood water in the basement and firefighter footprints from the dirty water in the first floor when they were inspecting the entire property to ensure that fire had not spread. I covered the footprints primarily under what Chuck described - emergency services personnel not excluded. Beyond that I would extend coverage on the basis of emergency services personnel were mitigating the possibility of further damage to the risk even though the areas were not fire damaged. I would use this same logic to search and rescue. At the most cold and calculating end of insurance logic, search and rescue mitigated the risk of a dead body damaging the risk. I've had dead body claims and they do far more damage than muddy footprints in the carpet. |
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| 01/29/2013 6:43 PM |
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From a carrier perspective, we often paid for S&R or other potentially excluded causes that could have bad PR consequences. Most of the S&R claims would be from flood/swift water, which is excluded. However, the S&R damage is usually a lot cheaper than a lawsuit and a jury of their peers is probably going to be sympathetic to someone trying to get out of their house after a storm. By paying for it, it is then excluded from a lawsuit over non-covered flood damages and the lawsuit is easier to litigate. Having said all that, I would still defer to the carrier for a decision on it and then follow their direction.
My favorite example of non-covered was an insured that blew his head off in his living room. My supervisor pointed out the "intentional acts of insured" exclusion that should not pay for the damages. I then showed the "innocent spouse" definition of the mandatory amendatory endorsement to the policy to show that the spouse was entitled to some coverage if she did not know of the insured's intent and was not involved in the suicide. Then supervisor wanted to exclude the gunshot damage and only pay for residual damage. Finally, someone a bit higher up realized the lawsuit risks were a lot greater than just paying the extra $500 for roof damage. |
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MedulusModerator Veteran Member Posts:786
| 01/29/2013 7:52 PM |
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Another consideration for intentionality is whether it was the insured's intention to cause damage to the residence, which is patently ridiculous in the suicide example you cited. The intention was to kill himself, not to cause damage to the dwelling. In the depths of the CADO forum archives from the year 2000, at www.catadjuster.org/discus/messages/2893/473.html , is a discussion of the classic claim scenario called "Snakes in the Attic" which addresses the issue of what constitutes an intentional act. I, as a much less experienced adjuster, came up with a very different answer than some more experienced and wiser adjusters. Steve Ebner CPCU AIC AMIM
"With great power comes great responsibility." (Stanley Martin Lieber, Amazing Fantasy # 15 August 1962)
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CatAdjusterXVeteran Member Posts:964
| 01/29/2013 10:40 PM |
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Posted By ChuckDeaton on 29 Jan 2013 12:45 PM
Other than as a matter of curiosity what does it matter what Liberty Mutual did in S. Louisiana post Hurricane Katrina.
Any reference to Liberty Mutual, New Orleans or Katrina as an explanation for action taken in NY are dangerous. Dangerous and should be avoided. Even references made on this board might carry unpleasant consequences.
Determining causation is the first step in handling any insurance loss/claim. Preserving evidence, scoping damage and writing an estimate are next in line. Applying coverage is the next step.
My suggestion, in an area, like NY, that is famous for litigation, that the field adjuster do a stellar job of determining causation, preserving evidence, scoping the damage and writing an estimate and report. In order to protect your interests and avoid being subject to a judgement it is prudent to put the application of coverage and any denial off on to the company.
....................................................................................
Chuck, where do you see anything about this question being related toward a risk in the state of New York?
Medulus asked for the following:
Does anyone have a real life example of how a carrier with which they were working handled a scenario like this?
Steve painted this as a "hypothetical" scenario.
The details about a LM risk post Katrina was from Steve asking about "wind damage" "A good leader leads.....
..... but a great leader is followed !!"
CatAdjusterX@gmail.com
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LelandAdvanced Member Posts:741
| 01/31/2013 12:34 AM |
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I have handled a few suicide claims on dwelling policies. Suicide per se is not a covered cause of loss. But explosion is, and it is my understanding that gunfire has been well established in case law as being a type of "explosion" for named peril policies. So damage from suicide by gunshot gets covered.
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ChuckDeatonLife Member Senior Member Posts:1110
| 01/31/2013 10:54 AM |
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The obvious answer to your question, Robby, is nowhere.
Are you having cognitive problems?
"Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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CatAdjusterXVeteran Member Posts:964
| 02/01/2013 12:28 AM |
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Posted By ChuckDeaton on 31 Jan 2013 10:54 AM
The obvious answer to your question, Robby, is nowhere.
Are you having cognitive problems?
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I am probably going to regret this Chuck, cognitive problems? Huh? I don't get it.
"A good leader leads.....
..... but a great leader is followed !!"
CatAdjusterX@gmail.com
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ChuckDeatonLife Member Senior Member Posts:1110
| 02/01/2013 9:36 PM |
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"Old age and disease may affect cognitive function, causing memory loss and trouble thinking of the right words while speaking or writing ("drawing a blank")."
I've made numerous suggestions that you might want to have someone, hell, any one, edit your posts. Seems like, over time , you are getting worse.
Anyone , Robby, just have anyone read through your posts before you hit "Submit."
"Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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Alex_ChernovMember Posts:67
| 02/07/2013 2:55 AM |
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Ok. I just had a claim, where police went inside apartment house (6 units) and busted every door. House insured under CP0010 with special COL form. I wrote up all damages and bumped it to carrier for review. I pointed out to the carrier that governmnet actions exclusion may be in play here. I am not sure how this one is going to end up.
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MedulusModerator Veteran Member Posts:786
| 02/07/2013 10:42 AM |
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I trust you checked for any coverage provided under a Property Enhancement Endorsement, which is common for Commercial Property forms. On the commercial property policies I have dealt with the Property Enhancement Endorsement more often provides coverage than the CP0010/CP1030 combination of forms. Although, I will admit, I have yet to run across one that allows coverage for government action because it would probably be adverse to public policy to do so. Still, I always check that endorsement because it is specific to each company.
Steve Ebner CPCU AIC AMIM
"With great power comes great responsibility." (Stanley Martin Lieber, Amazing Fantasy # 15 August 1962)
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