|R.D. Hood (Dave)
|Posted on Sunday, April 30, 2000 - 2:41 pm: |
Ok, my turn. In this instance , the inscription would be an additional amount of coverage up to the policy limits. Well anyway, that's an opinion.
|Jim Flynt (Jim)
|Posted on Sunday, April 30, 2000 - 2:06 pm: |
Dave, Thanks for your vote of confidence.
And I know your confidence extends not only to me, but to Linda, Bill and others as well. Tom Toll gave correct answers to an earlier coverage question while approaching the question in a professional and reasoned manner. Tom Joyce has shared some wonderful coverage insights and ideas behind the scenes with me by email; so have Steve Ebner and Russ Lott. They all are in the elite cadre of savvy adjusters who are educated professionals striving constantly for self improvement, ongoing personal development, and a dedication to total quality service in the delivery of our "knowledge product" to carriers and the public alike. And in the end, that is all we are offering when we serve: our knowledge translated into "product."
In the instant situation, I was correct, but that does not mean that I am right every time. None of us are. Bill says that I "have paid my dues" as an adjuster but I see "paying our dues" as an ongoing process of learning and improving our policy knowledge and coverage question skills.
I try to read at least one new article per day about insurance and I also try to learn at least one new thing. I also try to take at least 4 or 5 classes a year not only to learn, but also to network among other professionals seeking self improvement and personal development. The more I study and learn, the more I realize how little I know. There is a vast amount of insurance literature out there for all of us to try and absorb. No one knows it all, and those who think they do, generally are only ignorant of their own ignorance.
ISO (Insurance Services Office) and carriers are constantly upgrading policies and policy language. To try to keep up with all of the change does indeed take a great deal of effort, continuing education, and the constant goal of self improvement.
Bill is absolutely correct that there is never any substitute for having a copy of the ACTUAL POLICY of coverage for a particular loss. I do keep a copy of the CPCU Handbook with me both at home and when I am on the road. Bill is also correct that the Alliance Kit is an excellent resource as well. He and I both share the same high regard for the Silver Plume CD Rom series which is the penultimate adjuster resource, albeit an expensive one.
Bill, you are correct that the CPCU Handbook does not contain the HO-1 and HO-2 policies, but they are identical in respect to the HO-3 in regard to definitions and other specific items as they relate to the given coverage scenario. Only the coverage perils are different with regard to the instant question, yet in the instant situation that is not important as the windstorm cause of loss is covered even under the HO-1.
I have and will continue to enjoy working with other savvy and professional adjusters, and that includes public adjusters as well.
Dave I will lay you 10 to 1 that Bill would get along fine with either Linda Asberry or myself, because I sincerely believe that he understands policy, and I honestly feel that all three of us (and others as well) are open to intelligent discussions of policy language. The true mark of a professional is in being able to share differing views while maintaining professional respect for the other side's position. I believe that Bill and I in the end would settle the claim fairly for all parties, while honoring the intent and language contained within the applicable policy.
And, I will be more than happy to buy the second round of beers while we continue our discussions of how best to improve the lot of all of us. I know that you, Linda, Bill, Roy, Tom Toll, Tom Joyce, Steve, Russ and many many others including myself, have that as our shared vision and ultimate goal. When we can all approach problems like these with the same professional and educated reasoning, then we all will have in the end lifted this profession to a higher plane worthy of greater respect by the carriers and public alike.
My Thanks to all who share the goal of continued professional development and self improvement.
|Jim Flynt (Jim)
|Posted on Sunday, April 30, 2000 - 11:25 am: |
TOMBSTONE FOLLOW UP QUESTION
The following question concerning the tombstone was received from Linda Asberry by email as a follow up question. It is being posted here for our CADO audience to ponder and answer. I will share my own opinion within a few days.
Both Linda and I are posing this question based on the ISO 04/91 HO-1 POLICY.
Thanks for the vote of confidence!
For the sake of the discussion, let's say that the inscription on that
tombstone was not included in the price of the stone (it seldom is). Then,
would the Special Limits kick in for personal records and I quote,
"regardless of the medium" up to $1,000.00 ? Is the inscription on the
stone "personal records"? I think it is but I would sure hate to see a
claim on a cat get this far. I had to pay $10.00 a letter/numeral.
I have had way too much time to read during the lull. When I was in
Wilmington last fall some of the others laughed at me and referred to me as
their information center. I read all the memos they put in my basket.
Someone had some information to share, took the time to compose it, had it
copied umpteen times and then distributed it. That memo almost always has
something important that I need to know. The company may have changed
pricing on certain items...well, you get my point. I think I'll just keep
reading and hopefully comprehending.
I do appreciate your kind remarks.
DISCLAIMER: THE COVERAGE QUESTION PRESUMES THE ISO 04/91 HO-1 POLICY
|Jim Flynt (Jim)
|Posted on Sunday, April 30, 2000 - 2:24 am: |
Bill, with regard to the 4th paragraph of your email, I do not give "extra credit" for when you MIGHT have been right (IF yours had been the CORRECT edition of the policy form).
Sorry but "close" only counts in hand grenades, horseshoes and slow dancing.
We, as adjusters are called to do it RIGHT each and every time we are called upon to serve an insured and an insurance claim.
It is called total quality management or TQM. Or, it is better known as "zero defects."
|Jim Flynt (Jim)
|Posted on Sunday, April 30, 2000 - 1:14 am: |
Henceforth now, and forever more, I will always reference the particular date of form of the policy, with which a coverage question at hand is being represented so as to avoid any misunderstanding.
For those who have been inconvenienced or misunderstood, please accept my apologies.
|Jim Flynt (Jim)
|Posted on Sunday, April 30, 2000 - 1:03 am: |
The following email from Bill Cook is posted for the benefit of CADO readers:
Response to Jim Flynt
The issues at hand in this exchange of scenarios confirms that review of the applicable policy is the only way to make the correct coverage decision, hence my disclaimer at the bottom of my explanation that reflects policy edition that I used to interpret the coverage. The CPCU handbook of policies is an excellent tool for teachers and students of insurance as it states in its introductory pages. My first response to any claim that I am involved in is to request a certified copy of the forms and endorsements that are applicable to the instant case as that is the only contract of insurance that can apply to the coverage. Since I donít have the copy of the HO1 policy on hand I can not dispute your agreement with Ms. Asbury's determinations of applicable coverage under other structures for the grave stone. Since I was not privy to the applicable policy edition or that coverage C was in effect in the test original question I felt it was necessary to include the appropriate disclaimer appended to my response to avoid eating any crow pie. There may be a 04/00 HO1 edition that covers grave markers under coverage "A" for all I know.
As a response to determine the coverage for fellow students of your coverage forum I did get my First edition CPCU book out to review the HO1 policy form. My first edition CPCU book does not reflect a copy of a HO1 policy edition of any date. I am curious if your CPCU book includes a copy of an HO1 form or if you are reading from a policy that you have on hand. I also looked in my Alliance Policy Kit for Professionals and noted that it did not have a copy of an HO1 included. So I had to rely on the only policy form I could find in the recess of my file cabinet. This is not a real popular form in today's insurance market.
If a modern adjuster were willing to rely and base decisions on anything other than a certified copy of the insured's policy he would have the latest Silver Plume CD-ROM on his computer. It does not contain the CPCU students study guide disclaimers. My wish list for modern tools of the trade includes a Silver Plume subscription. It is a great idea for an adjuster to have a CPCU handbook of policies on hand for reference purposes to reinforce his/her policy skills and a study guide for their courses. I am sure you will agree that The CPCU Handbook should never be relied on by good adjusters to allow interpretations of applicable coverage to an insured where rights of entitlements may be affected.
Surely the menu of crow would not apply to me as you have agreed that all of my answers were correct as they applied to the only policy form I could find and I so qualified the answers. Perhaps if loss notice had included the policy edition and the fact that coverage C was available I would have dug a little deeper. I had hoped for extra credit for finding the additional coverage debris removal that could have been easily overlooked if mine were the correct edition of the policy form.
I appreciate the opportunity to participate in your forum and have the greatest respect for your insurance background and knowledge. I would be honored to buy a beer for you or any of your equals anytime, I consider you to be a professional adjuster that has paid his dues in full.
William S. Cook
(Message edited by admin on January 28, 2002)
|Jim Flynt (Jim)
|Posted on Saturday, April 29, 2000 - 3:47 pm: |
Response to Bill Cook and the examiner at Louisiana Crawfish Mutual Insurance Company.
You are correct that the 04/84 form had a $1,000.00 sub-limit on "grave markers." Had you protested my answer and suggested that you were looking at the 1976 ISO HO-1 form, I would also agree that the 1976 form had a $500.00 sub-limit for grave markers. Now if you really wanted to challenge my answer using the 1943 165 Line New York Standard Fire Policy and argue that there was no coverage whatsoever, I guess I would have to agree with that as well.
If you want to argue the coverage question based on policy forms prior to 1943, I am going to have to go do some research as I do not have those forms readily at hand.
Bill, the sub-limits for "grave markers" were removed from the 04/91 policy form and thus, my answer as outlined stands correct. By the way, the sub-limit applied only to "grave markers" and not to crypts and mausoleum type structures.
But hey Bill, it is the year 2000 and all the companies I know are using the 04/91 ISO Forms.
Get yourself a "NEW" CPCU Handbook of Insurance Policies. It is only $21.00 plus shipping and is available from the American Institute of CPCU website at http://www.aicpcu.org This is good advice for any of you who want to be savvy in your approach to policy questions and coverage issues. No good adjuster worth his salt would ever be without one, whether at home or on the road.
You were correct that there would have been a $50.00 limit on debris removal under the 4/84 policy form. You also made an excellent point, worth noting to newer adjusters, that the deductible is first applied against the loss, and not the sub-limits.
I stand by my answer on the tombstone coverage question based on the 04/91 ISO HO-1 policy form. Any one else want to take a shot at me?
Bill, you and the Louisiana Crawfish Mutual examiner can make it up to me, while eating crow, by buying a couple of rounds of beers for the 3 of us!
|Jim Flynt (Jim)
|Posted on Saturday, April 29, 2000 - 3:12 pm: |
PUBLIC ADJUSTER RESPONSE TO THE TOMBSTONE COVERAGE QUESTION
I received the following email from Bill Cook who disagrees with the policy interpretation of both Linda Asberry and myself for reasons which he outlines. He does make one good point which is worth noting, but he is wrong and I will explain why in a post to follow.
Tombstone Coverage Question:
The examiner at Crawfish Mutual Insurance Company has advised that he has paid the claim based on the theory of liability proposed by you and Ms. Asbury. He now has requested a refund or the name of responsible parties insurers for E&O. He questions your interpretation of coverage on this issue.
Please note, my initial response to this question did correctly state that the gravestone is covered under Personal Property, however, it is limited by Coverage C Special Limits of Liability of $1000.00 for grave markers. Hence, the payment should be as follows:
$2500 - roof damage
$1000 - policy limit for grave markers
$50 - 5% additional debris removal coverage since policy limit exceeded (if it
costs $50.00 to remove the gravestone)
$3550- total net claim payment
Concerning the tree removal coverage, you are absolutely correct in your interpretation of how this applies. However, given the special limit of liability of $1000.00 for the grave marker, and the fact that the grave marker replacement cost is already over that limit by $200.00, and the tree removal is $650.00, the limit of available coverage has been exceeded.
We find later in the policy under Additional Coverages, since the replacement cost of the grave marker is already over $1000.00, there is an additional 5% of that limit ($1000) or $50.00 for debris removal should it cost that much to haul away the grave marker. I assume the $1200.00 for replacement of the grave marker includes hauling the old one away.
Note: the $250.00 deductible applies to the total insured loss of $4350.00 which leaves $4100.00 for a payment of $3550.00.
You are correct, I was low $50.00 in my initial claim payment. Ms. Asbury was right in reading the policy definitions but was wrong in her conclusions. The gravestone is not covered under Coverage B because coverage B refers to residence premises and not insured location. The definition of residence premises does not include anything referring to family cemetery plots or burial vaults. That definition refers to insured location which is used in Section II, Liability Coverage. It would be a covered location for liability purposes but not for Property Coverages.
This interpretation is based on my only available HO1 policy which is a 4/84 edition. This interpretation makes no allowances for Louisiana law that may allow an insured to reach to another portion of the contract for a definition to apply, creating a question of ambiguity which is always favorable to the insured.
(Message edited by admin on January 28, 2002)
|Jim Flynt (Jim)
|Posted on Friday, April 28, 2000 - 4:32 pm: |
ANSWER TO GRANDMA'S GRAVE COVERAGE QUESTION
The correct answer to the question posed earlier this week is: THE ENTIRE LOSS IS COVERED IN FULL BY THE HO-1 POLICY, LESS THE DEDUCTIBLE as follows:
$ 2,500.00 Roof Replacement
1,200.00 Tombstone Replacement
650.00 Tree section removal in order to make repair
$ 4,350.00 Gross Total of all damages
-250.00 Deductible (SIR)(Self Insured Retention)
$4,100.00 Net Payment to Insured
I would like to say that Linda Asberry was correct in her answer, and I like the way she approached the coverage question and her answer. One can tell she is a knowledgable and experienced adjuster who does not miss many details.
Now, here is why the answer is $4,100.00 and how the coverage question should be approached by the savvy adjuster.
As Linda did, the adjuster should first determine if the gravesite is a covered location. Linda did this by reading the policy definitions which say:
"Insured location" means:
g. Individual or family cemetery plots or burial vaults of an "insured";
Linda next checked the definition of "Insured" within the policy to see that it includes this language:
"Insured" means you and residents of your household who are:
a. Your relatives
Thus, by definition, the gravesite and tombstone of the insured's father, Ralph is an "Insured location" and Ralph is an "Insured."
The one thing that I think Linda and Bill Cook both missed on is in the question: What is the tombstone and gravesite? We know by definition the gravesite is an "Insured location" and we also know by definition that neither is "residence premises (which becomes somewhat important later on).
No other mention is made within the policy about gravesites and tombstones, so now we have to figure out whether they are Coverage A, B or C.
They cannot be Coverage A - Dwelling because by definitions under 1. Dwelling and 2. Materials and supplies, both refer to a requirement of being 'on the "residence premises."
They cannot be Coverage B - Other Structures because the definition language says: 'We cover other structures on the "residence premises."
Therefore, by default, the tombstone becomes "Personal Property" and is afforded coverage under Coverage C - Personal Property.
We do know they are covered property by definition and we also know that the cause of loss was windstorm, which is a covered cause of loss for all covered property under the HO-1. How and where they are covered (Coverage A, B or C) are only important in the sense of other exclusions or conditions which may apply to that particular coverage area of the policy and to the specific damage settlement under each different coverage area.
Since the damages to both the roof under Coverage A and the tombstone under Coverage C both occurred due to the peril of windstorm, they are both covered. Coverage A damage and Coverage C damage both include the peril of windstorm under the HO-1 causes of loss.
Further, since the damages under the policy to Coverage A and Coverage C property are both a result of direct physical damage from the peril of windstorm due to an "occurrence" on the same event day, there is only one deductible applied.
I did not mean to throw anyone with my comments about the tree removal cost from on top of the gravestone. The intent was to suggest that it would cost $650.00 to remove what would be a very large tree section from off of the gravesite and tombstone in order to make the repair. The policy provides for up to policy limits to remove a tree "section" in order to make repairs. Removing the tree section in order to make repairs is not the same as cutting the remainder of the tree up and hauling it off the site, which is limited to a $500.00 maximum under the policy.
BUT, if there were additional cost estimates to remove the remainder of the tree from the cemetery for $750.00, there would be absolutely NO COVERAGE for tree debris removal and here is why. Some of you may get confused about the $500.00 policy limit for tree removal, but remember, the limiting language:
1. Debris Removal
We will also [ay your reasonable expense, up to $500.00, for the removal from the "RESIDENCE PREMISES" of: (a) Your tree(s) felled by a Windstorm or Hail.
Remember, we have already established by definition that while the grave is an "insured location" it is NOT "residence premises."
The removal and haul off for the tombstone which was split in half when it fell, WOULD BE COVERED because of the policy language as follows:
1. Debris Removal. We will pay your reasonable expense for the removal of:
a. Debris of COVERED PROPERTY if a Peril insured Against that applies to the damaged property causes the loss.
Since there was damage by the HO-1 covered peril of windstorm to covered property, we have the coverage available only to remove and haul off the damaged item, in this case, the broken tombstone.
I would like to make the point, that in this example, it was important if not imperative for the savvy adjuster to read the policy "definitions," which became so important here in determing the coverage question.
Policy forms do not always define important words, and when the meaning of a term in an insurance policy is unknown, the following four sources should be consulted in order of priority:
1. Definitions listed within the policy
2. Definitions given to the term by previous court decisions
3. Definitions found in dictionaries or other references
4. Meanings from common usage.
I hope everyone enjoyed this case study, and if anyone has comments, please feel free to post here.
|Roy Cupps (Admin)
|Posted on Thursday, April 27, 2000 - 8:20 pm: |
Posted for Bill Cook:
A Public Adjuster's perspective of a Grave problem
If the policy is as described with coverage A only insured would be entitled to net payment of $2,250.00
If personal property coverage were added to policy insured would be entitled to a sum total payment of $3,500.00.
If any adjuster had confirmed more than this amount as an obligation of insurer to an insured, the insured could expect payment under a created estopple existence for any amounts greater than outlined above. The good folks at Louisiana Crawfish Mutual could expect a refund from the independent adjuster's vendor for any amounts they would have to pay due to adjuster obligating company for payment above amounts owed.
William S. Cook
Insured may be entitled to some consideration for a loss from uninsured casualty loss on his taxes.
|Linda Asberry (Linda)
|Posted on Thursday, April 27, 2000 - 10:17 am: |
Jim, No, they haven't lost their minds quite the opposite. Grandma's grave is covered and I quote, "Individual or family cemetery plots or burial vault of an "insured". It is, however, covered under "Other Structures." It plainly states "individual or family" so it doesn't matter because his dad is living with him and is an insured.
HO Form, Definitions, 4.g. It is covered as any other property so the tree removal and repair/replacing Grandma's tombstone is covered up to $9,500.00 or 10% of Cov. A. Now to the tree removal, you didn't say how much of the $1,200 was to physically removed the tree from the cemetery plot and how much of it was for debris removal. On the assumption that the debris removal is less than $500.00 then the total amount due NI is $4,350.00 less $250 deductible for a net of $4,100.
The insurance companies care because they insured the whole kit and kabootle! I would however, go inspect the cemetery plot and take a photo of the damage. That is what we are paid to do, adjust losses by inspecting the damages.
I have recently had experience with having to have family stones repaired due to vandalism. My deductible, 1%, prevented any payment.
|Jim Flynt (Jim)
|Posted on Wednesday, April 26, 2000 - 11:19 pm: |
"Grandma's Grave Coverage Question" (Or, I Swear On My Grandma's Grave)
This is the one of the more interesting and perhaps more challenging claims you may ever see. (Don't laugh, I have had two somewhat similar claims!)
You are assigned a claim in Shreveport for Bob and Carol Crawford, the Named Insureds. Carol's father, Ralph McGillicuty has lived with the N/I since his deceased wife, Irene, died a year ago.
Damage is from the peril of windstorm. Policy is an HO-1. Deductible is $250 and the policy is unendorsed. Coverage A is in the amount of $95,000.00. All damages claimed are from a windstorm of 04/24/00.
You inspect and scope the loss. Windstorm has blown 20 year comp shingles from all areas of roof, and you and N/I agree roof is total damage for remove and replace. Estimate from N/I roofer in the amount of $2,500 is agreed price with adjuster and insured. Roof is less than one year old and assume no depreciation for any covered items damaged.
Insured informs you that Carol's father, Ralph, took his grandchildren to his wife Irene's gravesite yesterday and discovered that a large oak tree had fallen across and totally damaged her tombstone by causing it to fall off it's base and split in half. Bob hands you photos of the damage as well as an estimate for the replacement of the tombstone in the amount of $1,200.00 along with an estimate to remove the tree in order to make the necessary replacement/repair in the amount of $650.00. The photos seem to indicate the damages described, and Bob offers to take you to the cemetery and show you the damages.
What is the amount the insurance carrier, Louisiana Crawfish Mutual owes to this insured for the damages from this windstorm event? Explain.
Why in the heck would the Insureds think the insurance company would cover or care about windstorm damage to a gravesite and tombstone? Have these Insureds lost their minds?