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Gary
USA
5 Posts |
 Posted - 01/31/2003 : 20:08:29
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Maybe someone could shed some friendly light on this question. In a HO3 ISO ploicy under section 1 exclusion #1 "We do not insure for loss caused directly or indirectly by any of the following. Such loss is excluded regardless of any other cause or event contributing concurrently or in any sequence to the loss.1 Ordinance or Law. 2 Earth Movement. 3 Water Damage. 4 Power Failure etc..."
I am interested in the words "any sequence." We all have dealt with situations in which a loss was caused by one of these excluded causes and then another loss subsequently took place; the insured wanted the claim covered because "all the damage was caused by the covered loss and none was caused by the excluded one." The words "any sequence" could refer to an occurence either before or after. Here are my questions:
1. Have you ever denied a claim that would have been covered had not one of these exclusions happened in sequence after the covered loss? Please don't reply with what the "spirit of the policy was trying to imply." I just want know what your experience has been.
2. How many different type losses have you denied using the wording "Contributing concurrently or in any sequence?" |
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JimF
USA
1014 Posts |
Posted - 01/31/2003 : 21:50:34
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Gary,
Why don't you give us more specifics of the situation you are adjusting?
What was the first peril causing your loss? What was the excluded peril?
What were the overall damages?
Finally which state is the claim located in? As state case law could play a role in resolution of this type claim.
Thanks. |
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Newt
USA
657 Posts |
Posted - 02/01/2003 : 07:29:15
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I don't have the experience to draw from, however the study I have done, I get the impression that a claim for damages as a result of an excluded peril are denied. In other words the damage would not have occured if there had been no uncovered peril.
My opinion: These type denials would be the result of water, riot or electrical failure off site, in some cases. If the sequence was the uncovered peril first and it was evident that the second event, a covered peril was trigered by it, the claim would be denied.
I don't know if it is a common occurance to deny claims such as these but it would be up to the adjuster to follow the policy.
The carrier may still want the claim worked up, and they would issue the letter of denial. The claim file would have all information should a suit be filed and for future claims info. I am sure the claims office would normally have some details on coverage before they assigned it.
I can see where a falling object could throw this for a loop. The policy reads ANY sequence, cause or event and that doesn't leave much slack for the adjuster.
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Edited by - Newt on 02/01/2003 07:32:39 |
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Gary
USA
5 Posts |
Posted - 02/01/2003 : 19:48:24
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| Jim, my intent in the question was not to bring resolution to a specific claim. I have had to properly apply policy language to claims dealing with a covered sewer backup loss and a non covered flood claim, and non covered flood claims with and additional wind loss creating an opening in the roof and personal property being damaged by both. I simply wanted to broaden my knowledge through the experience of others. It would be benifical to all adjusters when considering a denial to know of examples which are "tried and true"-have held up in in court. I would like to know some instances when you considered the policy language mentioned above and how the claim was settled. |
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Gary
USA
5 Posts |
Posted - 02/01/2003 : 20:54:31
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Jim,
Here is a hypothetical example. I Certian carrier which I will not mention Covers food loss to frozen food if the power failure takes place on the "residence premises" They would also cover the loss if the freezer was damaged due to power surge. What they they will not covered is food loss due to a general power outage ( off premises) The wording in the exclusion section of their policy is as stated above.
Power surge causes damage to a freezer and a few hours later a general power outage takes place. All food was loss. Does the wording under exclusion 1. allow for the claim to be denied?
Most carriers would say pay for the claim. If I were instructed to deny the claim, am I within the law to do so? |
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Denial due to concurrent and subsequent perils
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