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alanporco
USA
112 Posts |
 Posted - 03/26/2004 : 09:41:48
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| Czar, definitely get, the roofer on the roof if you can. I've found that if their claim of covered damage is bogus, they won't show. If they are ignorant, you can educate them as to what is covered and what is normal wear & tear, deterioration due to age, etc. And maybe you missed something. Reinspecting a roof at a different time of day can help locate damage that was unseen on the first inspection due to the difference in lighting conditions. If you are still unable to resolve the claim, notify your supervisor of the problem (basically, let them make the call). If you disagree, be sure there is a notation in your file that the decision to replace was made by the supervisor (standard CYA). |
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Johnd
USA
110 Posts |
Posted - 03/26/2004 : 10:38:37
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| Actually, I have had pretty good luck by getting the roofer on the roof, handing him/her a piece of chalk and telling them to make me a test square to prove the damage. You would be shocked at some of the "test squares" I have had the pleasure to "review." AND, a few times a GOOD roofer has shown me a very good test square that has immediately changed my mind. |
John Durham
sui cuique fingunt fortunam |
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trader
USA
236 Posts |
Posted - 03/26/2004 : 11:35:52
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Only comment after reading Alan and JohnD is: If you find no hail damage with poor light conditions such as dusk or cloudy days, and everyone is upset I suggest you reinspect on the next bright sunny day and you will see what you could not see under poor light conditions. I have apologized several times to the "upsetee".This was on light color shingles. In any light conditions
charcoal or black singles are very trickey, you may need the putty knife to feel underneath. I have been wrong so many times on new charcoal that I request permission to inspect the house next door sometime.
An ole timer said he would have a poor year if he was not inspectiong on Easter morning. |
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Czar
USA
66 Posts |
Posted - 03/26/2004 : 18:16:25
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JohnD/alanporco:
I usually meet with all roofers, as they are running around forcing uninformed insureds into signing a contract that basically entitles them to their first born and in some cases their second. The one problem with handing a roofer a stick of chalk, is that once he has completed circling every defect, tool mark, foot traffic, deterioration mark,(heck I've even had a roofer circle a mark that he made when he dropped his tape), the insured notes all of these circles and comes to the conclusion that its an early Christmas this year, and there never seems to be a way to get this out of their mind.
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alanporco
USA
112 Posts |
Posted - 03/26/2004 : 19:44:54
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Czar, The scenario you just described in very common. After the roofer has marked everything he considers to be damage, you can either point out the marks that are wrong or kick it over to a supervisor. If the roofer has marked a lot of stuff that is not covered damage, your supervisor will probably think better of you for not just caving in, albeit the supervisor might authorize you to pay more but, at least, then it's the supervisor's call. (Do not forget the CYA note.)I've had a roofer try to tell me that bullseyes on wood shakes are caused by hail hits and that curling of shakes is caused by high winds.
Here's another thought (something I've done): Many CAT adjusters are former roofers. If you have a really problem claim and the supervisor can't or won't help you, see if one of the adjusters at the CAT site has a roofing background. Offer to buy dinner if that adjuster will go with to show the roofer what's what. It is well worth it to able to close a problem claim. |
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KileAnderson
USA
875 Posts |
Posted - 03/26/2004 : 21:16:17
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| I don't see the problem. Inspect. If no damage, deny. If they call back and say there is a roofer who says there is damage and "everyone on my street got a new roof", meet with the roofer. If he can show you hail damage and convince you that the roof is in need of replacement, pay for it. If not, deny again and close the claim. If they call back, just say "Sorry, I've inspected, reinspected, no damage found, claim is closed." If you are in this business to make friends, maybe you need to find another business. |
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KileAnderson
USA
875 Posts |
Posted - 03/26/2004 : 21:17:32
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| Oh, and another thing, remember, when the roofer is circling every blemish on the roof, you don't have to explain what it is, just what it isn't. If it isn't hail damage and you are sure of it, say so and move on. |
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rbryanhines
22 Posts |
Posted - 03/26/2004 : 21:31:42
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| The bottom line when adjusting a claim is to follow the guidelines in claims handling (time tables, documentation, ect..). Assuming the above mentioned is done, then all that’s left is to make the right call. Your job is to adjust the claim properly. It is not to make the Insured feel "warm and fussy". Inspect once, if there is no damage then submit the file with no damage. If the insured or his roofer feels there is damage then reinspect. If your reinspection confirms your first opinion, explain to the insured your position and his right for appraisal under the policy. You've done your job, so sleep well. |
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LarryW
USA
126 Posts |
Posted - 03/26/2004 : 22:17:43
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| rbryanhines: The appraisal process outlined within the homeowner's policy is only meant to be used in the event that there is a disagreement over the amount of the loss. Not the cause of loss and not the fact that a loss occured. If everyone agrees the roof is a total and disagree about the cost to replace it, then the appraisal process is appropriate. If the disagreement is over the cause of the loss, the appraisal process is inappropriate. If the disagreement is over the fact of a loss (as in whether the roof was damaged or not), then the appraisal process is inappropriate. |
Larry Wright |
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alanporco
USA
112 Posts |
Posted - 03/26/2004 : 23:08:48
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| LarryW, What policy provision would be available to a policyholder per your post @22:17:43 if there is disagreement involving cause or something other than the cost? Don't say the policyholder can sue. Oh, they can sue, BUT the court will send it back to the appraisal process because that must be done before one can sue. |
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LarryW
USA
126 Posts |
Posted - 03/26/2004 : 23:31:38
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| alanporco: The appraisal process is purely optional. Both parties have the option to invoke it. It does not have to be utilized. It can or should only be utilized only for its stated purpose which is to resolve a disagreement about the amount of the loss. The only option I am aware of, other that the policyholder filing suit)is that arbitration may be undertaken, but then only if both parties agree to do so. And that is typically outside the adjuster's scope of authority. I am no attorney, but i doubt the court would send it back. The court cannot invoke the appraisal process, only the two parties to the contract may do so. |
Larry Wright |
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alanporco
USA
112 Posts |
Posted - 03/27/2004 : 00:09:09
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LarryW, I don't know of any policy that provides for arbitration. Appraisal is basically arbitration. The insurance industry likes to use their own jargon; unfortunately, they choose words that have different meanings to the rest of the world. As an example: Depreciation. Ask any CPA what depreciation is to an accountant, it is different than the depreciation used by the insurance industry. I started in this industry as a broker of primarily commercial insurance. I can remember many an accountant going nuts trying to figure out what information was needed to complete Loss of Earnings applications; same or similar words, different definitions.
I have seen 2 claims where the policyholder sued without first going through appraisal. In both cases, the court said that, per the policy, all terms of the policy must complied with before suit can be brought. Here I refer you to the policy section titled "Legal Action Against Us." I live in California, maybe the courts here do it different than where you reside.
The Appraisal clause states that if there is a disagreement about cost, either party can invoke appraisal. If the adjuster/insurance company says only half the roof is damaged and make their settlement offer based on that and if the insured believes that the entire roof is damaged, obviously there will be a disagreement about the cost. Thus appraisal. I have also seen insurance companies use appraisal in these cases when they feel they are right. Often times they win because the insured based their position on what some contractor had told them. |
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rbryanhines
22 Posts |
Posted - 03/27/2004 : 01:56:43
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Actually Larry, it depends what state your in. Some states don't allow arbitration. In those states, everything (cause and cost) is handled under appraisal. You're correct that in some cases appraisal is optional. However, a judge will typically send the case to arbitration/appraisal before he/she hears the case. My point was that as an IA adjuster just handle the file in a professional manner and make the right call. After that let management handle it.
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LarryW
USA
126 Posts |
Posted - 03/27/2004 : 02:45:19
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Alan: You are right, I guess, appraisal is similar to arbitration. But it is different. Arbitration is a process where a panel of people or an arbiter will hear both sides of an issue and the panel or arbiter will determine which party is correct. The policy does not provide for arbitration. I was responding to your question concerning an insured's options, but re-reading your earlier post I see that you asked what policy provisions are available to the Insured. The insured has one option (in the case of disagreement)under the policy: Invoke the appraisal clause of the policy. All of his other options are extra-contractual. If an insured files suit without invoking the appraisal process, the company may invoke the appraisal clause and may make that point in their responsive pleadings. That being the case, the courts will, as you point out, require compliance per the "legal action against us" provisions of the policy.
If both parties agree that half of the roof is damaged and they agree on the "amount of loss" or cost to repair that damage, there is no dispute. The insurance Co. should pay the undisputed amount of the claim. Concerning the other half, the dispute is not about the "amount of loss" or cost of repair, but instead the fact of loss or cause of damage is being disputed and that is not subject to the appraisal clause of the policy. As you point out, jargon comes into play or gets in our way here. The first thing the adjuster hears when he/she offers settlement is "I do not agree with the amount of the loss which you are offering. My roofer says it will cost $5,000 to replace my roof, but you say my loss is $2,500 to replace half of it".
I guess the best way to explain it is that you have to agree on the loss (damage) before you can agree on or dispute of the amount of that loss. In this example, the loss is not agreed. Unless or until you can agree on the scope of the loss, the amount of the loss can neither be determined nor disputed.
Suppose a roofer insists the roof is hail damaged and needs to be replaced and gives you an estimate of $5,000. You inspected it and you found no hail damage. Is your dispute over the amount of the loss? No, you are disputing that there even was a loss. A question of fact for a court to decide.
On the other hand, if you agree the roof needs to be replaced because of hail damage, but your estimate is $4,000, then you disagree on the amount of the loss. Now lets go to appraisal. |
Larry Wright |
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LarryW
USA
126 Posts |
Posted - 03/27/2004 : 03:13:38
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| rbryanhines: Hurricane strikes with major flooding. Policyholder has no flood insurance. The insured's oceanside house is insured by your homeowners policy in the amount of $300,000. There was one inch of rain with the storm, but six feet of floodwater (with a clear water mark) inside the insured dwelling. You agree with the insured's contractor that the wind damage on the roof will cost $250 to repair, but he says the interior damage of $260,000 is form roof leakage. The insured demands appraisal. Now what? |
Larry Wright |
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Is granule loss considered hail damage?
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