While legitimate insurance disputes can arise regarding covered perils, methods of repair or the value of a claim, there are other insurance disputes rooted in bad faith conduct by insurance companies. Insurers work diligently to find a defensible position to deny coverage or to avoid adequately investigating the claim.  When insurance companies engage in bad faith practices, they can be liable for damages that exceed the value of the claim.  These damages might include liability for attorney fees, consequential damages, and punitive damages.  Insurance companies aggressively defend against bad faith claims because a settlement or judgment can be extremely costly.  

Claims for insurance bad faith typically involve the handling of a claim under a policy provided by an insurance company for the benefit of an insured.  The range of improper conduct that can justify bad faith liability is so extensive that it is not possible to enumerate all of these many forms of inappropriate practices by insurers.  

Insurance policies generally are comprised of four sections:

  • Definitions
  • Coverage
  • Conditions
  • Exclusions

The benefits offered under a policy, such as indemnity or coverage for property damage is described in the policy.  The coverage section of the policy will be involved in most denied claims because this section of the policy enumerates the benefits a policyholder is entitled to under the policy.

Defenses to denied claims raised by an insurance company usually originate in other parts of the policy.  The definition section of the policy, for example, might be referenced by the insurer because key definitions more specifically describe and limit the benefits provided in the coverage section.

Insurers also might base their defense to a denied claim on the failure of an insured to satisfy a condition.  Conditions are requirements that impose duties on an insured under a policy.  If a policyholder does not comply with a condition precedent to coverage, the insured’s claim might not be valid, so the insurer typically will not be liable.  While policy disputes based on conditions can be factual  based on relevant evidence, they also can be a matter of law which is determined by a judge.  Common types of conditions that impact bad faith litigation include:

  • Duties following a loss (e.g. notice of loss, sworn proof of loss)
  • Responsibilities to cooperate with an insurance investigation
  • Obligation to avoid fraud or concealment

There are a number of policy exclusions that often provide the justification for an insurer’s defense of a claim denial.  The exclusion might be related to the denial of a benefit or a reservation of right, which involves preserving the right to deny the claim at a later point or to pursue a declaratory judgment.

If the insurance company defends against a denied claim based on a policy exclusion, the insurer will assert a factual defense.  In other words, the insurer will allege that the exclusion applies to the specific facts of the case, so the denial was valid.  The insurer has the burden of proof on the issue of establishing that the exclusion applies to the facts of a claim.  By contrast, the insured bears the burden of proof regarding whether the loss occurred during the policy term and the types of coverage provided by the policy.

You can reach Miami Insurance Claims Lawyer J.P. Gonzalez-Sirgo by dialing his direct number at (786) 272-5841, calling the main office at (305) 461-1095, or Toll Free at 1 (866) 71-CLAIM or email Attorney Gonzalez-Sirgo directly at[email protected].

J.P. Gonzalez-Sirgo
J.P. Gonzalez-Sirgo, P.A.
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