When policyholders experience a loss after faithfully fulfilling their obligation to make premium payments, it is reasonable to presume that the insurance carrier will cover a loss when disaster strikes.  Unfortunately, many claims are denied or underpaid when policyholders lack legal representation.  Sometimes policyholders notify their insurance company of a claim and presume it is being resolved only to discover that they have run afoul of some policy term or condition.  There are other times that an insured does not pursue a claim because it does not appear that the claim is covered.  An experienced insurance claims attorney will carefully analyze the policy language and may be able to develop a persuasive argument for coverage. 

The recent case of Rodrigo v. State Farm Florida Insurance, Case No. 4D12-3410 (4th Dist. 2014) provides a compelling example of how easy it is for an insured to make a mistake in pursuing a claim when unrepresented.  The insured made a claim for property damage to her condominium, the property within the condo and related expenses.  While she never filed a sworn notice of loss, she did supply invoices and a list of specific damages.  An adjuster for the insurance company directed a contractor to inspect the policyholder’s condo.  The insurer tendered payment to the insured who rejected the payment because it did not cover personal property damage.

Failure to Provide a Proof of Loss

The language of the policy specifically provided in pertinent part:

“Loss Payment. We will adjust all losses with you. . . . Loss will be payable 60 days after we receive your proof of loss and:

a. reach agreement with you;

b. there is an entry of a final judgment; or

c. there is a filing of an appraisal award with us.”

The appellate court upheld the trial court’s ruling that filing a sworn proof of loss was a condition precedent for payment of the claim under the policy.  The policyholder contended that the insurer waived the proof of loss prerequisite for payment of a claim by tendering payment.  However, the court noted that an insurance company does not waive any policy provision or defenses by investigating a claim or negotiating a potential settlement.

Because the insurance company did not waive the sworn proof of loss requirement, the insured had to rebut the presumption that the insurance company suffered prejudice.  The policyholder did not present any evidence rebutting this presumption, so the court upheld the trial court’s ruling in favor of the insurance company because of the policyholder’s failure to provide the proof of loss.

While the policyholder’s belief that submission of invoices and other documents satisfied the notice requirements, this decision demonstrates the importance of careful compliance with all conditions and policy terms when pursuing a claim.  When policyholders are represented by an experienced Florida homeowner’s insurance claims attorney, the lawyer can assist an insured in navigating the procedures necessary to obtain the full value of a claim.

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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