Where Questionable Insurance Claims Come From

Wanna blame someone for your high insurance premiums?

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Point to the residents of California, Florida, Texas, New York and Michigan.

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Combined, these five states generate half of the nation’s questionable insurance claims — most of which are either suspect auto policy submissions or fake injury claims.

These states account for 49 percent of all “questionable claims” as tabulated by the National Insurance Crime Bureau (NICB).

Questionable claims are those claims that NICB member insurance companies refer to NICB for closer review and investigation based upon one or more indicators of possible fraud.

NICB just released its three-year analysis of questionable claims in the United States from January 1, 2008 through December 31, 2010.

New York, Los Angeles, Houston, Tampa and Detroit are the cities generating the most QCs. Florida has three cities in the top 10 for QCs—Tampa, Miami and Orlando.

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Of course, a large reason that these states have so many fishy claims is that they are so large. Some 110 million people live in the five states mentioned.

But while they do contain about 36% of the nation’s population, that doesn’t actually explain why these locations create 49% of the questionable claims.

A Year of Unprecedented Tornadoes and Floods — And How Insurance Helps Companies Rebuild

(This is a special guest post written by Barry I. Buchman and Benjamin R. Davidson of Gilbert LLP, a firm that represents companies on a wide variety of insurance issues. Buchman is a partner and Davidson is an associate in the company’s Washington office. – JW)

A young girl beholds the devastating power of Mother Nature following an EF5 tornado in Joplin, Mississippi. (Photo: Dustie / Shutterstock.com)

As floodwaters have threatened Missouri communities along the Mississippi River, and as the town of Joplin, Mississippi, reels from the recent devastating tornado, the residents of these communities are quite appropriately absorbed with efforts to regain some semblance of normal daily life. But, eventually, the waters recede, the debris is cleared, and business owners must turn their attention to rebuilding their businesses and recouping losses sustained.

Depending on the circumstances and the insurance purchased, insurance contracts may help businesses recover losses resulting from damaged buildings, vehicles, equipment and other property. Here are a few of the business losses that may potentially be insured.

Property Damage
The most basic type of loss that may be covered by insurance is property damage. Buildings, equipment, records, vehicles, and other property may sustain direct damage, or damage from disaster events.

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A typical property policy would cover the cost of rebuilding or repairing such property, if the property is “covered property” and if the cause of damage is a “covered cause of loss.”

Commercial property policies also often provide some protection for lost profits that result from damage to “covered property” based on a “covered event,” such as a flood, tornado, or earthquake. These types of losses generally fall into one of two categories of coverage: “business interruption” and “contingent business interruption.” Business interruption losses occur when a company loses profits due to damage to its own facilities. Contingent business interruption losses occur when a company loses profits due to the inability to get materials from a supplier or to sell its products to a customer, due to property damage sustained by that supplier or customer at its facilities.

A third category of loss that may be covered consists of expenses that businesses may incur in order to address the impact to their business of the flooding or tornado. For example, a business may incur expenses to shift production away from a damaged plant to other facilities.

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A business also may incur “extra expense” if, during the period that its normal suppliers cannot operate, the business has to use more expensive suppliers. These types of losses often fall under the extra expense coverage of a typical property policy, which also may cover costs and fees for professional services (e.g., from accounting firms and consultants) that are necessary for the company to deal with the disaster.

Potential Coverage Disputes
One dispute that often arises under property policies is whether there actually has been physical damage to insured property, which, as noted, typically is required for business interruption and contingent business interruption claims. For example, an insured company or its supplier may not have sustained physical damage to its factory, but because of a lack of power or an inability to get people/items in and out of the property, the company cannot use the facility.

Businesses have several tools at their disposal to address such disputes. For example, even if neither an insured company nor its direct suppliers have sustained physical property damage, some courts have interpreted the term “supplier,” for contingent business interruption purposes, to include more than direct suppliers (e.g., suppliers of direct suppliers).

Many property policies also provide types of coverage that may not require physical damage to the insured company’s own premises, such as “civil authority” coverage, “ingress/egress” coverage, and “service interruption” coverage.  Civil authority provisions, for example, typically cover business interruption losses caused by an order, such as a curfew or road closure, that prevents use of insured facilities. For example, due to flooding, the Mississippi Gaming Commission shut down nine casinos in the city of Tunica, leaving the companies with no way to continue generating revenue.

Although such provisions often provide coverage only when the civil authority order results from property damage, civil authority provisions tend to vary materially between policies, and not always in obvious ways, so a careful examination of the precise language is critical.

For example, after the terrorist attacks of September 11, 2001, U.S. Airways and United Airlines each litigated with their insurers over whether their civil authority coverage provisions applied to losses caused by the closure of Reagan National Airport.

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U.S. Airways won, and United lost, the merits of that coverage dispute, based on nuanced differences in the language of their civil authority provisions. (U.S. Airway’s victory was later vacated on appeal, on grounds independent of the merits of the policy interpretation dispute between U.S. Airways and its insurer.)

The same careful review of policy language is necessary for “ingress/egress” provisions and “service interruption” provisions.

Another potential dispute arises from the fact that some property policies contain flood exclusions, and insurers almost certainly will raise any such exclusions as a complete defense to claims based on the recent flooding. But in instances where the floodwaters themselves did not directly cause damage, but instead precipitated events (such as fires) that caused damage, businesses may have rights to coverage under insurance law concepts like the “efficient proximate cause” and “concurrent causation” doctrines.

Although the insurance industry has attempted to contract around these causation doctrines through the use of so-called “anti-concurrent causation clauses,” courts have taken differing approaches to the scope and enforceability of these clauses. Thus, as in many insurance disputes, the issue of which jurisdiction’s law applies to these issues will be important.

Insurers also may challenge the efficacy of loss mitigation measures that businesses adopt to address the effects of the recent tornado or flooding. Typical property policies require business owners to take reasonable steps to minimize losses, and insurers often question, after the fact, the measures that businesses take to do that. Businesses should be prepared to rebut any such hindsight-based arguments, and to defend their business decisions. Furthermore, under many property policies businesses may be able to recover expenses incurred in order to mitigate loss.

Practical Pointers for Preserving Insurance Rights
There are steps that businesses can and should take now to put themselves in the best possible position to secure coverage if and when the need arises.

  • First, businesses should collect, organize, and review their insurance policies. This process should include an effort to identify and obtain policies issued to other businesses, such as current and former affiliates, that may also provide coverage.
  • Second, most property policies require policyholders to provide notice of potential claims and to submit “proofs of loss” quickly, and these policies also often have express deadlines for when any lawsuit against the insurer must be brought if there is a dispute.
    For example, many property policies require that businesses “immediately” give notice of a loss that may give rise to a claim, and policies often further require that a policyholder submit a “proof of loss,” documenting the insured damage, business losses, and expenses, within 60-90 days. These policies often also require that any lawsuit against the insurer be brought within one or two years. It is critical that businesses promptly give at least precautionary notice, absent business reasons to refrain from doing so. Business owners should also keep their insurers informed of their efforts to mitigate their damages and to reopen their businesses, in order to limit future disputes.
    Moreover, businesses should consider approaching their insurers about postponing, or “tolling,” the referenced proof of loss and lawsuit deadlines, by agreement. Insurance companies often are willing to do so in situations that involve widespread losses, like those that can be anticipated with the recent tornado and flooding. Note, however, that some jurisdictions differ in their rules regarding the extent to which parties can enter into such “tolling” agreements, and thus an examination of the applicable law is necessary.
  • Third, businesses should carefully document their property damage, lost revenues, and additional expenses, and they also should set up protocols for communicating both internally and externally about any losses and insurance issues. Because of the nuances in the coverage issues raised, such protocols are important to help protect against inadvertent characterizations regarding the nature or cause of losses, for example, that insurers might use later if a coverage dispute arises.  Thus, businesses should consider involving their legal departments and insurance lawyers in such communications.
  • Finally, because of the complicated coverage questions and potential procedural traps previewed here, businesses should consider consulting with experienced professionals, such as insurance brokers, accounting consultants, and coverage counsel, who can help prepare for a potential coverage claim.

The coverage provided by a business’s insurance policies can be an extremely valuable business asset.  Business owners can maximize the benefits of insurance, and minimize the chances of protracted disputes later, by acting proactively now to assess and preserve their rights.

Georgia Storms Cause $32 Million in Insured Losses

Georgia has been through some pretty intense weather this week. Severe storms ripped through Georgia and neighboring states, ushering in high winds, hail, lightning and at least 20 tornadoes.

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It has been reported today that seven people were killed in Georgia alone and hundreds of thousands were left without power.

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Needless to say, communities in the area are left with much to clean up.

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And insurance companies are left with a lot of claims. In fact, insured losses from the storms in Georgia are estimated at $32 million, according to Georgia Insurance Commissioner Ralph T. Hudgens. This number does not include uninsured losses and is likely to grow, he warned.

“We’ve been quite busy the last couple of — actually we’ve been busy this year,” said Richard Tison, a Claim Representative for State Farm. And the damage is not just in one place.

As Georgia residents continue the cleanup process, most can do so knowing that their electricity has been restored. As of this morning, only 300 metro Atlanta residents remained without power.

The Top 25 Property/Casualty Insurance Writers

No, neither Johnathan Franzen nor myself made the list. We’re talking about the companies that wrote the most business in 2010. Here’s the full list of the top 25 U.S. carriers in terms of net premiums written, according to AM Best.

1. State Farm Group—$50,808,635
2. Allstate Insurance Group—$24,796,656
3. Liberty Mutual Insurance Cos.—$21,483,996
4. Berkshire Hathaway Insurance—$21,358,316
5. Travelers Group—$20,594,458
6. American International Group—$19,687,720
7. Nationwide Group—$14,489,531
8. Progressive Insurance Group—$14,476,676
9. Farmers Insurance Group—$14,129,512
10. USAA Group—$10,679,414
11. Hartford Insurance Group—$9,688,760
12. Chubb Group of Insurance Cos.—$8,927,736
13. CNA Insurance Cos.—$6,188,618
14. American Family Insurance Group—$5,324,290
15. Allianz of America—$4,666,301
16. Auto-Owners Insurance Group—$4,485,442
17. Munich-America Holding Corp.—$4,413,834
18. Zurich Financial Services NA Group—$4,400,123
19. Erie Insurance Group—$4,019,273
20. Ace INA Group—$3,705,475
21. Transatlantic Holdings Inc. Group—$3,418,020
22. W.R. Berkley Group—$3,392,330
23. The Hanover Insurance Group Property & Casualty Cos.—$3,053,508
24. MetLife Auto & Home Group—$2,983,236
25. Cincinnati Insurance Cos.—$2,965,462