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A video explaining an insurer's dispute or denial of a claim



See the full video at https://youtu.be/PLeDKgsp-1I [195659002] Before an insurer can dispute or deny a claim from its insured, it must carefully examine the claim to prove that loss is a particular exemption from coverage . The Supreme Court of California declared the insurer's obligation and noted that although the task of "distinguishing fraudulent from legitimate claims can sometimes be difficult for insurers," the insurer cannot in good faith deny liability under the policy "but thoroughly examines the basis for its denial. ”[ Egan v. Mutual of Omaha 24 kal. 3d. 809, 157 cal. Rptr. 482 (1979)].

In the case of a first party, the implied agreement on good faith and fair trade forces the insurer to make a thorough examination of the insured's claim for benefits. It is inappropriate for a first party insurer to unreasonably delay or withhold payment of benefits. If the insurer "without appropriate cause" (ie unreasonably) refuses to pay in advance what is due under the agreement, its conduct may act as a liability for damages. a way to avoid payment. An adjuster must work to justify paying for any loss that can be included in the coverage through a thorough investigation, even if it is contrary to the insurer's own financial interests. If the adjuster does not carry out such an investigation with that intention, the insurer opens up for accusations of breach of good faith and fair trade and an assessment of damages. A thorough investigation aims to avoid unnecessary disputes and prevent payment of losses for which there is no coverage.

Before the insurer can deny a claim, it must first conclude that:

  • the claim and the cover were thoroughly examined; [19659007] the basis for the denial was thoroughly investigated.
  • the investigation was carried out with as much interest in the insured's rights as in the insurer's rights.
  • all reasonable doubts and ambiguities regarding the coverage were resolved in favor of the insured;
  • the insurer listened to all information provided by the insured in an attempt to find cover;
  • the insurer sought help from the insured to recover the loss in coverage;
  • all lines were followed, especially those that would favor the position of the insured;
  • the insurer did everything to help the insured to prove that the loss was compensable; and
  • The insurer consulted an experienced local coverage council.

© 2020 – Barry Zalma

Barry Zalma, Esq., CFE, now limits his practice to working as an insurance consultant specializing in insurance coverage. handling of insurance claims, fraud and insurance fraud almost equally for insurers and policyholders. He also acts as an arbitrator or mediator for insurance-related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims lawyer and more than 52 years in the insurance industry. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual Claims Magazine / ACE Legend Award.

For the past 52 years, Barry Zalma has devoted his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to enable insurers and their claims staff to become professional in insurance claims.

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