It is no secret that insurance adjusters will not hesitate to mention several insurance provisions that justify a refusal of claim. I refer to this method as the "kitchen sink" method, as it accurately describes the attempt to take advantage of all possible exceptions / conditions that are remotely applicable in various insurance claims. It is quite common for an insured to receive a rejection letter with reference to a laundry list with excluded reasons for loss. [Insert Insurance Company name here] has determined that no coverage is provided for conditions due to wear, deterioration, deterioration, inherent screw, latent defect, defect, mechanical degradation and / or improper installation as it affects conditions on your roof whether observed or not. Consequently, no payment will be made at this time.
The letter then goes on to cite the value of a few pages of exclusionary language, half of which may be irrelevant to the subject matter. Although this method is questionable in the face, it is consistently used for three very specific reasons / goals. The first, and without a doubt the most important reason, is to use as many arguments as possible at their disposal to deny claims and ultimately save money. Furthermore, this method serves to discourage policyholders from applying for an otherwise meritorious claim, as they now have the impression that their insurer can rely on several exceptions / conditions for insurance that justify their coverage decision. Finally, insurers rely on several provisions to "cover the back" if the policy provision they would otherwise have trusted would prove to be seriously inapplicable in the future.
This strategy presents only problems, but perhaps even more serious is when the letter of denial cites conflicting policy provisions that try to justify their refusal of the claim. An example is when an insurer cites one of the many exceptions listed above, such as wear and tear, and also claims that they were affected by their investigation due to late reporting of the damage. For example, I have seen many letters of denial with languages almost identical to the following:
Based on the inspection, our investigation determined that the damage to your roof appears to be related to lack of maintenance, wear and tear, which is not covered by your policy. (Emphasis added.)
Due to the time that has elapsed since the alleged loss date, [Insurance Company] is unable to determine the cause of the alleged damages, and has therefore had prejudices in his investigation. (My emphasis added.)
No expert is required to see the inherent contradiction that arises by simultaneously relying on these provisions to deny a claim. This raises a question that reveals the logical inconsistency: How can you determine that the damage was due to an excluded danger if you could not determine the cause of loss due to delayed notice? [1
Florida Statute 626.9541 (1) (i) (3) (f) states the following:
Fails to immediately provide a reasonable written explanation to the insured of the basis of the insurance policy, in relation to facts or applicable law, for refusal on demand or for an offer of a compromise settlement.
Furthermore, Florida Statute 626.9541 (1) (i) (3) (b) provides:
Misrepresentation of relevant facts or insurance provisions relating to coverage in question.
It seems obvious that both claim that you "determined" the cause of the loss while claiming that you "could not determine the cause of the loss" do not provide a reasonable explanation for rejecting a claim. In the same way, it is difficult to imagine a convincing argument that it is not a manifest misrepresentation of insurance provisions that concerns the coverage in question. Nevertheless, insurance companies and their representatives will continue to cite conflicting policy provisions in an attempt to achieve their goals, and lawyers, such as those in the Merlin Law Group, will continue to hold them accountable.