Evaluation according to an insurance involves a contractual process through which the insurer and the insured select a third party to determine the amount of a damaged loss when the insurer and the insured can not agree on the amount of the loss. This appeal raises the question of how an insurer's payment of an evaluation contract triggers the deadlines and penalties for the act that requires insurers to process and pay insurance claims in a timely manner – the Texas Prompt Payment of Claims Act (TPPCA or Act).  In Sanford Crayton v. Homeowners Of America Insurance Company No. 02-20-00037-CV, Court of Appeals Second Appellate District of Texas at Fort Worth (December 23, 2020), Sanford Crayton left a wind and hail claims on his homeowner's policy against his insurer, Homeowners of America Insurance Company. Eventually, Crayton's claims boiled down to the question of whether the homeowner violated the TPPCA by initially rejecting his claim but later paying an appraisal price on the claim after Crayton sued. from an independent adjudication agency visited Crayton's property and investigated the claim. The adjuster concluded that the damage to Crayton's home amounted to approximately $ 300, calculated on the basis of both a replacement cost value and a real cash value. The adjuster also estimated the damage to a fence and an outbuilding to a total of approximately USD 2,200, calculated on both a replacement cost value and an actual cash value.
Within six days of the inspection, the homeowner notified Crayton by letter of the adjuster's results and of the fact that the estimated damages were less than his policy deductible. The homeowner's letter told Crayton that he would notify the homeowner if further damage was found or if a contractor who made repairs estimated the damage to be higher than the adjuster's results.
There was no more communication between Crayton and homeowners until more than a year later. Homeowner Letter When Crayton, in January 2016, sent homeowners a letter of request in which they claimed that homeowners had failed to adjust and pay Crayton's claims adequately. The request for enumeration listed a number of alleged unfair settlement methods and incorrect presentation of the insurance policy. The letter claimed that Crayton's property had suffered $ 31,000 in damages and that he had had $ 3,900 in expenses and $ 30,000 in law firms to date.
There was no more communication between Crayton and homeowners until more than a year after the homeowners' letter when, in January 2016, a lawyer sent Crayton homeowners a petition claiming that homeowners had failed to adjust and pay Crayton's claims appropriately. The trial court granted the homeowners' proposal.
The assessors concluded that, before the application of the deductible in Crayton's policy, Crayton's compensation cost for loss was approximately $ 13,000 and that the actual cash value of the loss was approximately $ 11,000. Homeowners paid about $ 9,000 to Crayton "[i] according to the appraisal price."
Crayton responded to the homeowners' summary assessment proposal, but he did not attach any conflicting evidence to his answer. Instead, Crayton noted the latest authority from the Texas Supreme Court that the payment of an appraisal price did not isolate an insurance company from a TPPCA claim. The trial court denied reconsideration and a new trial by written order. Crayton then filed an appeal.
The TPPCA sets a number of deadlines for insurance companies to process claims and penalizes a failure to meet their deadlines by assessing the interest rate on the claim at a rate of eighteen percent per annum and paying the insured's law firms.
This appeal concerns the interplay between the section of the law requiring payment within sixty days, the law's enforcement provision, and whether the interrelationship creates a factual question that the time of the homeowners' payment of the appraisal price violated these provisions.
The final game in the TPPCA process is an investigation and evaluation of the insurer that culminates in a decision either that the damage is covered and that the loss amount exceeds the deductible, in which case the insurer must notify the insured that it will pay the damage, or that the claim is rejected, in in which case the insured must notify the insured of the reasons – for example because s is not covered, the loss amount does not meet the deductible or for any other reason according to the insurance.
When an insurer rejects a claim, the insurer can only be liable under section 542.060 if the latter accepts the claim or is deemed to have incorrectly rejected the claim. Here, the insured submitted a case after the insurer examined, evaluated and finally rejected the claim. The insurer invoked the evaluation provision because the insured questioned the insurer's decision that the amount of the loss was lower than the insured's deductible, which resulted in the rejection of the claim. assessment, the difference between the original adjustment and the assessment is not likely that homeowners and homeowners do not violate section 542.058 of the Act.
Without telling the court if he is trying to establish a violation of section 542.058 or section 542.060, Crayton argues that "there is some evidence to support the assessment of [Homeowners’] liability for [his] claims."
Payment of an evaluation price does not trigger a violation of section 542.058 (A) of the TPPCA.  To read the evaluation process in section 542.058 (a), the payment of an assessment is required to be linked to the process in section 542.055 by making the payment an act showing the insurer's failure to act after having "all objects, statements and forms reasonably requested and required under section 542.055. "
Homeowners paid by noting that they did so "[i] in accordance with the appraisal price."
Homeowners' payment of the appraisal did not constitute a retroactive approval of Crayton's claim that triggered the TPPCA deadlines. nor did the payment of the valuation certificate have a probative value as to whether the homeowners 'original damages decision was erroneous, raising an actual question of the homeowners' liability.Finally, the Court of Appeal concluded that when an insurer pays an assessment after a 60-day time limit in one of the laws, TPPCA and that the insurer can release itself from that infringement only by proving that it had no liability because the insured's claim is "invalid".
In a statement of more than 50 pages, the Court of Appeal clarified that when an insurance company rejects a claim because its assessment showed that the loss was less than the policyholder's s deductible, it does not violate the statute or act incorrectly when it paid the claim in accordance with an assessment. Evaluation awards presuppose that the amount of the loss is assessed and an insurance company is forced to pay for the judgment. By paying before it becomes a judgment Homeowners acted properly and deserved the favorable result after a lengthy review of a decision of the Supreme Court of Texas.
© 2020 – Barry Zalma
Barry Zalma, Esq., CFE, now limits his practice to employment as an insurance consultant specializing in insurance coverage, insurance claims handling, fraud and insurance fraud almost equally for insurers and insurers. 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 business. He is available at http://www.zalma.com and firstname.lastname@example.org.
Mr. Zalma is the first recipient of the first annual Claims Magazine / ACE Legend Award.
For the past 53 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 insurance claims staff.
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