Claims denials

• Author: David Frangiamore
• Pages: 447-476

CLAIMS DENIALS

9-1

CHAPTER 9

CLAIMS DENIALS

§900 IN GENERAL

§910 FIRST PARTY DENIALS

§911 No Insurable Interest or No Covered Loss Location

§912 No Coverages

§913 Expiration of Statutes of Limitation and Tolling Issues Related to Suing an Insurer

§914 Failed Conditions of Policy

§914.1 Late Notice by Insured of Insurance Claim

§914.2 No Cooperation—Failure to Submit to Examination Under Oath

§914.3 No Proof of Loss

§915 Fraud by Insured

§916 Material Misrepresentation

§916.1 Life Insurance

§917 Intentional Act

§917.1 Criminal Act

§918 Policy Cancellations and Policy Rescissions

§919 Date of Loss Outside Policy Term and Trigger of Coverage Issues

§920 POLICY EXCLUSIONS

§921 Exclusion Riders

§921.1 Driver Exclusion

§921.2 Vehicle Exclusion

§921.3 Territory Exclusion

§922 Punitive Damage, Penalties, and Fines

§923 Family Member Exclusion Void: Public Policy

§930 WORD GAMESEXAMPLES OF HOW UNDEFINED POLICY TERMS CAN RESULT IN COVERAGE

§931 Not a “Vehicle”

§932 Not an “Insured”

§933 Not an “Agent”

§934 Not an “Accident”

§935 Not a “Roof”

§936 Not a Reasonable and Necessary Medical Treatment

§937 Not an “Occupant” of a Vehicle

§937.1 Vacant or Unoccupied Buildings

§938 “Use” of Vehicle; “Loading and Unloading”

§939 “Employee” v. “Independent Contractor”

CLAIMS DENIALS

How Insurance Companies Settle Cases 9-2

§940 THIRDPARTY DENIALS

§941 No Coverage in Force

§942 No Liability on the Part of the Insured

§942.1 A Trap for the Insurer

§943 Fraud by Insured or Third-Party Claimant

§943.1 Not a “Claim”

§944 No Cooperation

§945 The Running of the Statute of Limitations

§946 Intentional Act

§946.1 Intent Diff‌icult to Prove

§950 DUTY TO DEFEND VERSUS DUTY TO INDEMNIFY: WHAT IS THE DIFFERENCE?

§951 Dangerous Stand by Insurer

§960 BLIND DENIALS

KEY POINTS TO REMEMBER