Insurance Claim Decision

How to Dispute an Insurance Claim Decision

Once it is established what the claimant’s standing is in relation to the insurer that helps determine the available courses of action to dispute the insurer’s claims decision. In a third-party liability case, the absence of a direct contractual relationship limits the claimant’s pre-judgment or pre-settlement options. If the claimant is unhappy with the amount offered by the tortfeasor’s insurer the most common available remedy is to bring suit against the tortfeasor directly. The tortfeasor will be defended and indemnified by the insurer. The claimant/injured party’s best avenue for relief is to file a civil remedy/bad faith demand following the procedures set forth in Fla. Stat. § 626.9541 which can enable the injured party/claimant to recover from the insurer the full judgment amount (without regard to the policy limits) should the injured party/claimant prevail in court. The principle of extending the insurer’s exposure for payment beyond the policy amount is simple: a policy holder places his or her trust in the insurer to defend and indemnify the claim and attempt to resolve it within the limits of the policy. The insurer controls the defense and settlement of the claim—which can often far exceed the policy amount. So, a $100,000 claim can be in the hands of an insurer with $10,000 of risk (a $10,000 policy). To prevent insurers from wrongfully refusing to settle valid claims (and thereby exposing its insureds to judgments far in excess of the coverage amount) Florida’s common law and statutory bad faith remedies provide a mechanism whereby an insurer who in bad faith fails to settle a claim within the policy amount may be liable for the full amount of any future judgment.

Uninsured Motorist Disputes

For uninsured motorist disputes, where the issue in question is damages, some policies call for arbitration of the damages dispute. The language of the policy should be consulted closely. A claimant is not required to sue the owner/driver of the uninsured vehicle before bringing an action for uninsured motorist coverage. Such a requirement is considered void as against public policy even if the language of the insurance contract requires it.

Property Damage Disputes

For property damage disputes involving simply the amount of damages (how much will the damaged property cost to repair or replace) an insurer may force a process of appraisal to resolve the dispute. Each side selects (and pays for an appraiser), who then select a third neutral appraiser. A lawsuit can be brought, however, to compel an insurer or policyholder to participate in the statutory or contractual appraisal process if a party drags its feet. Some courts even hold that a court can compel an appraisal involving the insured even if the insured has assigned the insurance benefits. Fla. Stat § 627.428 is said to be a one-way attorney’s fees statute in favor of insureds so the insurer would generally not have a claim to attorney’s fees for a successful petition to compel appraisal. To justify the award of attorney’s fees and costs against the insurer most courts have held that the insurer’s conduct (i.e. refusal to participate in the appraisal process) must have forced the filing of a lawsuit. Accordingly, the insurer’s mere act of participating in appraisal after a lawsuit to compel appraisal is brought does not automatically warrant the imposition of an award of attorney’s fees and costs against the insurer. It seems that courts will engage in a case-by-case inquiry into the insurer’s conduct when determining entitlement to attorney’s fees and costs on a motion to compel appraisal.

P.I.P. Disputes

The dispute resolution process for a P.I.P. claim is a bit more technical. While persons covered under the P.I.P. policy (or their assignees) may bring suit to enforce the contract and obtain payment of contractual benefits due, specific conditions must be met first which include the filing of a proper presuit demand letter. The process is outlined in Fla. Stat. § 627.736 and states that before a Plaintiff can file suit against an insurer, the insurer must be provided with written notice of an intent to initiate litigation. Such notice may not be sent until the claim is overdue, including any additional time the insurer has to pay the claim pursuant to Florida law. The notice required shall state that it is a demand letter and must state all of the following information:

• Name of the insured upon which such benefits are being sought, including a copy of the assignment giving rights to the claimant if the claimant is not the insured.

• Claim number or policy number upon which such claim was originally submitted to the insurer.

• Names of any medical provider who treated the claimant and must include the types of treatment, services, accommodations, or supplies that form the basis of such claim.

• An itemized statement specifying each exact amount, the date of treatment, service, or accommodation, and the type of benefit claimed to be due.

• A completed form satisfying the requirements of paragraph (5)(d) or the lost-wage statement previously submitted may be used as the itemized statement.

• If applicable, a copy of the insurer’s notice withdrawing such payment and an itemized statement of the type, frequency, and duration of future treatment claimed to be reasonable and medically necessary.

Each notice is required to be delivered to the insurer by United States certified or registered mail, return receipt requested. Such postal costs shall be reimbursed by the insurer if so, requested by the claimant in the notice, when the insurer pays the claim. Such notice must be sent to the person and address specified by the insurer for the purposes of receiving notices under this subsection. Each licensed insurer, whether domestic, foreign, or alien, shall file with the office designation of the name and address of the person to whom notices pursuant to this subsection shall be sent which the office shall make available on its Internet website. The name and address on file with the office pursuant to § 624.422 shall be deemed the authorized representative to accept notice pursuant to this subsection in the event no other designation has been made. If within 30 days after receipt of notice by the insurer, the overdue claim specified in the notice is paid by the insurer together with applicable interest and a penalty of 10 percent of the overdue amount paid by the insurer, subject to a maximum penalty of $250, no action may be brought against the insurer.

Contact an Experienced Personal Injury Attorney Today!

There is no replacement for quality legal advice after being involved in a car accident. The car accident attorneys at Suarez and Montero would love to have an opportunity to explain the law in Florida to assist you in presenting a strong claim against the at fault party. Every firm is distinctive and auto accident victims have needs that are also distinct. needs are different. The Florida auto accident attorneys at Suarez & Montero encourage you to reach out so that we can explain more about the different ways that our law firm and attorneys can provide legal help and guidance after an auto accident. Make an appointment with us at one of our many locations. Remember, we work on a contingency basis so you will owe us nothing If we are unable to obtain successful results for your case. The attorneys at Suarez & Montero can meet with you to discuss further. always available to talk with you and answer your questions. Our skillful attorneys are genuinely committed to our clients. We will fight to make sure that you get the maximum amount of compensation owed to you. Let us help you get the medical care you need and fight to make sure you are compensated for your injuries! Our attorneys are ready to provide proven legal representation in pursuing your claim and stand ready to protect your rights. We are available 24/7 to give you a free, no risk case consultation.

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