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Generally speaking, in Florida and throughout the country, disability insurers will utilize whatever means necessary — whether you have short-term disability insurance coverage or long-term disability insurance coverage — to undervalue a policyholder’s claim, or to otherwise avoid having to payout the claim altogether.  Insurers rely on the fact that many policyholders are unwilling to challenge their decision, even if their decision is not justified by the evidence. If you’ve had a legitimate disability claim denied by your private insurer, you do not have to standby and accept their decision — if you appeal the decision or pursue traditional litigation thereafter, it may be possible to have it reversed. What is Long-Term Disability Insurance? Long-term disability (LTD) insurance is private disability insurance coverage that acts as an income replacement if you are rendered disabled and therefore incapable of working.  LTD insurance lasts for a year (at minimum), and up to a lifetime (at maximum) — depending on the policy that you have entered.  As such, it can function as a permanent income replacement in some cases. By contrast, short-term disability (STD) insurance is private disability insurance coverage that acts as a temporary income replacement, usually between three months and one year in duration. STD insurance and LTD insurance need not conflict.  In fact, comprehensive insurance coverage generally involves purchasing STD and LTD insurance policies that overlap.  Once the STD insurance benefits period has ended — assuming that you are still disabled — then the LTD benefits will kick in, ensuring […]

In Florida (and throughout the country), disability insurance policyholders must take special care not to post potentially compromising text, photos, and videos to their various social media accounts.  Insurance companies are increasingly making use of evidence that their investigation teams dredge up on social media accounts to undermine policyholder claims and thereby justify a denial. Insurers Have Always Investigated Inconsistencies Disability insurers have a long history of using privacy-invasive tactics in order to investigate potential inconsistencies in policyholder claims.  In decades past, insurance companies would direct their internal investigation team (or hire out a third-party investigation team) to commit to surveillance activities — after some time, they might discover that the policyholder was not suffering from as severe a disability as was originally claimed. How Social Media Has Changed the Investigations Process With the advent of social media, insurance investigations teams have expanded their activities to include digital surveillance.  Posts that you make on social media will almost certainly be monitored by your disability insurer. How does it work? Remember, disability insurers only owe benefits if you are actually disabled — in other words, if you are suffering from a condition that renders you incapable of working, to the degree set out in the policy.  Insurers conduct surveillance so that they can “catch” you doing something that you should not be able to do given your claimed disability. For example, imagine that you suffer a back injury in a motor vehicle accident that causes you to experience severe pains and […]

In Florida, where hurricanes, tropical storms, and other natural disasters are a regular feature of life, property insurance claims frequently involve “loss of use” coverage issues.  Standard property insurance coverage does not necessarily cover all the various losses suffered by a policyholder.  Loss of use coverage — which may be its own separate policy, or simply a provision built into an existing homeowner’s insurance or renter’s insurance policy — helps fill in the gaps, so to speak. What is the Purpose of Loss of Use Coverage, Exactly? Loss of use coverage is rather straightforward in terms of its function — simply put, it is designed to account for losses related to the policyholder’s inability to make normal use of the property.  What constitutes “use” will vary depending on the policy and depending on the particular nature of the loss. Generally speaking, most loss of use coverage makes provisions for benefits in three different and broadly-applicable situations: Heightened cost of living Loss of rental income Legal prohibition on access All this legalese may seem confusing at first glance, so let’s do a brief walk-through of some examples to clarify how it all works. Suppose that you have loss of use coverage through your existing homeowner’s insurance policy.  One day, your primary residence is severely damaged by a hurricane, and as a consequence, you are forced to move out and seek out an alternative residence (at least temporarily). The damage to your residence is significant enough that it will take up to […]

If you are covered by business interruption insurance, then you may find yourself in a particularly vulnerable situation when some event occurs that interrupts the normal flow of business and thus leads to unexpected losses.  A significant enough interruption to business can cause irreparable damage to one’s brand and reputation.  Depending on the nature and extent of the damage, submitting an insurance claim and successfully obtaining benefits may be fundamental to the continuance of the business. Business Interruption Insurance at a Glance Business interruption insurance is essentially a form of disaster-related insurance that covers the losses associated with the interruption of business in the event of a disaster.  Business interruption policies are not merely intended to cover actual damages — they are intended to account for the lost profits, too.  As such, they are a more comprehensive form of insurance than, say, property insurance. Calculating Losses Every business interruption policy is written differently and may have slightly different exclusions and coverage limitations.  Generally speaking, however, business interruption insurance tends to cover damages associated with: Lost profit Expenses for repair Operating expenses that continue to be borne by the business Claim preparation costs Rental expenses (such as a property rental to serve as an alternative until repairs are complete) New equipment expenses Training costs for new equipment Forced business closure And more It’s important to note that business interruption insurance claims — just like other insurance claims — should not serve as a financial windfall.  The claimant is expected to claim […]

In Florida, as is the case in other states, recipients of disability benefits — whether through private disability insurance or through a public program like SSDI — must reasonably follow the treatment plans required by their physicians, and must regularly update their insurer as to their condition.  Failure to do so could result in a loss of benefits (through premature termination of benefits), or a reassessment of disability benefits that reduces the amount you receive on a monthly basis. Reasonable Efforts to Mitigate Generally speaking, insured policyholders in Florida (including disability insurance policyholders) have a duty to mitigate — in other words, they must make reasonable efforts to minimize their losses.  In the disability context, this means that disability claimants must attempt (to the degree possible) to “fix” their disabling condition, or at the very least, to minimize the impact of the condition on their life. Once your physicians recommend a treatment plan, it is important that you follow said treatment plan.  Failure to do so will likely constitute a violation of your duty to mitigate your losses — if you do not follow your physician’s recommended plan, your insurer may terminate benefits prematurely and will likely argue that your disability would have resolved had you followed the plan. If you failed to follow a given treatment plan, you may still be able to receive benefits, but you’ll have to introduce evidence that demonstrates that your disabling condition would not have improved or resolved even if you had followed the […]

In some cases, your insurer may deny your claim due to a specific misrepresentation in your insurance application — even if the misrepresentation at issue was not intentional and was merely a mistake borne of a simple misunderstanding. Material Misrepresentation as a Defense Insurers can use a material misrepresentation defense to avoid having to pay out for your legitimate insurance claims.  Oftentimes, an insurer will discover some mistake in your application and will anchor their arguments on it.  For example, if you fill out a disability insurance application and write down your family history of disability (and other health conditions) incorrectly due to a lack of information, the insurer may argue that this mistake constitutes a material misrepresentation. If you’ve had your claim denied or delayed (or otherwise handled in an unfavorable manner) due to a purported “material misrepresentation,” then you may feel as though you don’t have many options.  In reality, however, policyholders can utilize a number of different arguments to overcome this defense. Not all Misrepresentations Preclude Insurance Coverage The mere fact that you made a mistake — or even intentionally misrepresented something on your insurance application — is not enough to preclude insurance coverage.  According to Florida Statutes section 627,409(1), a misrepresentation, omission, or mistake will only prevent the insurance claimant from recovering damages if the insurer would not have issued the policy in the first place (given the misrepresentation at-issue). Further, your insurer cannot preclude coverage unless the particular misrepresentation is causally linked to the loss […]

In Florida, insurance litigation disputes — often involving over-broad and unexpected policy exclusions — may lead one to question the liability of their insurance agent.  After all, if the insurance agent obtained the policy on your behalf, it’s possible that they have not satisfied their obligations and have somehow misled you into entering into an insurance agreement that did not adequately meet your needs. In the event that your insurance agent failed to adhere to their duties, you may be entitled to sue them for negligence (and thereby recover damages for the losses over which your insurer has refused to extend coverage).  There are, of course, limits to consider — the law does not grant you an absolute right of action against your insurance agent.  Arguably, every dispute over a denied insurance claim is (to some degree) unexpected, or else you would not have agreed to it in the first place. Duties Owed by the Insurance Agent Insurance agents in Florida owe a number of duties to the insured (their client).  Pursuant to currently-applicable case law, they must: Exercise reasonable care in securing insurance coverage that the client has specifically requested, and notify the client as to any issues regarding its availability; Properly consider the explicitly-defined needs of the client when obtaining insurance coverage; and Inform and explain the coverage that has been secured at the client’s direction. This can be difficult to take in all at once!  Consider the following example for clarity. Suppose that you engage with an […]

In Florida, and elsewhere, health insurance policyholders are entitled to appeal adverse determinations by their insurer — such as a denial of coverage — and thereby request that the insurer conduct a full review of their original decision. The appeals process is the first of several steps in challenging the determination made by your health insurer.  After you have exhausted the internal appeals process, you can move forward with an external, third-party review of the insurer’s decision, submit a complaint with a Florida state agency (such as the Florida Agency for Health Care Administration), or bring an action against your insurer (thus precipitating litigation). Even if you’re not sure whether you’d like to file a lawsuit against the insurer and pursue litigation in the Florida courts, it’s worth consulting with an experienced Miami health insurance lawyer to help guide you through the appeals process.  Depending on the circumstances surrounding the denial of your health insurance claim, you may be able to persuade the insurer to accept your claim. The Appeals Process in Florida So, how does the appeals process work? When you file a claim, you’re essentially requesting that your health insurer cover (and therefore reimburse) the costs of treatment.  If your insurer denies your claim, however, then that qualifies as an adverse determination, which you are entitled to challenge pursuant to the appeals process. Every insurer tends to have somewhat different grievance and appeals procedures (though they all must comply with state and federal regulation).  For example, some Florida […]

In Florida, insurers have a duty of good faith that they must adhere to.  Simply put, insurers must act fairly, honestly, and with due regard towards the interests of their policyholders.  If they fail to do so — for example, by wrongfully denying a claim, unreasonably delaying the handling of a claim, or otherwise interfering with the policyholder’s ability to recover the damages to which they are entitled — then they may be held liable pursuant to Florida bad faith insurance law. Bad faith disputes can be multi-layered and complicated.  In order to prove that the defendant-insurer has committed bad faith, you’ll have to show that they acted unfairly or dishonestly, or that they acted without due regard to your interests.  This is a “holistic” determination that depends on the total circumstances surrounding your claim.  You’ll have to prove that — given the circumstances — the insurer violated their duty of good faith.  Doing so is not always easy, but our Miami bad faith insurance lawyers are here to help. The insurer will almost certainly fight tooth-and-nail to avoid bad faith liability.  When you bring a bad faith claim, in Florida or elsewhere, the insurer will expose the weak points in your arguments.  For example, an insurer might argue that the circumstances justified a delay to give them time to investigate the insurance claim further, given that there was not sufficient evidence in the original submission for them to determine whether to payout. Potential Weaknesses to Avoid When Bringing Your […]

Usually, property loss does not involve exclusive damage to the dwelling unit itself — there may also be damage to other, non-dwelling structures (such as a fence around the property), or more commonly, to items of personal property that also reside within the dwelling.  In some cases, the personal property of the policyholder may be of significant value, and as such, their loss may expose the policyholder to unexpected financial vulnerability. For example, suppose that you own a number of antiques of significant value.  You intend to sell them to help pay for your child’s college tuition fees.  One day, however, a fire destroys much of your home, and the antiques are damaged beyond repair.  Their value is lost in an instant.  If the insurer does not provide adequate coverage that accounts for the losses you sustained due to the damage to your personal property, then you could be left in a very challenging financial position. If you have valuable personal property, it’s therefore critical that you consult with an experienced Miami property insurance lawyer for guidance. Duty to Cover Losses Sustained Personal Property In Florida, insurance companies providing homeowner’s insurance must grant policyholders coverage for their personal property, though limits on such recovery are frequently written into the policy to minimize the insurer’s eventual liabilities. It’s worth noting that Florida law requires insurers to give a policyholder the option to exclude their personal property from coverage (so long as the policyholder gives a formal, written statement of intent).  Excluding […]