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As a general rule, insurers will act to avoid or otherwise minimize their liabilities under their insurance contract with a policyholder.  Sometimes, however, the actions taken by an insurer clearly violate their duty of good faith, and thus give the policyholder an opportunity to sue and recover damages pursuant to a bad faith claim.  Actions giving rise to bad faith claims include those that involve unreasonable delays in handling, resolving, and processing an insurance claim submitted by the policyholder. Bad faith claims can be somewhat confusing for those who are unfamiliar with the push-and-pull typical of many insurance disputes — as such, you’ll likely want professional guidance to help you navigate the challenges and complexities of bad faith litigation.  Get in touch with a qualified Miami bad faith insurance lawyer for assistance. Insurers Have a General Duty to Act in Good Faith In Florida, insurance companies owe a general duty of good faith towards their policyholders.  Essentially, the duty of good faith requires that the insurer act fairly and honestly towards one of their policyholders, with due regard of the interests of the policyholder.  In determining whether the insurer acted in bad faith, Florida courts must consider the totality of the circumstances surrounding the unreasonable delay at-issue. Suppose, for example, that you have submitted a claim, but the insurer continues to delay their decision on whether they will pay.  After investigating further, your attorney discovers that the insurer did not properly investigate and evaluate your insurance claim, and further, that […]

As a business owner, CGL insurance coverage is fundamental to effectively running your business in a highly-litigious society.  When a improperly mopped floor can result in hundreds of thousands of dollars, or even millions, in potential liability to injured third-parties, the value of CGL insurance skyrockets — CGL insurance provides the “peace of mind” necessary for a business to successfully operate. This reliance on CGL insurance can lead to challenging situations when the insurer wrongfully denies a legitimate insurance claim, or otherwise fails to step in and adhere to their duties under the contract.  Businesses facing millions in potential liability are put in an exceedingly vulnerable position, and insurers often take advantage of this power dynamic to undervalue claims and deny coverage.  Fortunately, Florida law entitles CGL policyholders to sue and recover damages on the basis of bad faith. Consider the following. Wrongful Denial In Florida, bad faith requires that insurers conduct a reasonable investigation of the facts surrounding the insurance claim at-issue, that the insurer not misrepresent the extent and nature of coverage, and that the insurer not wrongfully deny a legitimate insurance claim (i.e., without reasonable justification for such denial).  If your CGL insurance claim has been wrongfully denied, and you can prove that the defendant-insurer did not have reasonable justification for the denial, you could potentially recover damages for bad faith. Failure to Defend CGL insurance requires that the insurer step in and defend you in the event that an injured third-party makes a claim against you […]

Short term disability insurance benefits serve as a form of temporary wage replacement for those who are suffering from a serious disability (though it’s worth noting that not all plans require employment, or a history of employment, to qualify for disability benefits).  If you have been seriously injured in a car accident, for example, to such and extent that you can no longer work for a period of time following the accident, then your short term disability insurance will kick in and you will be entitled to receive benefits. Many people unfamiliar with disability insurance do not understand what short term disability insurance is, and whether they can actually receive benefits pursuant to their policy.  There is a real and unfortunate “knowledge gap” when it comes to short term disability, particularly in scenarios where the policyholder may be automatically covered under an employer-based group plan. In reality, short term disability insurance is fairly straightforward to understand.  Consider the basics. Short Term Disability Benefits Short term disability benefits payout when you have been injured, or are suffering from an illness or condition that is severe enough to disable you — in other words, enough to prevent you from fully and adequately handling your job/career duties for a specified time period (up to one year, usually).  Benefits vary depending on the insurance plan, and sometimes, on the nature of the work that you are involved in.  Some plans pay a percentage of your wages, while other plans pay a set amount of […]

If you are challenging the wrongful denial of your property insurance claim, the insurer is likely to assert that the language in the insurance contract is rather ambiguous, and that it should be interpreted in a manner that favors them. For example, suppose that your property insurance contract includes various provisions that exclude lightning damage from coverage.  A tree near your house is hit by lightning, which results in a fire.  The fire then spreads to your house, causing it to burn down.  Would you be entitled to make a property insurance claim, given the exclusionary provision at-issue?  The insurer is likely to argue no.  On the other hand, the provision is rather ambiguous with regard to the chain of causation.  It could be argued that the damage was not directly caused by the lightning, but instead by fire, which is covered. Ambiguity has often been used by insurers to entice policyholders into signing, only later to be construed in a manner that retracts coverage, thus minimizing the potential liabilities for the insurer.  Fortunately, Florida case law favors policyholders in the interpretation of ambiguous policy language.  Let’s take a quick look. Ambiguous Property Insurance Provisions Must Be Construed in Favor of Coverage In Florida, ambiguous provisions — where true ambiguity exists — of an insurance policy must be liberally construed in favor of the policyholder (coverage), and strictly construed against the insurer.  As the policyholder, this is highly protective and is likely to benefit you when it comes to litigation […]

Insurers — whether in the health insurance context, or some other context — will look for any possible justification to support their denial of a policyholder’s substantial claims, however legitimate those claims may be.  Recent scandals plaguing health insurers have shaken the industry to its core and revealed that many health insurers do not enforce their guidelines or properly supervise their assessors, which can lead to systemic wrongdoing. If you have a legitimate health insurance claim that has been denied by your insurer, you may be entitled to damages on the basis of their wrongful denial.  With the assistance of a qualified health insurance attorney, you can gather additional evidence and repackage your health insurance claim, appeal the denial, or — ultimately — pursue trial litigation against the insurer to recover the compensation to which you are entitled. Understanding the reasoning that insurers use to rationalize their claim denial is fundamentally important, as it highlights those issues that must be circumvented or challenged.  Consider the following. Common Justifications for Claim Denial Treatment Not Medically Necessary Whether treatment is deemed medically necessary depends on a number of factors, from the language and provisions of the insurance policy, to the circumstances of your injury (and potential treatment thereof).  Each plan may differ in terms of its definition of medically necessary treatment, with some plans executing a broader construction, and some plans executing a stricter construction.  For example, your plan may require that only certain type of medical devices be use to treat […]

Property insurance policyholders have an obligation to mitigate their losses whether they’re in Florida or any other jurisdiction.  Failure to mitigate such losses can have a myriad negative consequences for the would-be claimant, up to and including a relinquishment of reimbursement rights under the insurance contract.  As such, if you have suffered various property losses for which you are entitled to be paid out, it’s important to consult with an experienced property insurance attorney as soon as is practicable — your attorney will help you identify the steps you can take to ensure that you have expended reasonable mitigation efforts, and that you remain qualified to make a claim for such property losses (pursuant to your coverage plan). Mitigation Basics All property insurance policyholders have a duty to mitigate their losses in the wake of some adverse event that causes covered losses.  Though the specific obligations imposed upon the policyholder may differ from plan to plan, as a general rule, policyholders are expected to make reasonable efforts to mitigate losses to the extent possible. Reasonable mitigation efforts do not require that you exert unlimited efforts in order to prevent further losses.  What is deemed “reasonable” will depend largely on the circumstances.  Exposing yourself to significant harm is not required, nor is the exertion of effort that may confound your abilities. For example, suppose that a tree has fallen onto your house during hurricane-force winds.  Substantial damage has been caused to your house.  When the tree fell, however, an additional nearby […]

In Florida — and in other jurisdictions throughout the country — many health insurance claims are denied on the basis of the insurer evaluating the treatment that their policyholder received as “medically unnecessary” or “medically inappropriate” given the circumstances of the injury or condition.  Despite the fact that most insurers view the claims filed by their policyholders as little more than a nuisance, the gritty reality is that a denial can be life-changing.  Denial of one’s legitimate health insurance claims can lead to significant financial stresses, and even bankruptcy. If you have been subjected to a wrongful denial of your health insurance claim, then it’s important that you get in contact with an experienced Florida health insurance attorney as soon as possible.  You have the right to appeal the denial of your claims, and — potentially — to sue and recover damages pursuant to litigation, if the denial was wrongful.  Contact Ver Ploeg & Marino, P.A. to connect with a skilled health insurance attorney today. What is Medically Necessary? If your claim has been denied on the basis of it not being medically necessary, then you are likely wondering what constitutes “necessity” in the health insurance context.  There is no universal definition of medical necessity.  Generally speaking, each health insurance coverage plan defines “medically necessary” differently. For example, suppose that you suffer serious injuries in a motor vehicle accident and you have to get your leg partially re-constructed using metal scaffolding.  There are a variety of different brands, types, and […]

Florida insurers owe a duty of good faith to their policyholders.  Essentially, Florida law (as is the case in various other jurisdictions throughout the country) requires that insurers avoid acting purely out of self-interest in handling the claims filed by their policyholders.  In processing the claims filed by their policyholders, insurers must act with a degree of care and diligence akin to that a reasonably prudent person who is managing the affairs of their own business.  Failure to act in good faith can expose the insurer to substantial liability, thus giving the policyholder a remedy at law. Importantly, timely processing of claims is among the many violations that legitimate bad faith insurance litigation.  Timeliness is inextricably tied to “bad faith,” as policyholders may be exposed to significant financial distress when there has been a delay. In contexts besides the processing of claims, for example, Florida law ties issues of timeliness to bad faith liability.  Specifically, section 624.155(b) of the Florida Statutes gives policyholders a civil remedy in the event that their insurer has failed to settle their claims in a timely manner. A Florida court will assess whether the insurer has violated their duty of good faith by assessing the “totality of the circumstances.”  For example, if the processing delay is justified by a lack of clarity on relevant facts pertaining to the claim at-issue, and if the insurer has notified the policyholder about the need for further delay (perhaps to perform an additional investigation into the facts), then in […]

In Florida, as is the case in other jurisdictions, almost all property insurance coverage includes exclusionary clauses that are meant to constrict the ability of policyholders to claim a covered loss.  Depending on the language of the insurance contract at-issue, your claim may be clearly excluded from coverage, or the exclusionary clause may be ambiguous enough that a skilled attorney can convince a court of law to find on your behalf. Fortunately for Florida policyholders, ambiguities in the language of the exclusionary clause are more favorably interpreted for the policyholders, as opposed to the insurer.  Let’s take a look at how it all works. Ambiguities and Exclusionary Clauses in Florida According to the Florida Supreme Court in Swire Pacific Holdings, Inc. v. Zurich Insurance Company, an established principle of insurance law is that — where the insurance contract may be construed either as providing or limiting coverage — the particularities of coverage must be strictly construed against the insurer.  More specifically, exclusionary clauses are construed even more strictly against the insurer than coverage clauses.  As such, ambiguities in the language of your exclusionary clause are much more likely to be construed in your favor.  An insurer cannot therefore benefit from ambiguous exclusionary clauses in the insurance contract that are intended to induce you into entering the contract, only to later interpret them in ways that circumscribe coverage and prevent you from claiming a loss. The Concurrent Cause Doctrine In Florida, the concurrent cause doctrine is applied when there are independent […]