Category: Fine Print

Deadlines in Policy Fine Print Can’t Cut off IFCA Rights Says Court of Appeals

Washington’s Insurance Fair Conduct Act (IFCA) protects policyholders from insurers’ unreasonable refusal to pay covered losses or provide insurance policy benefits. Unfortunately, many insurers include fine print in the insurance policy contract that supposedly provides the policyholder cannot sue the insurer once certain time period has passed since the loss. These time periods are typically much, much shorter than statutes of limitations, and are often as short as one year.

Insurers often claim this language lets them off the hook for violating policyholders’ rights under IFCA or other laws once enough time has passed. This is particularly problematic because insurers often drag out disputed insurance claims for as long as possible. Accepting these insurers’ arguments would allow insurers to immunize themselves from suit by simply stalling until the deadline runs.

Can they do that?

Fortunately for Washington State policyholders, our Court of Appeals recently said “no way.” On January 13, 2020, the Court of Appeals decided West Beach Condominium v. Commonwealth Insurance Company of America, ruling that the deadline in the insurer’s fine print could not bar the policyholder from pursuing IFCA and similar consumer protection claims.

West Beach, a West Seattle condo owners’ association, had insurance coverage for the condo complex through Commonwealth Insurance. West Beach found substantial water damage in the condo complex and made an insurance claim with Commonwealth on September 26, 2016.

In March of 2017, Commonwealth denied coverage. Commonwealth claimed that the water damage had been happening for the past ten years. Commonwealth’s insurance policy contained fine print requiring West Beach to sue within a year after the loss, i.e., within a year after the initial water damage.

West Beach sued, alleging that Commonwealth breached the insurance policy contract. West Beach also sued under IFCA and Washington’s Consumer Protection ACT (CPA). The lower court dismissed the entire lawsuit because the claimed damage occurred more than one year before West Beach filed suit.

The Court of Appeals reversed and ordered that the lower court should not have dismissed the IFCA and CPA claims. Commonwealth claimed on appeal that by failing to file suit by the contractual deadline, West Beach gave up its right to any insurance coverage. Therefore, Commonwealth argued, West Beach had no right to bring IFCA or CPA claims because it had given up its insurance coverage.

The Court of Appeals determined the suit limitation clause only prevented West Beach from filing a very specific type of claim for breach of the insurance policy contract. But, the court ruled, Commonwealth could not use the contractual deadline to immunize itself from suit under IFCA and the CPA. These statutes give policyholders rights that do not go away merely because the policyholder missed a deadline buried in the insurance policy.

The West Beach decision is important because it preserves policyholders’ rights under Washington’s consumer protection statutes. These laws exist to protect Washington policyholders from sharp practices. Allowing insurers to exempt themselves from these laws simply by adding arbitrary deadlines to their insurance policy fine print would allow insurers to circumvent these protections by using the very type of sharp practice these laws exist to prevent.

Court of Appeals Confirms Insured Can Reform Policy Language to Provide The Coverage The Insured Purchased

The Washington Court of Appeals recently answered an important question for policyholders: what if your agent sells you coverage but the insurance policy fine print fails to reflect the coverage you thought you purchased?

On November 4, 2019, the Washington Court of Appeals decided Digitalalchemy, LLC v. John Hancock Insurance Company (USA). The court held Digitalalchemy could sue John Hancock for denying coverage under a life insurance policy because, even though the policy language supported John Hancock’s denial, Digitalalchemy had purchased broader coverage than the policy reflected.

Digitalalchemy bought John Hancock’s life insurance policy to cover its key executives. When buying the policy, John Hancock’s agent agreed to backdate the insurance coverage’s start date. That means the policy would effectively begin providing coverage before the date Digitalalchemy purchased the policy. However, due to a mistake, the policy language failed to reflect the backdated start date.

One of the covered executives died by suicide, and Digitalalchemy made a claim under the policy. John Hancock denied coverage under the policy’s suicide exclusion. The policy excluded coverage if the insured died by suicide within two days of the “issue date.” Because the parties agreed to backdate the policy start date, the insured died after the two-year exclusion period, and John Hancock should have paid the claim. But because the policy failed to reflect the backdating, John Hancock denied coverage under the suicide exclusion.

The court agreed with John Hancock that the policy language did not backdate the start date. However, the court also found that Digitalalchemy sufficiently alleged the parties had agreed to backdate the policy and that the failure to reflect the backdating in the policy was a mistake. Accordingly, the court agreed Ditigalalchemy could argue the policy should be reformed to reflect the backdated start date because that was what both parties had intended.

That ruling is important because it is another recent case confirming insureds can still obtain recourse if they purchase coverage but the insurer writes a policy failing to accurately reflect the purchased coverage.

WA Supreme Court Confirms Insurers Must Follow Their Agents’ Promises

Let’s say you go to an insurance agent to buy an insurance policy. You tell the agent you want coverage for something specific, for example, fire damage to your boat. The agent sells you a policy the agent tells you covers fire damage to your boat. The agent gives you some documents summarizing the policy that say fire damage to your boat is covered. Then your boat catches fire and you make a claim, but the insurer denies coverage. The insurer says the policy fine print excludes fire damage, even though the agent said it was covered.

Can they do that?

The answer is no, according to the Washington Supreme Court. On October 10, 2019, the Washington Supreme Court decided T-Mobile v. Selective Insurance Company. The decision confirms insurance companies may be bound by statements their agents make when selling insurance policies.

In this case, T-Mobile hired a contractor to build a cell phone tower. T-Mobile required the contractor to obtain insurance coverage protecting T-Mobile. The contractor’s insurance policy only covered a small T-Mobile subsidiary, not T-Mobile itself. But the insurance company’s agent issued a series of insurance certificates stating that T-Mobile itself was covered in addition to the subsidiary.

T-Mobile was sued over the cell tower construction project and made a claim under the policy. The insurer denied coverage on the basis the policy did not name T-Mobile as an insured. 

In the resulting lawsuit, the insurance company argued T-Mobile should not have relied on the insurance agent’s representations that T-Mobile was covered. The insurer said T-Mobile should have read the policy and seen that T-Mobile was not covered.

The Washington Supreme Court disagreed. The Court determined T-Mobile was justified in believing that the insurance company’s agent was authorized to speak on behalf of the insurer.  The court found the agent’s specific statements that T-Mobile was covered overcame boilerplate disclaimers the insurer had made.

The court also emphasized the importance of holding insurers to their agents’ promises. Without that rule, the court noted, insurers would have no incentive to make sure their agents’ statements to people buying insurance were true. The court observed that allowing insurance companies to ignore their agents’ statements was important because “Otherwise, an insurance company’s representations would be meaningless and it could mislead without consequence.”

This ruling is important. Many folks buy insurance after discussing with their agent, reading brochures, or browsing the internet. They rarely read the policy fine print. Even T-Mobile, a huge corporation presumably represented by a team of insurance lawyers, relied on the insurance agent’s representations without noticing the policy fine print. If insurance companies could let their agents sell policies promising coverage that didn’t exist, consumers would pay for coverage they never received and would have little recourse.

 

Can your disability insurer offset your benefits because you are receiving other income?

Let’s say you become ill and can’t work anymore. Fortunately, you have disability insurance coverage through your employer. You apply and get awarded benefits. The policy says your benefits are two thirds of your salary. But the insurance company is paying you less. They say that they can subtract from your benefits any money you are collecting from Social Security Disability.

Can they do that? Like many insurance questions, it depends on the insurance policy fine print.

Most disability insurance policies provide an offset for so-called “other income” or “deducible income” you receive because of your disability. For instance, if your monthly disability insurance benefit would normally be $1,000, and you have $300 in deductible income, the disability insurance benefit is reduced to $700. What counts as deductible income that counts against your benefits depends on the wording of the insurance policy.

Deductible income often includes:

  • Social security disability payments;
  • Workers’ compensation payments;
  • Payments from other insurance policies; or
  • Payments from the person who inflicted the injuries that made you disabled (if a third party is responsible for your disability).

Moreover, disability insurance policies often require you to apply for potential sources of deductible income. For instance, your disability policy may require you to apply for Social Security Disability benefits.

The key is that the insurance company can’t deduct income that isn’t specifically listed in the policy. If you are receiving benefits under a disability insurance policy and the insurer tries to reduce your benefit because you are receiving other disability income, consult a lawyer to review the policy and make sure you know your rights.

When is it “too late” to make an insurance claim?

Let’s say the insurance company denies your claim. They don’t dispute you had a covered loss, but they say you missed a deadline buried in your insurance policy requiring you to notify them of the claim within a certain time. Can they do that?

The answer, often, is no. But the devil’s in the details.

Virtually all insurance claims involve important deadlines. For instance, there can be deadlines to tell your insurance company about the claim, to provide the insurer with documentation about the claim, to appeal the insurer’s denial of a claim, or to file a lawsuit. Which deadlines apply and the effect of missing them depend on the details like the insurance policy fine print and whether the policy is subject to ERISA.

Because the rules can vary and the consequences of missed deadlines can be draconian, it’s critical to consult an attorney to know your rights and obligations. Here are some general examples:

Deadlines to notify your insurer about the claim. Most insurance policies require you to notify the insurance company of your claim within a certain time period. Sometimes it’s “as soon as possible.” Sometimes’s it’s a specific date, for example, within one year of the loss.

The consequences of missing a claims notice deadline vary, but, often, the insurer cannot deny your claim just because you missed the deadline to give them notice. If you’re in Washington State, most insurers can’t deny claims just because you gave them late notice – the insurer has to prove that your delay in giving notice hurt the insurer’s ability to investigate your claim. If your delay in giving notice doesn’t stop the insurer from investigating your claim, the insurer typically can’t use the late notice as an excuse to deny coverage.

That means if your insurer denies your claim because you gave them late notice, there is a good chance you could challenge the denial. But beware – this rule does not apply to every insurance policy, especially policies subject to ERISA.

Deadlines to provide the insurer with information about the claim. Most insurance policies contain language requiring the policyholder to cooperate with the insurer by providing information about the claim. That could include, for example, allowing the insurer access to your home for a homeowner’s insurance claim, or providing the insurer medical records for a disability insurance claim.

Many insurance policies contain no specific deadline for you to provide this information. However, insurers will sometimes give you an arbitrary deadline to provide information they demand. They may tell you they will deny the claim if they don’t receive certain information by a specific date.

Similar to the claims-notice deadline, insurers typically have to prove that your delay in providing information harmed their investigation in order to deny coverage on this basis. But there are exceptions, and it’s important to bear in mind that policyholders have an obligation to cooperate with their insurers, which generally includes responding to reasonable requests for information. And, as a practical matter, looking obstructionist rarely helped anyone’s court case.

Deadlines to appeal the insurer’s denial of a claim. Many insurance policies provide that, if the company denies a claim, the policyholder can “appeal” the denial internally. An internal appeal means the company takes another look at the claim and any new evidence the policyholder submits.

Policyholders often have deadlines, sometimes just a few weeks, to submit an appeal. In some insurance policies, the appeal is voluntary, so failing to submit an appeal on time is unlikely to affect your rights. Other insurance policies – especially those governed by ERISA – make the appeal mandatory. That means missing the appeal deadline can cause you to permanently give up your right to contest the denial or seek insurance benefits.

Deadlines to file a lawsuit if your claim is denied. If it becomes necessary to go to court to fight an insurance claim denial, it’s critical to know the applicable statute of limitations, i.e., the deadline by which you have to file a lawsuit. Failing to file suit within the statute of limitations can mean you permanently lose the right to go to court. Most statutes of limitations are at least year from the date of loss. But there are important exceptions that depend on the details. For example, many homeowner’s insurance policies require you file suit within one year of the date of loss. Also, ERISA-governed insurance policies typically have far shorter deadlines to file suit – sometimes measured in days.

The upshot is that filing a late claim doesn’t make it a foregone conclusion that you lose your right to insurance benefits. If the insurance company denies your claim because you missed a deadline, there are often steps you can take to contest the denial and, potentially, obtain insurance benefits notwithstanding the missed deadline. But it’s critical to have an attorney review the facts and your insurance policy to make sure you know what deadlines apply and the consequences of missing any deadlines.