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Insurance Claims

Serving clients throughout East and Southeast Texas in Beaumont, Port Arthur, Jasper, Lumberton, Orange, and other cities within Jefferson, Orange, Hardin, Newton and Jasper counties and throughout Texas

Consumers or their employers pay premiums for insurance coverage. Insurance companies take the premiums, sometimes for years. It seems that only when claims are filed on the insurance policies do problems arise. Suddenly, the insurance company finds that there is an issue with the coverage for the claim, often citing some technical or complicated reason never before discussed. The only reason anyone ever gets insurance is to protect against the risk of some future loss or need. The insurance company has promised this protection based on the terms and conditions outlined in the policy.

Denial, delay, and underpayment of claims and/or cancellation of policies only occurs when the insurance coverage is needed and the consumer is depending on the insurance company honoring the contract for which it was paid premiums–often for many years.

Now there has been a catastrophe, death, illness, fire, storm, severe freeze or other covered event. The friendly insurance agent who sold the policy has been replaced by a not-so-friendly claims adjuster or investigator. The insurance company already has its permanent lawyers to defend the case hard at work. Now it is time for the consumer–the person insured under the policy–to find the qualified legal help needed to advise and to deal with the suddenly reluctant insurance company.

Bush Lewis lawyers have decades of experience handling insurance claim disputes of all types. None of our lawyers are involved in the defense of insurance clients, their corporate clients, or their other insured clients for the insurance company. We only represent consumers in their insurance claim cases.

Our insurance claims focus

The three main types of insurance claims that Bush Lewis focuses on are:
  • Life Insurance. When you spend a lifetime earning a substantial living and paying life insurance premiums, your hopes are for beneficiaries to maintain a certain quality of life after you are gone. Life insurance claim denial or attempts to pay benefits to the wrong person is relatively common but not always warranted or legally justified. More about life insurance claims>>
  • Property Damage, including Hurricane & Storm Claims. Hurricane Ike and Katrina ravaged the Texas coastal area, causing millions of dollars in home and business property devastation. Insurance policy holders have the right to good faith and fair dealing from insurance companies to honor their property claims. More about hurricane and storm claims>>
  • Health Care & Disability Policies. Insurance companies often use tactics of denial, delay or prematurely closing claims to the detriment of seriously ill or disabled policyholders. However, with seasoned legal help you can fight the injustices.

State vs. Federal law on insurance claims

The two main ways in which individuals get insurance policies are by personal purchase in the marketplace and through their employers. State laws will determine consumer rights under the terms of policies bought in the marketplace, while federal law will control rights under the terms of policies procured through qualified employer benefit plans. Texas state law provides significant protection to consumers when it applies because Texas has very strong laws, statutes and regulations that apply to non-employee insurance policies.

Legal remedies for policy holders under Texas law

Any time an insurance company fails to pay what is due under the insurance policy, the consumer or policyholder has a claim for breach of contract. Success in that claim forces the insurance company to pay what it should have paid before a lawyer got involved. It is the other legal remedies available to policyholders based on the Texas insurance laws that provide the best remedies for Texans against insurance companies that fail to do what the law and their policies require. These remedies include:
  • Texas Insurance Code Chapter 541 Deceptive Insurance Practices Claims
  • Texas Insurance Code Chapter 542 Late Payment of Claims
  • Bad Faith Denial or Delay of Payment of Claim or Cancellation of Insurance Coverage Claim
These Texas laws are powerful tools for successful results in insurance claims when used by qualified insurance lawyers.

Texas Insurance Code Chapter 541 Deceptive Insurance Practices Claims

Any person or other entity injured by another’s deceptive acts or practices in the business of insurance has a claim under the Texas Insurance Code. The following deceptive practices are specifically prohibited by the Texas Insurance Code:
  • Making, issuing or causing to be made any statement misrepresenting the terms of any policy (Section 541.051(1)(A)).
  • Making an untrue statement of material fact about an insurance policy (Section 541.061(1)).
  • Not disclosing any matter required by law to be disclosed (Section 541.060(a)(1)).
  • Misrepresenting to a claimant a material fact or policy provision relating to the coverage at issue (Section 541.060(a)(1)).
  • Not attempting in good faith to bring about a prompt, fair, and equitable settlement of a claim once the insurer’s liability becomes reasonably clear (Section 541.060(a)(2)(A)).
  • Attempting to pressure the claimant to settle a claim under one portion of the coverage by refusing to bring about a prompt, fair, and equitable settlement under a second portion of the coverage, once the insurer’s liability on the second portion becomes reasonably clear (Section 541.060(a)(2)(B)). [This prohibition prevents an insurer from refusing to settle under one type of coverage provision unless a property owner also agrees to settle a claim under another coverage provision.]
  • Not promptly giving a policyholder a reasonable explanation, based on the policy as it relates to the facts or applicable law, for the insurer’s denial of a claim or for the offer of a compromise settlement of a claim. (Section 541.060(a)(3)).
  • Not affirming or denying coverage of a claim to a policyholder within a reasonable time (Section 541.060(a)(4)(A)).
  • Refusing, failing to make, or unreasonably delaying an offer of settlement under coverage on the basis that other coverage may be available or that third parties are responsible for the damages suffered, except as specifically provided in the policy. (Section 541.060(a)(5)).
  • Attempting to enforce a full and final release of a claim from a policyholder when only a partial payment has been made, unless the payment is a compromise settlement of a doubtful or disputed claim (Section 541.060(a)(6)).
  • Refusing to pay a claim without conducting a reasonable investigation (Section 541.060(a)(7)).
  • Requiring a claimant, as a condition of settling a claim, to produce federal income tax records for examination or investigation unless so ordered by a court or the claim involves a claim for lost profits or income (Section 541.060(a)(9)).
Persons injured by such deceptive acts or practices can recover actual damages caused by such prohibited conduct (even if the damages were not necessarily foreseeable). Recoverable actual damages include lost profits, lost income, damaged credit reputation and the policy proceeds. If there is a finding that the insurer acted knowingly (with actual awareness of the falsity, unfairness, or deceptiveness of the act or practice on which the claim is based), the policyholder may recover for any proven mental anguish suffered. (Sections 541.152(b) and 541.002(1). If it is found that the insurer acted knowingly, additional damages may be recovered for up to twice the total amount of actual damages (Section 541.152(b)). A successful claimant is also entitled to attorney’s fees, court costs and prejudgment and post judgment interest.

Texas Insurance Code Chapter 542 Late Payment Claims

The first communication from a property owner to the insurer after property damage that informs the insurer of a potential loss triggers very specific duties and deadlines under the Texas Insurance Code. In general, the insurer is then required to perform a full investigation and make the full payments required by the insurance policy. Different sections of the Texas Insurance Code provide the details of when and how the insurer must meet these requirements:
  • Acknowledge receipt of claim in writing within 15 days of receipt of notice of the claim (Section 542.055(a)(1)).
  • Begin investigation within 15 days of receipt of a notice of claim (Section 542.055(a)(2)).
  • Request items “reasonably” required from the insured consumer within 15 days of receipt of a notice of claim (Section 542.055(a)(3))
  • Request additional information from the insured consumer whenever it is necessary during the investigation (Section 542.055(b)).
  • Notify the insured consumer in writing within 15 business days (30 business days in a fire claim where arson is suspected) after the insurance company receives the requested necessary investigation materials whether the insurance company accepts in whole or part or rejects the claim (or, requests additional time to complete the investigation) and, if rejected, state the reasons for the rejection (Section 542.056(a),( d)).
  • Pay all or the part of the claim accepted within 5 business days of giving the insured consumer notice of accepting the claim (Section 542.057(b)).
  • If the insurance company receives all reasonably requested and required items from the insured consumer but neither accepts nor rejects the claim within 60 days, the insurance company will be liable (Section 542.058(a)).
  • If an insurance company receives notice of an adverse claim under a life insurance policy, the insurance company must either pay the claim or file the policy proceeds with the court within 90 days of the notice (Section 542.058( c)).
Persons injured by such delays or non-payments are entitled to recover the amount they should have been paid for the damages under the policy plus automatic statutory damages of 18% per year from the date the statutory deadline was missed until paid or the date of the trial judgment, prejudgment interest, attorney fees, court costs, and post-judgment interest on the entire judgment.

Bad Faith Denial or Delay of Payment of Claim or Cancellation of Insurance Coverage

In addition to the Texas Insurance Code requirements of Chapter 542 of prompt payment and Chapter 542 of non-deception claims handling, Texas law provides a general duty of good faith and fair dealing as part of every insurance contract. The duty of good faith and fair dealing is separate and distinct from the actual agreements or provisions of the insurance policy itself. An insurance company violates this duty whenever it denies or delays payment when liability is reasonably clear or cancels an insurance policy without a reasonable basis. Liability becomes reasonably clear whenever an insurer has actual knowledge of an occurrence of a condition giving rise to coverage under the policy or an insurer should have known that coverage was reasonably clear under the policy if it had fulfilled its duty to investigate. The reasonableness of an investigation depends on whether it was thorough and performed in good faith. Starting an investigation as a pretext for denying a claim will not shield an insurer from bad faith liability. This means that an insurer cannot conduct an investigation just to disprove a claim. It is a pretext for an insurer to rely upon engineering reports that were not objectively prepared as the basis for denying a claim. A policyholder can recover direct and foreseeable damages caused by an insurer’s bad faith. Such damages can include:
  • Mental anguish where the denial or delay has seriously disrupted the insured’s life Economic damages in the form of lost credit reputation and increased business costs The policy benefits to the extent due and unpaid.
  • Exemplary damages can be recovered in cases where actual damages are recovered and the insurer’s conduct is found to be fraudulent, malicious, intentional, or grossly negligent.
  • Prejudgment and post judgment interest and court costs are recoverable but attorney’s fees cannot be recovered for the bad faith claim (but may still be available under some other theory)

Federal Insurance Claims (ERISA Claims)

The Employee Retirement Income Security Act of 1974 (ERISA) is a comprehensive federal statute designed to protect the interests of employees and their beneficiaries in employee benefit plans. Its provisions include standards for management of employee benefit plans, fiduciary responsibility toward participants and over plan assets, funding and vesting requirements for pension plans, and rules concerning reporting and disclosure.

ERISA was enacted after the Studebaker Company closed its automotive plant in South Bend, Indiana, in 1963 when it was discovered that the Studebaker employee pension plan was seriously under-funded leaving thousands of workers without the promised pension benefits. ERISA was designed to prevent employers from failing to pay whatever employee benefits were owed to employees–pension benefits in particular–and to see that those employee plans were properly administered. Whenever an insurance policy is provided through an employer, it will almost always be covered by ERISA.

Being an “ERISA-plan” is both a good and bad thing for the insured consumer. Lawsuits involving claims for benefits under ERISA must always be filed in federal court (after using all of the plan’s non-lawsuit administrative remedies) and can never recover the damages allowed under Texas state law. Damages on most ERISA claims are limited to the benefits due under the insurance policy plus reasonable attorney fees if the claim is at least partly won. The good news is that ERISA cases tend to move along quicker in federal court than state claims do in state court and that Bush Lewis lawyers are experienced handling these claims in federal court.

Not all ERISA claims are limited to policy benefits and attorney fees. Section 510 of ERISA is entitled “Interference with Protected Rights” and is the anti-discrimination and anti-retaliation provision of ERISA. Section 510 makes it unlawful to retaliate or discriminate against any employee exercising rights to which the employee is entitled under the provisions of the employee benefit plan or for the purpose of interfering with the attainment of any right to which a participant may become entitled under the plan. Damages for such retaliation or interference are not limited to benefits and attorney fees. ERISA’s Section 510 benefits might apply in cases where:
  1. An employee is laid off shortly before one or more of the employee’s rights to plan benefits vest.
  2. Discharge before a significant increase in benefits vests.
  3. Discharge when a self-insured employer learns that an employee has a major and probably costly illness that will require the employer to pay substantial benefits.

Legal help with policy interpretation and insurance claims

Insurance policies usually contain terminology and language difficult for most people and many lawyers to understand. Even opposing lawyers often argue over terms or the lack of a clear definition, with policies sometimes open to different interpretations. Years of dealing with insurance companies, knowledge of legal nuances of policies, a thorough knowledge of the Texas Insurance Code, case rulings, E.R.I.S.A. and federal law have allowed lawyers at Bush Lewis lawyers to help hundreds of clients deal with unfairly delayed, denied and underpaid insurance claims.

Call 409.835.3521 or contact a personal injury attorney at Bush Lewis online today for a free consultation to find out your legal rights and options. We serve clients throughout East and Southeast Texas in Jefferson, Orange, Chambers, Galveston, Hardin, Newton, Jasper and other Texas counties.

Know This Before An Accident

No one plans to have an accident and no one expects to sustain a serious injury or lose a loved one to death from someone else's actions or mistake. It helps to at least have heard what experienced lawyers say you can do to ease the situation. At Bush Lewis, we think there are some helpful guidelines that we recommend to you. Our lawyers suggest: Learn more.