INSURANCE COVERAGE TIPS

INSURANCE COMPANY CLAIMS HANDLING

LINKS TO INSURANCE COMPANY INFORMATION & COVERAGES

Articles:
State Farm Scare Tactics

Insurance Videos:
Explanation of Health Insurance Policy Terms
CNN Anderson Cooper 360 "Keeping them Honest: Insurance Battle"
CNN Anderson Cooper 360 "Auto Insurance" Part 2
Harvard law professor Elizabeth Warren on healthcare
Insurance Company Rules (hilarious)
Healthcare Jeopardy from "National Health Emergency" (funny)

WHEN SHOULD I REPORT AN ACCIDENT?  As soon as possible.  Failure to report an accident could subject you to personal liability if the party later finds themselves to be injured and your insurance company denies the claim due to your failure to report the accident promptly.  You should always call the police and request an accident report when you have had an accident. If you were injured, allow an ambulance to take you to the hospital; an injured person is usually in shock at the time of the accident and does not fully realize the extent of injuries suffered.

CLAIMS HISTORY REPORTS:  Most insurance companies report your claims to Comprehensive Loss Underwriting Exchange (C.L.U.E.). C.L.U.E. maintains a database much like a credit reporting agency.  When you file a claim, it gets reported to C.L.U.E.  When you apply for insurance, the company will obtain a C.L.U.E. report which will reveal all claims filed by persons residing at your address.  The frequency and severity of your losses will be considered in determining whether the company will sell you a policy and the premium you will be charged, if a policy is offered. You may obtain a copy of your C.L.U.E. report by calling 800-456-6004.

DECLINE GLASS COVERAGE:  Some insurance companies will report all claims to C.L.U.E., including glass claims. For instance, Allstate reports claims made against your "full glass coverage" under your automobile insurance policy.  For this reason, it may be advisable not to take "full glass coverage".  In New York, Allstate will elect not to renew your policy if the frequency and severity of your losses is excessive.  For instance, Allstate has declined to renew the writer's auto insurance policy in Long Island, NY due to the policy holder making 4 claims in less than 5 years.  The 4 claims consisted of:  1) a stolen & recovered car; 2) a windshield cracked by snow;  3) a windshield cracked by a stone on the highway; and 4) an accident where a witness said the Allstate insured ran a red light, but the police report found otherwise, citing the other driver for failure to yield right-of-way when it made a left turn in front of the Allstate insured. The windshields were replaced by Safelite Auto Glass, an Allstate authorized repair center.  Allstate claims that they spent $367.00 and $447.00 on each of the windshields, for a 1986 Honda Prelude, however, Safelite will sell them, installed at your home, to a retail customer for less than $150.00 each.  Even at Allstate's price, the cost of the windshields were far less than the amount of premium increase suffered by the Allstate Insured.  Allstate refused to renew the policy and offered to insure their insured with Allstate Indemnity resulting in a total premium increase costing almost $5,000!!!

Find out another reason why you shouldn't bother with glass coverage and what you need to know about glass coverage when you have a leased car.

CAR RENTAL & TOWING COVERAGE:  While it may be a good idea to have these endorsements, it is not always a good idea to use them.  Although these endorsements may be available to you, even though you have not been in an accident, it is generally recommended that you do not use any of these endorsements unless you you need to use them due to an accident. The reason is that a single towing claim of $35.00 or a car rental claim can affect your claim status with CLUE (mentioned above) and may increase the premium your insurance company will charge you when your policy renews. If this occurs, it can cost you several thousand dollars for a $35.00 claim!  (see decline glass coverage above)  If you use these endorsements in conjunction with an accident then it probably will not affect your premium since you will have a claim, anyway, from the accident and it will likely all be considered one claim. Tips on Renting a Car

THE OTHER BENEFITS OF LIABILITY COVERAGE:   Besides protecting your assets from the claims of a person who you may inadvertently injure, your automobile liability policy will provide you with free legal counsel to defend you.  If you do not have liability insurance, you would have to pay an attorney to defend you against a law suit.  The cost of your legal defense could cost tens of thousands of dollars.   In the event of a law suit against you, your insurance company is contractually responsible to fairly pay claims made against you.  Should you accidentally injure someone, due to your negligence, your insurance company should make a fair offer to compensate the injured party.  If the offer is fair and the injured party agrees, then a settlement will be reached.  When a settlement is reached, your insurance company will require that the injured party sign a release and a stipulation of discontinuance if a law suit has been started.. The release will release you from any further liability beyond the settlement amount and thereby protect your personal assets and income from any further attack. The stipulation of discontinuance will terminate the law suit against you.  You should not rely on your insurance company to fairly pay a claim (as can be seen below, sometimes they do and sometimes they don't) and you should inquire from time to time from both your insurance company claim representative and the lawyer assigned to represent you as to the progress of the case; whether any demands to settle have been made; whether any offers have been made; the nature of the injuries sustained by the plaintiff; and a copy of verdicts of similar cases and injuries.  The attorney assigned to represent you, although paid by your insurance company, is your attorney and is governed by attorney-client ethics.  Ethics regulations require that your attorney respond to your communications within a reasonable period of time.  It is suggested that you put your communications in writing (they do not have to be typed). 

SUM, UM, Underinsured and Uninsured:  You should request your broker, agent or insurance company sales agent to give you the maximum underinsured and uninsured coverage with limits equal to your liability coverage.  This coverage is inexpensive and one of the most important endorsements you can buy for your insurance policy.  This coverage pays you when you are injured by someone who doesn't have insurance, has less liability insurance than you have, or in a hit & run.  Most brokers and agents never mention this coverage to their customers either because they are foolish or because they are afraid that you may buy somewhere else where the agent quotes a lower premium without it. Once you have higher liability limits than the minimum required, this coverage is inexpensive. Most of my clients with serious injuries could have benefited from this coverage. An example is a client who was hit in the rear by a drunk driver who had the minimum $25,000 liability coverage required by New York State. My client suffered a torn rotator cuff (shoulder ligament) and had surgery. He not only suffered a serious injury with possible lifelong implications, but he also lost his job as a waiter because he was unable to work after the injury. My client has $100,000 liability coverage and $25,000 uninsured/underinsured coverage. In New York State, the amount of the underinsured coverage is deducted from the liability coverage of the other car, in this case $25,000 which is the same as my client's underinsured coverage, so he was not able to collect from his underinsured coverage. He received only $25,000 from the other driver's insurance company. If my client had underinsured coverage of $100,000, he would have received $25,000 from the other driver's insurance company and $75,000 from his underinsured coverage, for a total of $100,000.

No-Fault:  Is your state a No-Fault state? You should request your broker, agent or insurance company sales agent to give you the maximum medical payment or No-Fault coverage available.  This coverage is inexpensive and is also one of the most important endorsements you can have.  This coverage will pay your medical bills when you are injured in an automobile accident.  This coverage is usually better than most major medical coverage policies.  For some reason, most brokers and agents never mention this coverage to their customers.

What is No-Fault coverage?  No-Fault insurance covers medical payments for injuries sustained by anyone injured from an accident involving the use and operation of a motor vehicle, without regard to whose fault caused the accident or injury.  This would include all occupants/passengers and may even provide medical payments coverage for non-moving accidents, such as when someone is injured while entering or exiting the insured automobile.  No-Fault insurance law also places limitations on the insured's ability to sue other negligent drivers and owners for damages.  

No-Fault coverage is primary, which means that your medical bills must first be submitted to the No-Fault carrier before any other medical insurance carrier. Use of a motor vehicle is defined very broadly, i.e.. a person who trips getting out of a car may be covered by No-Fault. In New York, the No-Fault insurance carrier must be notified of your intent to file a claim within 30 days of the date of accident and an application for No-Fault benefits must be filed within a reasonable time thereafter.  Medical bills including all other bills must be submitted to the No-Fault insurance carrier within certain time periods.  In NYS, medical bills must be submitted to the No-Fault insurance carrier within 45 days of the date of treatment.

What is a No-Fault IME? The No-Fault insurance carrier will require you to attend what they call an IME, (Independent Medical Exam).  We call it an Insurance Medical Exam because we believe the word Independent is a misnomer. The No-Fault insurance carrier will usually assign the exam to a company which the insurance company chooses.  That company will then assign the exam to a doctor. The doctors who perform this exam are usually paid by the company assigned by the No-Fault insurance company. The doctor will examine the injured claimant for usually from 5 to 15 minutes and then write a report to the insurance company advising the carrier as to whether the claimant needs any further treatment. Most IME doctors do a substantial amount of IMEs and some doctors do not maintain a private practice of medicine, doing only IMEs. Since the injured claimant's doctors have a financial interest in continuing treatment, sometimes when no longer needed, the insurance company has a right to determine, by the use of an IME whether continued treatment is necessary. Since the purpose of the IME is to determine whether continued treatment is necessary, the exam is an adversarial one and the claimant has an absolute right to be represented at the IME by an attorney. Performing IMEs can be a substantial source of income for the doctor. Since the income originates from the insurance company, the doctor may be biased.  For these reasons, well call the IME an Insurance Medical Exam.

SHOULD I INSURE MY CAR IN ANOTHER STATE?  It is very unwise to tell your insurer that you live in another state and insure your car in that state to obtain lower insurance premiums.  Most insurers use investigators who can determine that your car was really garaged somewhere else and your insurer may deny coverage for your claim, whether it is for a stolen car, property damage to your car or another car, or personal injury.

SHOULD I PAY A PROPERTY DAMAGE CLAIM WITHOUT REPORTING THE ACCIDENT WHEN IT'S MY FAULT & NO ONE IS INJURED?  If you do, you better get a general release!  Failure to report an accident could subject you to personal liability if the party later finds themselves to be injured and your insurance company denies the claim due to your failure to report the accident promptly.  You should always call the police and request an accident report when you have had an accident.  (see "When Should I Report an Accident", above)

Can You Trust Your Auto Insurer - CBSNews.com  More on Allstate.  But, of course, that's why you need a lawyer!

Allstate - Before you buy insurance from Allstate, read the transcript on ABC's show 2020.  ABC's 2020 stated: "Allstate Insurance has made billions of dollars selling insurance with its famous slogan, "You’re in good hands with Allstate." But Brian Ross reports on allegations that the insurance giant played hardball with desperate homeowners after a Los Angeles earthquake four years ago, relying on questionable experts and falsified reports and short-changing policy holders, perhaps for as much as millions of dollars.".

Allstate - cancelled the writer's auto insurance policy (in December 1998) for failure to pay the premium when due.  Although I stated that I did not receive any notice warning me that the policy would be cancelled and offered to sign an affidavit stating so and to pay the premium immediately, Allstate refused to reinstate the policy.  Allstate claimed that they did send a notice and only offered to sell a new policy at a higher premium.

Liberty Mutual - has apparently begun scheduling IMEs (Insurance Medical Exams) within just weeks of an automobile accident, so soon after the accident, that diagnostic records are not yet available to be reviewed at the IME. Liberty Mutual has done this recently in several cases the writer has had with Liberty Mutual.  The IMEs were even scheduled before the injured claimant could file an application for No-Fault benefits and before the injured claimant retained an attorney. Without diagnostic records to substantiate the injuries, it is difficult for the IME doctor to justify continuing treatment and treatment could be denied early on.

Liberty Mutual - denied orthopedic medical treatment and therapy to a 12 year old who was sitting in the right front passenger seat of his father's car when his door was struck by a 4 wheel drive vehicle which was speeding at a very high speed in a drag race. The 12 year old was airlifted to the hospital with multiple and severe injuries, including a lacerated liver and back injuries.  Although the accident occurred on 05-06-97, on 08-21-97, Liberty Mutual asserted its right to send the boy to a doctor for an IME (Insurance Medical Exam) whereupon the doctor stated that the injuries had resolved and Liberty Mutual then denied further coverage.  The boy and his parents have stated that the injuries had not resolved at that time and his own doctors said that he needed further therapy.

Atlantic Mutual Insurance Company settled a personal injury claim in Rockland County, NY (not a good county for getting high jury verdicts) where the plaintiff, Mr. V., was struck in the rear and suffered a discectomy at C5-6 (removal of a vertebral disc in the neck).  This is a serious injury and Atlantic Mutual did the right thing by offering $290,000 from their $300,000 policy early in the case before depositions had been conducted. This saved the company legal defense costs to defend an undefendable position; saved their insured from a verdict in excess of the policy; and allowed the injured party to attempt to get his life back in order at an earlier date.  We believe Atlantic Mutual acted as a responsible insurance company and did the right thing!  Plaintiff's Counsel: PHILIP L. FRANCKEL, ESQ.

Progressive Insurance Company allowed Mr. V., in the above mentioned case, to obtain two years of beneficial medical treatment without being harassed by Insurance Medical Exams and denied further medical payments! Progressive deserves substantial praise for their responsible handling of this No-Fault claim!

State Farm Insurance Company  ($473,000 Verdict reduced by the jury from 1.3 million!, Supreme Court Nassau County May 1999).  State Farm's insured, while driving a rented Ryder Truck, struck the injured plaintiff in the rear, on 06-29-90, causing a serious and permanent TMJ injury (the TemporoMandibular Joints which allow the jaw to open & close) requiring the plaintiff to undergo bi-lateral surgery (on both sides) of the jaw.  State Farm never made an offer (not even $1.00) to settle a claim against their insured's, $500,000 policy for 8 years.  Approximately one year before the trial, State Farm offered $200,000.  At the trial, State Farm offered $250,000, then $260,000, then in the middle of trial, the law firm that State Farm hired, replaced their attorney with the senior partner and offered $310,000.  The plaintiff wanted to accept the offer of $310,000, however, at midnight, after a night of many telephone calls, Philip L. Franckel, Esq., had convinced the plaintiff to decline the offer and continue to verdict.  The case went to the jury on 05-17-99, resulting in a verdict of $473,000 on 05-18-99.  It is Mr. Franckel's policy not to accept even reasonable settlement offers in the middle of trial.  Once trial has started, the amount of resources and money to prosecute the case has mostly been spent and Mr. Franckel believes that his client should tell her story to the jury and receive a verdict, good or bad. Unfortunately, the plaintiff is not entitled to interest on the judgment from the date of the accident, so State Farm was able able to keep the interest earned on the money.

Allstate settled (in Dec 1995) and paid $90,000 of a policy with a limit of $100,000 to Mr. Villalobos, a claimant, represented by PHILIP L. FRANCKEL, ESQ., who suffered 50 sutures (stitches) at his right eye.  This case was not in suit and while I wanted the entire policy, I certainly can't say Allstate was unfair in this case.

The Hanover Insurance Company settled and paid $50,000 to a claimant, represented by PHILIP L. FRANCKEL, ESQ., who's shoulder belt ruptured a saline breast implant when she was struck in the rear by Hanover's insured.  The plaintiff had to undergo additional surgery to replace the implant. This amount was paid quickly and prior to a lawsuit being started.  Hanover acted responsibly and fairly with this claim!

The Hanover Insurance Company settled and paid $45,000 to a claimant, represented by PHILIP L. FRANCKEL, ESQ., who slipped on an orange peel in a parking lot which came from an overflowing garbage bin. The problem of overflowing garbage had been previously reported to the condominium association.  The 68 year old claimant had an MRI which indicated a suspicion of a torn rotator cuff tear and had four months of physical therapy.  This amount was paid quickly and prior to a lawsuit being started. Hanover acted responsibly and fairly with this claim!

Eagle Insurance Co.  This is an interesting case.  The client/plaintiff who's car was struck in the rear by Eagle's insured, went to one attorney to get reimbursement for her car which was totaled, however, the client also went to another attorney (Philip L. Franckel, Esq., creator of this web site) to recover for her personal injuries.  Neither attorney knew about the other.  The attorney handling the property damage claim brought suit in small claims court (I have no idea why, since the plaintiff was struck in the rear) and settled the claim in court.  That attorney had his client sign a pre-printed form release.  The release was a general release releasing all claims and the attorney failed to write wording on the release to exclude personal injuries. Upon serving a complaint for personal injuries, the defense attorneys hired by Eagle Insurance called saying "we have a problem, your client signed a release for all claims including personal injuries.".  

Allstate settled and paid the policy limit of $25,000 to Mr. Sedgh, a plaintiff, represented by PHILIP L. FRANCKEL, ESQ., who suffered a fractured right 5th finger (pinky) without surgery, but which involved the joint.  They strenuously objected, but finally gave in. Not only were they fair, but believe it or not, it was Allstate!

State Farm Insurance Company settled and paid the policy limit of $16,000 to Ms. Fisse, a claimant, represented by PHILIP L. FRANCKEL, ESQ., who suffered a very small scar on the inside of her lip without surgery or sutures.  She bit her lip when she was hit in the rear while stopped at a light.  The case was not in suit and State Farm was very fair. (I have usually found State Farm to be fair with the lesser injuries, but never with serious injuries).

Tri-State Consumer Insurance settled and paid $18,000 to Mr. Fouerti, a claimant, represented by PHILIP L. FRANCKEL, ESQ., who suffered a fractured right 5th finger (pinky) (the claimant was left handed) without surgery and without joint involvement. The case was not in suit and Tri-State was very fair.

Travelers Insurance and CNA Insurance Co settled and paid $300,000 to a plaintiff, represented by PHILIP L. FRANCKEL, ESQ., who suffered a torn Achilles tendon with surgical repair (not disputed as caused by the accident) and a torn meniscus which was disputed as having been caused by the accident because the first complaint of knee pain was four years after the accident; and $130,000 to the other plaintiff, also represented by PHILIP L. FRANCKEL, ESQ., who suffered an injury to the elbow bursa which required an Olecranon bursectomy (surgical removal of the bursa at the elbow) (not disputed as caused by the accident) and a possible scapula fracture (diagnosed by the patient's orthopedist because of a slight translucency in the X-Ray) which was disputed because the patient's radiologist's X-Ray report stated that there was no fracture. Liability was not in dispute, since the Plaintiffs were injured when they fell as a staircase leading from the ground floor to the basement, in a private home, collapsed. Travelers and CNA cooperated and got together to fairly settle this case at a mediation.

Fireman's Fund settled at mediation and paid $50,000 to a plaintiff, represented by PHILIP L. FRANCKEL, ESQ., who suffered a TMJ injury without surgery.  The TMJ MRIs were normal.  Liability was not disputed. Fireman's fund was very fair.

State Farm Insurance Company refused to make an offer and this case was arbitrated at National Arbitration & Mediation with a high low parameter of $0 to $100,000 (policy limit).  In this case the plaintiff, who was the driver of his car, hit his knee on the dashboard when he was struck in the rear.  An ambulance arrived and treated his knee with an ice pack and ace bandage.  The plaintiff did not go to the hospital, but drove a few blocks to work and called his sister to pick him up because his knee was swollen and he couldn't drive.  The plaintiff saw a chiropractor three days later, who referred him to an orthopedic surgeon for treatment of his knee.  A torn meniscus was diagnosed and arthroscopic surgery was performed.  Defendant's contentions:  the plaintiff did not go to the hospital; the ambulance report could not be found;  the first doctor the plaintiff saw was a chiropractor;  and the orthopedic surgeon indicated on the operative report a post operative diagnosis of "degenerative tear" of the medial meniscus.  The arbitrator awarded $65,000.00.

Colonial Penn The plaintiff was hit in the rear and suffered a herniated disc at L3-L4 and L5-S1; surgery to repair a deviated nasal septum and right and left TMJ displacement with arthroscopic surgery recommended.  The defendant's insurance policy was $250,000.  This case was settled at a settlement conference in Nassau County Supreme Court for $225,000.00.