Reading an Insurance Policy

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1 Reading an Insurance Policy Here are some tips for maximizing your understanding of insurance policies. A. Get the Complete Policy Sometimes just obtaining the policy is a challenge. The client may not have all or vital portions of the policy or may not have a copy which corresponds to the loss date. Therefore, it is essential to get a certified copy of the policy from the carrier. This is simply a copy which the carrier assembles and swears is accurate as of the date of loss. Interestingly, it is sometimes the case that the so-called certified copy is not accurate because the certified policy was created by a clerk at the company who simply looked at a computer printout of coverage and form numbers and then assembled a new policy from specimens. Thus, utilize the parts of the policy you can secure from the insured, public adjuster or the insured s insurance agent/brokerage that sold the policy to the insured to compare with the so-called certified copy. If possible, you should secure a copy of the policy for the year(s) previous to the loss and the year following the loss. If you see that the coverage for the insured is different in certain years, it is a red flag to find out why. It may be a sign of a mistake in the certified copy, or may raise awareness about the insurance agent s competence if the policy coverage for the event is somehow inadequate. It is equally important to see if your insured has any of the marketing materials or other information given by the insurance company or the broker/agent, which often also comes with renewal notices. These documents may also provide helpful explanation as to certain policy terms and changes. B. Understand the Policy Structure There are FOUR basic parts to every policy: 1. Declarations; 2. Conditions; 3. Insuring Agreements; and 4. Exclusions. 1. Declarations. This special page of the policy identifies who is insured, what risks or property are covered, policy limits, and the effective dates of coverage. The Declarations also tell you the identity of the insurance company so you will know the proper name of the company (and who to sue/serve). More specifically, a declaration page includes the name and address of who is insured, the issuing carrier, what risks or property are covered, the policy limits, the coverage effective dates 1

2 and policy numbers. Depending on the policy type, you may also see the premium, deductible and other information. The Declarations Page also contains a list of form numbers and endorsements. The form numbers identify every portion of the policy. You can compare the form numbers against the pages of the policy to help determine complete policy. You can also find edition dates on the form numbers and compare them to edition dates on the policy pages, and to the effective dates on the policy. Carriers often make mistakes in assembling certified policies. Therefore, carefully analyze and compare form numbers to insure that this information in accurate. Your insurance policy will separately discuss each area of Coverage. For each type of coverage, the policy will usually define the meaning of the limits listed on your declaration page. Read these very carefully, because sometimes there are lower limits for certain defined types of loss. In addition to the definition of the limits, each coverage type will have what is called an insuring agreement and a list of exclusions. 2. Conditions. Conditions are simply requirements that the insured must fulfill to obtain coverage. You ll find them in a separate section labeled "Conditions Applicable to Entire Policy," or "General Conditions." You will also find conditions within each coverage part applicable only to the coverage part in which they are found (liability, PIP, UIM, collision, etc). Conditions often represent traps for unwary counsel. Definitions usually appear in general conditions, but can also show up in conditions applicable to particular coverage. The policy will show defined terms in bold face, so the reader knows to search for definitions of bold terms. Absent a definition in the policy, the law says that undefined words will be given their plain, ordinary and popular meaning. If the term is reasonably susceptible to more than one meaning, the Court must adopt the meaning favorable to the insured. 3. Insuring Agreements. This is the main part of the insurance document. Insuring Agreements will define all of the coverage you have just purchased. Make sure you have your definitions handy when you are reading this section; it will be full of defined terms. You may find the coverage section with its own set of Definitions (or re-definitions) of some of the terms. This portion of the agreement generally uses broad language to describe the coverage offered. 4. Exclusions. This section literally takes away much of what was described in the Insuring Agreement. This part informs you how the coverage is limited. Usually, the exclusions are much longer and more specific than the Insuring Agreement. It is important to understand what is excluded. It would be interesting to determine what your client s understanding of their coverage is/was. This may raise the need for you to further consider the insurance agent/broker s responsibility in providing sufficient coverage and explaining Exclusions. 2

3 There is some good news in that courts have repeatedly held that Exclusionary clauses are to be most strictly construed against the insurer and in favor of coverage as the purpose of insurance is to insure (not exclude). There is also a General Conditions section, which provides instructions on what you are required to do in the event of a loss. You may also find other general policy terms. It is critical to ensure that the insured has followed the insurance agreement s terms in filing/processing the claim. C. Compare the Policy With Itself. You will find the incredible importance of a word or two. If the dispute concerns liability coverage, you should look to see if the key word appears in different places in the policy. You can also locate other policies by the same carrier. Words like "caused by" and "arising from" can have disparate meanings, especially if the carrier uses them differently in different policies. As the court has said in many cases, "the industry knows how to protect itself and it knows how to write exclusions and conditions." Nothing the carrier writes into a policy should be ignored, or considered accidental. D. The Terminology in Homeowner Insurance Policies A typical homeowner s insurance policy is divided into two parts: 1) Property Protection and 2) Liability Protection. 1. Property Protection Section. Property is usually listed on the Declarations page. Property Protection is normally broken down into four additional sections: (a) Dwelling; (b) Other Structures; (c) Personal Property and (d) Loss of Use. The Dwelling section covers your house, attached structures, plumbing, heating, and electrical. The Other Structures section covers detached structures, such as garages, storage sheds, fences, driveways, sidewalks and patios. The Personal Property section covers personal property, including the contents of your home and other personal items. The Loss of Use section covers living expenses sometimes called Additional Living Expenses (often referred to by the acronym A.L.E.) - if you can not live in your home while it is being repaired. 3

4 2. Liability Coverage Section. This section is broken down into two parts: Personal Liability and Medical Payments. The Personal Liability section provides personal liability coverage against a claim or lawsuit resulting from bodily injury, or property damages to others that was caused by an accident on your property. The medical payments section includes coverage to pay medical expenses for people accidentally injured on your property. E. Different Kinds of Policies There are seven basic kinds of home insurance policies (which apply in all states except Texas), which cover different types of peril: Seven Basic Policies HO-1: Basic Homeowner. The Policy covers your dwelling and personal property against losses from 11 types of perils: Fire or lightning, windstorm or hail, explosion, riot or civil commotion, aircraft, vehicles, smoke, vandalism or malicious mischief, theft, damage by glass or safety glazing material that is part of a building, and volcanic eruption. HO-2: Basic Homeowner Plus. This Policy covers dwelling and personal property against 11 perils plus six more: falling objects, weight of ice, snow or sleet, three categories of water-related damage from utilities or appliances, and electrical surge damage. HO-3: Extended or Special Homeowner. This Policy covers the 17 stated perils plus any other peril not specified in your policy, except for flood, earthquake, war, and nuclear accident. HO-4: Renters Coverage. This Policy covers only personal property from 17 listed perils. HO-5: All Risk Coverage. This Policy provides the broadest Florida condominium, townhouse, and homeowner s insurance protection because it will cover losses that are due to any peril except those specifically excluded in the policy. A "Named Perils" policy covers losses that are due to only those perils listed in the standard homeowner s insurance policy and typically include fire, hail, windstorm, and other physical losses. HO-6: Condominium Owner Coverage. This Policy covers personal property from 17 listed perils along with certain building items in which the unit owner might have an insurance interest. HO-8: Basic Older-Home Coverage. This kind of Policy covers dwelling and personal property from 11 perils. It differs from HO-1 in 4

5 that it covers repairs or actual cash values; it does NOT cover rebuilding costs. You will find this kind of coverage in homes where some historic or architectural aspects make the home's replacement cost significantly higher than its market value. You may also find this kind of coverage in situations where the insured is looking at price and will accept this kind of coverage. F. Definitions ACTUAL CASH VALUE An amount equivalent to the replacement cost of a stolen or damaged property at the time of the loss, less depreciation. For vehicles, this amount would be determined by a local area private party sales and dealer quotations. Kelly Blue Book would only be used as a guide and not the final word. APPLICATION: BINDER CLAIM A printed form developed by an insurer that includes questions about the prospective insured and the desired insurance coverage and limits. CLAIMANT A temporary or preliminary agreement which provides coverage until a policy can be written or delivered. Notice to an insurer that under the terms of a policy, a loss maybe covered. The first or third party. That is any person who asserts right of recovery. CONTENTS-ONLY COVERAGE In personal property insurance, this coverage is for personal property items that are movable, that is, not attached to the building's structure (the home), such as television sets, radios, clothes and household goods. Not included under the coverage are animals, automobiles and boats. 5

6 DEDUCTIBLE The amount of the loss which the insured is responsible to pay (before the benefits from the insurance company are payable. You may choose a higher deductible to lower your premium. DEPRECIATION A decrease in value due to age, wear and tear, etc. ENDORSEMENT Amendment to the policy used to add or delete coverage. It is also referred to as a "Rider." EXPIRATION DATE INSURED INSURER LIMIT The date on which the policy ends The policyholder - the person(s) protected in case of a loss or claim. The insurance company. Maximum amount a policy will pay either overall or under a particular coverage. MATERIAL MISREPRESENTATION PERIL POLICY When a policyholder/applicant makes a false statement of any material (important) fact on his/her application, an insurance policy may be rescinded (the insurance company does not have to pay, and policyholder may be held civilly or criminally liable. The cause of a possible loss (such as hurricane, fire, theft, hail, etc.). The written contract of insurance. 6

7 POLICY LIMIT The maximum amount a policy will pay, either overall or under a particular coverage. REPLACEMENT VALUE RIDER The full cost to repair or replace the damaged property with no deduction for depreciation, subject to policy limits and contract provisions. Usually known as an Endorsement, a Rider is an amendment to the policy used to add or delete coverage. 7

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