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Insurance Claims Introduction An insurance company makes money when it collects more in premiums from its insureds (those who purchase or hold a policy) than the company pays out in claims. Insurance companies have an incentive to delay payment of claims and to deny many claims. Although insurance companies are regulated (by the Oregon Insurance Division in Oregon and by the Office of the Insurance Commissioner in Washington), consumers and small business sometimes must retain legal counsel to enforce their contract rights under a policy issued by an insurance company.
Insurance policies are generally made up of the application for insurance, coverage grant, declarations page, exclusions, conditions and endorsements. Insurance contracts are to be interpreted to ascertain the intent of the insurance company and insured. Generally, terms in an insurance contract are ambiguous if they are susceptible to two reasonable meanings. Insurance companies write many different types of policies: property insurance (such as automobile, truck, commercial, fire and home insurance), life insurance, health insurance, accident or disability insurance, aviation insurance and maritime insurance. If you have had an insurance company deny your claim or if you have a problem with an insurance company, it is important to have an Oregon attorney or Washington attorney evaluate any potential claim you may have. The law provides strict deadlines for bringing claims against insurance companies. It is critical that you contact an Oregon attorney or Washington attorney if you think that you may have a claim. An Oregon attorney or Washington attorney at Vangelisti Kocher LLP can provide you a free consultation. Legal Actions Against Insurance Companies An insured can hire an attorney and, if necessary, bring a legal action against an insurance company if it breaches its contract with the insured to take some action required under the insurance policy. These failures may include the insurance company’s failure to pay losses, failure to pay a judgment or failure to defend the insured. In some circumstances, the insured may bring an action against the insurance company for tortuous breach of the covenant of good faith and fair dealing, interference with business relations or intentional infliction of emotional distress. Additionally, the insured may bring an action against an insurance company for misrepresentation or fraud. Generally the insured must first file a proof of loss and/or notice of loss with the insurance company before bringing any legal action. If a legal claim against an insurance company is successful, the insured in some instances may recover prejudgment interest and attorney fees. In some cases, it is appropriate for an insured to represent a class of other people who have experienced the same or similar wrongful treatment by the insurance company. Generally, a court will approve a class action where an insurance company has breached its contract with many insureds by treating all of them in the same or similar wrongful way, and other legal requirements for an appropriate class action have been met. In some cases, only a class action can have an effect that is significant enough to force an insurance company to stop a wrongful practice. For example, doctors and physician associations have recovered for claims against health plans and health insurers for their failure to reimburse for medical procedures and services provided by the doctor. In one case, physician plaintiffs forced a health insurer to change its procedures and stop using software programs that systematically low ball or deny payment or reimbursement for legitimate patient claims. In some cases, these types of legal actions can give relief to doctors who suffer from long term billing disputes and unfair reimbursement practices. If you have had an insurance company deny your claim or if you have a problem with an insurance company, it is important to have an Oregon attorney or Washington attorney evaluate any potential claim you may have. The law provides strict deadlines for bringing claims against insurance companies. It is critical that you contact an Oregon attorney or Washington attorney if you think that you may have a claim. An Oregon attorney or Washington attorney at Vangelisti Kocher LLP can provide you a free consultation. Health insurance generally provides benefits for injury or illness, including expenses necessary for the prevention of illness. Health insurance policies or plans usually exclude treatment that is unnecessary or experimental. Experimental medical treatments usually include procedures that are not conforming to accepted medical practice or are not approved by a governmental agency. Sometimes health insurance companies’ denial of medical claims can be challenged in court before or after an informal review process occurs. Although each case depends on its own unique facts and applicable law, some health plan members in some states have been successful in forcing health insurers to interpret “medical necessity” or “medically necessary” in a way that ensures that patients receive medically necessary care as defined by their physicians rather than the insurance company. Health insurance policies—as well as life insurance policies—can include exclusions for pre-existing conditions. Exclusions for pre-existing conditions, however, are substantially limited by recent federal and state legislation. Most liability insurance policies require the insurance company to pay or indemnify the insured for any damages or losses that the insured is legally obligated to pay in particular circumstances. In addition to a duty to pay or indemnify, liability insurance policies can also require the insurance company to defend an action against the insured and to settle a claim against the insured. An insurance company generally can be held liable by an insured if the insurance company fails to act reasonably or with due care in the payment, defense or settlement of a claim. Automobile insurance policies generally include coverage for liability, collision, comprehensive, uninsured motorist (UM), underinsured motorist (UIM), and personal injury protection (PIP). Liability coverage generally provides that the insurance company will defend and indemnify the insured against claims arising out of the use of a vehicle. For example, if the insured negligently causes injury to a driver or passenger of another car, the insurance company of the negligent insured must pay the claims of the injured driver or passenger who were not at fault. Drivers or passengers injured by a negligent driver are often required to retain a lawyer to force the bad driver’s insurance company to pay for injuries of the driver or passengers who were not at fault. Collision coverage generally covers the insured for damage to the insured’s car or truck that is caused by accidental collision with another vehicle, object or automobile. Comprehensive coverage does not include those events covered by collision but rather covers other accidental or direct damage to the insured-owner’s auto. For example, comprehensive would cover theft or vandalism. Uninsured motorist (UM) coverage generally covers the insured for all sums which the insured shall be legally entitled to recover as damages for bodily injury or death caused by accident and arising out of the ownership, maintenance or use of an uninsured motor vehicle in amounts or limits not less than the amounts or limits prescribed for bodily injury or death by law. Uninsured motorist coverage in a policy usually cannot be less that the level required by state law. Uninsured motorist satutes are often revised by state legislatures. Underinsured motorist (UIM) coverage generally covers the insured for damages when the negligent driver does not have sufficient insurance to cover the insured's losses. Generally underinsurance benefits are required to be equal to uninsured motorist coverage benefits less the amount recovered from other automobile liability insurance policies. Personal injury protection (PIP) coverage generally covers the insured and passengers in the vehicle for reasonable and necessary medical expenses, funeral expenses, loss of income, child care and essential services. A pedestrian can be covered by PIP in some circumstances. Personal injury protection or PIP is mandatory in Oregon and has certain minimums as required by state law. In Washington, personal injury protection is optional, but the insured must waive personal injury protection or PIP in writing if they do not want the coverage. Diminished Value refers to the fact that an automobile may be worth much less after it has been involved in a collision. Diminution in value is especially large where an insurer attempts to repair major damage, such as frame damage, to a newer vehicle. Often, insurers will pay for extensive repairs rather than declare a car or truck a total loss and replace it. When the insurer then refuses to pay for diminished value, the insurer saves money and leaves the vehicle owner with the loss. When the insured's own insurance company is responsible for the damage, the insurer's duty to pay for diminished value generally is determined by the language of the insurance policy. When another driver is responsible, that driver's insurance company generally is required to pay for diminished value. Our firm has extensive experience litigating diminished value claims in individual and class actions. If you have experienced problems with diminished value coverage, please contact us for a free consultation to learn about your options for recovery. If you have had an insurance company deny your claim or if you have a problem with an insurance company, it is important to have an Oregon attorney or Washington attorney evaluate any potential claim you may have. The law provides strict deadlines for bringing claims against insurance companies. It is critical that you contact an Oregon attorney or Washington attorney if you think that you may have a claim. An Oregon attorney or Washington attorney at Vangelisti Kocher LLP can provide you a free consultation. Property insurance generally covers real property or personal property. Property insurance includes standard fire insurance, homeowners’ insurance, inland marine insurance, and commercial property insurance. Property insurance can cover “all-risks” or “named-perils” as specified risks in the policy. Life insurance generally provides benefits for accidental death to a particular beneficiary. Life insurance is offered in various forms: term insurance, whole life insurance, modified life insurance, trip insurance, annuities, or industrial life insurance. Insurance Agents Insurance companies are generally bound by the acts and statements of their insurance agents. An insurance policy can sometime be “reformed” if the policy does not reflect the agreement that the insurance agent and insured had about the scope of coverage. In this case, the insured may hire a lawyer and bring a legal action against the insurance company to “reform” the insurance policy to conform with the actual agreement. An insurance agent’s knowledge and any fraud or misrepresentation are imputed to the insurance company. In other words, if the insurance agent makes a false statement, commits fraud, or makes a misrepresentation, the insurance company is liable for the false statement, fraud or misrepresentation. Insurance Companies Vangelisti Kocher LLP has had experience dealing with the following insurance companies: Aetna, Allstate, American Family Insurance, Amica Mutual, AFLAC, AIG, Chubb, Farmers Insurance Exchange, GEICO, Hartford, Jackson National Life Insurance Company, Kaiser Permanente, Liberty Mutual, Mid-Century, Nationwide Insurance, Oregon Mutual, Pacific Employer’s Insurance Company, Progressive, Providence, Regence Blue Cross Blue Shield of Oregon, Safeco Insurance, State Farm, St. Paul Companies, Truck Insurance, Unitrin, USAA, USF&G, Zurich. If you have had an insurance company deny your claim or if you have a problem with an insurance company, it is important to have an Oregon attorney or Washington attorney evaluate any potential claim you may have. The law provides strict deadlines for bringing claims against insurance companies. It is critical that you contact an Oregon attorney or Washington attorney if you think that you may have a claim. An Oregon attorney or Washington attorney at Vangelisti Kocher LLP can provide you a free consultation.
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An insurance contract is generally a contract in which the insurer undertakes to indemnify or pay the insured a specified or ascertainable amount of money or benefit upon a loss or determinable risk contingency. An insurance binder is a writing given to the insured that obligates the insurer to pay insurance if a loss occurs before the policy is issued or an application for insurance is denied. An application for insurance can be accepted by an express statement, acts or conduct of the insurance company.
