By PLRB
5
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The podcast currently has 154 episodes available.
Surveillance video shows a woman wearing a salon cape exiting through the front door of a hair salon. She spends a few moments in front of the salon examining her hair in a large handheld mirror. On reentry, she stumbles on the second and falls. Notable Timestamps
[ 00:32 ] - This is not her first time at the salon, and not her first time through the door that day.
[ 01:16 ] - Tripping and falling is a common experience.
[ 02:45 ] - The team watch & react to the video (only available for staff).
[ 04:08 ] - Ruth details the layout of the step.
[ 05:03 ] - The riser heights are within an acceptable range.
[ 05:40 ] - The tread depth is likely compliant, even if they are longer than usual.
[ 06:07 ] - The riser heights are not uniform, which may present a code issue.
[ 06:45 ] - In this case the 2018 IBC applied, and handrails are required on both sides. No handrails were present here.
[ 07:17 ] - The term "Legacy Code Exceptions" is typically preferred to describe when a code does not apply because the structure was built prior to the code's establishment.
[ 08:30 ] - A "triggering event" such as remodeling or occupancy change can mean that a legacy code exception would not apply. It also may not apply if something else, e.g. deterioration, made the area unsafe.
[ 09:18 ] - In some cases, an exception to a building code may be made if the structure of the building does not permit the code requirement, e.g. handrails.
[ 10:22 ] - In some states, if the steps were not up to code, the salon is negligent automatically or "negligent per se." In other states, evidence of code violation means there is a presumption of neglience; finally, other states merely find a code violation to be evidence of negligence.
[ 11:30 ] - Even in "negligence per se" states, establishing that the negligence existed is not the same as demonstrating that the negligence caused the injury as opposed to an intervening factor, e.g. the insured's behavior.
[ 12:33 ] - Ruth provides a recap of the scenario and the points above.
Your PLRB Resources
Address Report: Find a code adoption for insured's address with link to code book - https://www.plrb.org/building-codes/building-component/
Commercial Stairs Diagram: Interactive diagram with excerpts from code for each of the main components of stairs - https://www.plrb.org/building-codes/building-component/
Legal Duty Created by Building Codes: State-by-state analysis of case law and defenses - was the insured negligent based on failure to comply with building codes? - https://www.plrb.org/documents/overview-of-duty-created-by-building-codes/
Ask a Code Question - https://www.plrb.org/building-codes/ask-plrb-building-code-question/
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
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Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0).
Today our adjuster is leveling up in their career and handling their first large loss property claim. The adjuster quickly runs into trouble-- where can a claims professional go for help? This October 23 to 25 in Tampa, join PLRB for the 2024 Large Loss Conference. Notable Timestamps
[ 00:39 ] - Alissha asks HERSELF "what's the scenario?" This scenario features late notice, Category 3 water, and additional damage during a claim.
[ 01:57 ] - The team talks Tampa taco trucks & Cuban cuisine.
[ 03:24 ] - Late notice issues? Attend the educational session "It’s Too Late, Baby, It’s Too Late: Navigating a Late Reported Large Loss" with Andy Rock (Rock Law Group) & Gregg Golson (J.S. Held LLC).
[ 04:34 ] - For water mitigation issues, check out "Interpreting the Microbiology of Storm Damage" with Jeremy Beagle (SDII Global).
[ 05:05 ] - For other large storm issues, see "A Coastal Catastrophe: Navigating a Large Hurricane Loss in the Northeast" with Anthony Antonellis and Brendan Labbe (both of Sloane and Walsh LLP), and "Double Trouble: Multiple Storms at the Same Property" with David Frantz (Kubicki Draper, P.A.).
[ 05:45 ] - The Large Loss Conference is intended for claims professionals involved in these losses or hoping to get experience with larger claims, as well as the experts, attorneys, and accountants who provide insights on these claims.
[ 06:43 ] - The Large Loss Conference is differently structured than PLRB's other conferences. The educational sessions are 90 minutes long, often more focused on case studies, and involve more interactivity.
[ 07:56 ] - Andrew features the educational session "Back to the Future: How Adjusters Can Use Forensic Meteorology in Hail and Wind Claims" with Howard Altschule (Forensic Weather Consultants).
[ 08:48 ] - The Large Loss Conference features many casualty and personal lines sessions as well, such as "We Didn't Start the Fire: Was it Smoking or Smokin'" with David Heemann (Mutual of Enumclaw), Pete Fowler (Fowler Construction Consultants), and Jennifer Kalvestran (Anderson, McPharlin & Conners LLP).
[ 11:08 ] - The conference's general session will feature "Fraud and Other Abuses In CAT Claims, What The Hail Is Going On?" with Steve Badger (Zelle LLP).
[ 11:56 ] - Most educational sessions are approved in FL, TX, DE, NC, and OK Continuing Education credit, and even some courses approved for GA CE credit!
[ 12:56 ] - To register, visit PLRB.org and click on the banner on the main page OR the Events tab. Registration is free for members.
[ 13:50 ] - Jeff Kerensky & Maria McNally will be available to discuss membership or website questions.
[ 14:45 ] - Alissha provides a recap of the scenario and the points above.
Your PLRB Resources
PLRB's Events tab: https://www.plrb.org/plrb-events/
Direct Link to PLRB's Large Loss page: https://cvent.me/Ze4y1w
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
Subscribe to this Podcast
Your Podcast App - Please subscribe and rate us on your favorite podcast app
YouTube - Please like and subscribe at @plrb
LinkedIN - Please follow at “Property and Liability Resource Bureau”
Send us your Scenario!
Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0).
The insured was making fried green tomatoes when they had to help a neighbor with an emergency. The tomatoes caught fire, and damaged the kitchen. The city building inspector came to sign off on the kitchen repairs, and noticed the rear deck was improperly constructed. Notable Timestamps
[ 00:27 ] - The policyholder is asking her insurance company to include fixing the deck as part of her fire claim. Since the deck wasn’t touched by the fire, the adjuster denied it. Now the public adjuster is coming back seeking coverage for the deck under the Ordinance or Law Additional Coverage.
[ 01:47 ] - Tim talks traditional Tennessee recipes.
[ 03:07 ] - The fire is likely covered, even if the homeowner left the skillet unattended.
[ 03:50 ] - To paraphrase, Ordinance or Law Additional Coverage covers increased costs due to enforcement of ordinance or law for the portion of "the undamaged part" of a covered building "necessary to complete" the repair of the damaged part.
[ 06:00 ] - If the inspector had insisted on fire alarms, the argument that the "necessary" language applies would be stronger.
[ 06:30 ] - In Chattanooga Bank Associates v. Fidelity & Deposit Co. of Maryland, 2004 WL 187409 (E.D. Tenn. 2004) [reviewed at PLRB, Prop. Ins. L. Rev. 6657 (2004)], Ordinance or Law coverage did not extend to code violations discovered in areas that were not affected by fire damage.
[ 07:10 ] - It seems city inspectors do sometimes withhold permits for seemingly unrelated code violations.
[ 08:10 ] - An inspector's order is likely considered an "ordinance or law" though it is not, strictly speaking, either one. Compare to the demand of a private HOA, which would not be an ordinance or law.
[ 09:11 ] - If something is built prior to a code change, it typically only needs to be updated when it is remodeled. The correct term for this is "Legacy Code Exceptions."
[ 10:30 ] - Commercial "ordinance or law" Additional Coverage forms specifically do not include violations that existed prior to the loss, but personal forms are often silent on that point.
[ 11:30 ] - The contractor who built the deck could be considered negligent, but the policy's faulty work exclusion may or may operate to override Ordinance or Law coverage.
[ 13:43 ] - It can be difficult to determine that a deck is out of code!
[ 14:30 ] - Tim provides a recap of the scenario and the points above.
Your PLRB Resources
Chattanooga v. Fidelity - https://www.plrb.org/documents/ordinance-or-law-ho149/
Webinar: Cracking the Code: Navigating the Complexities of Ordinance or Law Coverage - https://www.plrb.org/courses/cracking-the-code-navigating-the-complexities-of-ordinance-or-law-coverage/lessons/cracking-the-code-navigating-the-complexities-of-ordinance-or-law-coverage/
Adjuster Resource Sheet: Ordinance Or Law Issues - https://www.plrb.org/documents/adjuster-resource-sheet-ordinance-or-law-issues/
State-By-State: Tennessee: Faulty Workmanship - https://www.plrb.org/documents/tennessee-faulty-workmanship/
Tennessee Mountains Stack Cake Recipe - https://www.food.com/recipe/tennessee-mountains-stack-cake-46814
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
Subscribe to this Podcast
Your Podcast App - Please subscribe and rate us on your favorite podcast app
YouTube - Please like and subscribe at @plrb
LinkedIN - Please follow at “Property and Liability Resource Bureau”
Send us your Scenario!
Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0).
After a storm, a warehouse roof seems to leak more often, and a manager notices some water pooling on the edge. The adjuster’s inspection reveals only minor dents, and the policy has a cosmetic damage exclusion. The manager argues the damage is not cosmetic. Notable Timestamps
[ 00:19 ] - The manager even hires an expert to contest coverage.
[ 01:25 ] - Tim and Mike discuss the leaks in the PLRB offices.
[ 02:46 ] - See prior episode "That Damage is Just Cosmetic!" for the version of this scenario with no exclusion.
[ 03:50 ] - When cosmetic damage exclusions first debuted, many courts found the clause ambiguous.
[ 05:13 ] - Let's say there's no leak, just pooling. In Dragoo v. Allstate Veh. and Prop. Ins. Co., No. 4:16-CV-984-O, 2018 WL 1536639 (N.D. Tex. 1/05/18), cosmetic damage was read as damage that "only changes its appearance."
[ 06:30 ] - If the damage increased the likelihood of future damage, that may not be considered cosmetic.
[ 07:20 ] - In Fisher v. Am. Fam. Mut. Ins. Co., No. 17-CV-01949-MEH, 2019 WL 142204 (D. Colo. 1/09/19), the exclusion applied to components that would not "(1) prevent water from entering the building; or (2) perform any other intended function." The second clause was found to potentially include aesthetics.
[ 08:00 ] - In Valleyview Church of Nazarene v. Church Mut. Ins. Co., No. 2:20-CV-222-Z-BR, 2023 WL 4504595 (N.D. Tex. 6/13/2023), the policy read "cosmetic damage means that the wind and/or hail caused marring, pitting or other superficial damage that altered the appearance of the roof surfacing, but such damage does not prevent the roof from continuing to function as a barrier to entrance of the elements to the same extent as it did before." This was found to be not ambiguous.
[ 09:11 ] - In J&S Welding, Inc. v. Liberty Mut. Ins. Co., No. 1:22-cv-01122-STA-jay, 2023 WL 6150730 (W.D. Tenn. Sept. 20, 2023), the court said that testimony about the functionality of a metal roof qualified as a matter of scientific, technical, or other specialized knowledge.
[ 12:07 ] - Check for Cosmetic Damage Regulatory Bulletins, e.g. https://www.plrb.org/documents/2017-regulatory-cosmetic-damage-exclusions-wy/ or https://portal.ct.gov/cid/-/media/cid/1_protertycasualty/aerial-imagery-notice.pdf
[ 14:30 ] - Jeff provides a recap of the scenario and the points above.
Your PLRB Resources
For Regulatory Bulletins and State-By-States, check out PLRB's hubs, e.g. https://www.plrb.org/property-lines/
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
Subscribe to this Podcast
Your Podcast App - Please subscribe and rate us on your favorite podcast app
YouTube - Please like and subscribe at @plrb
LinkedIN - Please follow at “Property and Liability Resource Bureau”
Send us your Scenario!
Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0). Hail Sounds: Buckine. Freesound.org. https://freesound.org/people/Buckine/sounds/574928/
One day a hailstorm hits a bike manufacturer's warehouse, and the property owner is overwhelmed by the loud sounds of the hail hitting the metal roof. But when the adjuster gets up on the roof, the dents turn out to be minor, arguably cosmetic.
Notable Timestamps
[ 00:18 ] - Despite the dents appearing to be cosmetic, the insured requests a new roof.
[ 01:08 ] - Jeff and Mike compete for the best "dad joke."
[ 01:53 ] - The hail was "direct" and "physical", but was it a "loss"? If the roof is now leaking, that would qualify as damage because it is a loss of functionality. Without a leak, it's a harder question.
[ 04:05 ] - Another claim is that the dents lessened the life expectancy of the roof. That becomes a fact question.
[ 06:40 ] - The "ugly" factor? Another claim is that the dents lessened the eventual sale price of the building. Many loss in value claims fall under the deductible, but others can qualify as a direct physical loss.
[ 09:50 ] - If the dent is hard to see, that can impact the loss in value claim, but not necessarily defeat it.
[ 10:40 ] - A third argument for coverage would be that the dents invalidated the insured's warranty on the roof, and that loss should be considered a "loss" as in "direct physical loss".
[ 14:00 ] - Some insurers have argued that it's wasteful to replace a roof that is not functionally impacted, but this argument is unlikely to be successful.
[ 15:40 ] - Replacement Cost may be significantly higher than Actual Cash Value in a scenario like this.
[ 16:16 ] - Jeff provides a recap of the scenario and the points above.
[ 18:35 ] - We'd like to shout out "The Future of Insurance," PLRB CEO Bryan Falchuk's podcast.
Your PLRB Resources
Is Hail Splatter a Direct Physical Loss? – PCQ.2019.09.26.jch.a - https://www.plrb.org/documents/is-hail-splatter-a-direct-physical-loss-pcq-2019-09-26-jch-a/?search=cosmetic
Webinar: Coverage Challenges with Common Endorsements (Includes discussion of Cosmetic Damage) - https://www.plrb.org/courses/coverage-challenges-with-common-property-endorsements/
Annotation - Cosmetic Damage HO 06 43 & HO 06 44 (HO16E) - https://www.plrb.org/documents/cosmetic-damage-ho-06-43-ho-06-44-ho16e/
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
Subscribe to this Podcast
Your Podcast App - Please subscribe and rate us on your favorite podcast app
YouTube - Please like and subscribe at @plrb
LinkedIN - Please follow at “Property and Liability Resource Bureau”
Send us your Scenario!
Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0). Hail Sounds: Buckine. Freesound.org. https://freesound.org/people/Buckine/sounds/574928/
Anytime something with wheels leads to a claim, Parker's colleagues come to Parker to find out whether the claim should fall under the CGL policy or the auto policy… or a secret third option.
Notable Timestamps
[ 00:22 ] - Mike details the above scenario.
[ 01:15 ] - An "auto" would usually be covered under Business Auto policy, whereas "mobile equipment" would typically be covered under CGL.
[ 02:20 ] - "Auto" means: 1. A land motor vehicle, "trailer" or semitrailer designed for travel on public roads; . . . However, "auto" does not include "mobile equipment".
[ 03:15 ] - For the full definition of "mobile equipment", see: https://www.plrb.org/documents/gl14-mobile-equipment-defined/
[ 05:00 ] - The game begins! Is it an "auto" or a piece of "mobile equipment"? Cars are autos, while bulldozers are mobile equipment.
[ 07:10 ] - Dump trucks are considered autos.
[ 07:50 ] - What about a road grader that is used for snow removal? Recall that "self-propelled vehicles with the following types of permanently attached equipment are not "mobile equipment" but will be considered "autos:" ... Equipment designed primarily for: Snow removal;" In this case, it was not designed "primarily" for snow removal.
[ 09:35 ] - Backhoes, skid steers, and combines are equipment, but a boat is neither!
[ 11:40 ] - An auto with a permanently attached tree removal device? "Mobile equipment" means... "Vehicles, whether self-propelled or not, maintained primarily to provide mobility to permanently mounted ... Power cranes, shovels, loaders, diggers or drills;"
[ 13:29 ] - A cherry picker is dual purpose: can be considered an auto or a piece of mobile equipment, depending on if the stabilizers are down and the truck is in use.
[ 16:01 ] - Mike provides a recap of the scenario and the points above.
Your PLRB Resources
Policy Annotation - GL14 – “Mobile Equipment” Defined - https://www.plrb.org/documents/gl14-mobile-equipment-defined/
Will CGL Liability Coverage Apply When the Insured Loses Control of a Bobcat at a Work Site Damaging a Parked Vehicle? 2023.07.27jrm - https://www.plrb.org/documents/will-cgl-liability-coverage-apply-when-the-insured-loses-control-of-a-bobcat-at-a-work-site-damaging-a-parked-vehicle-2023-07-27jrm/
In South Carolina, Is A Golf Cart Mobile Equipment? 2023.01.12 - https://www.plrb.org/documents/in-south-carolina-is-a-golf-cart-mobile-equipment-2023-01-12/
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
Subscribe to this Podcast
Your Podcast App - Please subscribe and rate us on your favorite podcast app
YouTube - Please like and subscribe at @plrb
LinkedIN - Please follow at “Property and Liability Resource Bureau”
Send us your Scenario!
Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0). 1971 Plymouth Roadrunner. Greg Gjerdingen from Willmar, USA. Wikimedia Commons. CC-2.0. Other images: Pixabay, CC0, Public Domain, or Adobe Stock.
The named insured has retired and moved to his condo in Florida. His adult daughter accepted a new job in the city her father is leaving, so she and her two children have moved into the insured dwelling. A fire occurred destroying the entire home and all of its contents.
Notable Timestamps
[ 00:37 ] - John details the above scenario.
[ 02:30 ] - Who is "You"? "You" is the named insured or insureds indicated in the Declarations, and the spouse of that person if the spouse is a household resident.
[ 03:45 ] - How does the insurance policy define "y'all"? Or "youse"?
[ 04:11 ] - "Residence Premises" is the one-, two-, or three-family dwelling listed in the Declarations in which "you" reside.
[ 05:26 ] - The majority of courts would hold that the named insured could not recover for this loss because he relinquished residency: left for six months, initially planned to sell, got a new driver's license, never planned to move back, changed voter registration, forwarded mail, etc.
[ 06:10 ] - Snowbirds who move back and forth have an intention to return, so they would likely be covered in a similar situation.
[ 07:05 ] - A minority of courts allow coverage as long as the insured resided in the premises at the inception of the policy period.
[ 07:40 ] - The insured's contents would be covered because coverage for contents are not tied to residency.
[ 08:55 ] - The daughter is not a named insured, and is likely not an "insured" (members of your household who are also your relatives) because she is not a member of the insured's household.
[ 10:10 ] - To determine who is a member of the household, courts generally look to (1) whether they live under the same roof, (2) whether they live in a close intimate relation, and (3) whether the length of stay is substantial. (ISO has added language to include college students, who intend to return.)
[ 11:55 ] - The children of divorced parents may be considered members of multiple households.
[ 12:45 ] - What if the fire had been set intentionally by the grandchild? Since the child is not an insured, it wouldn't fall under the intentional loss exclusion.
[ 14:26 ] - If the insurance company knew or had cause to know that the insured had moved and kept accepting premiums, they could be estopped from making the argument against coverage.
[ 16:33 ] - John provides a recap of the scenario and the points above.
Your PLRB Resources
To learn more about this issue specifically, look up our 50 state survey: Must Insured Reside At Premises? – An Introduction https://www.plrb.org/documents/introduction-must-insured-reside-at-premises/
Also see the PLRB’s annotation on the definition of “insureds” in the policy at PLRB, Homeowners Annot., Key HO5 https://www.plrb.org/documents/insured-ho5/?search=HO5
...and the definition of “residence premises” at PLRB, Homeowners Annot., Key HO10. https://www.plrb.org/documents/residence-premises-ho10/
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
Subscribe to this Podcast
Your Podcast App - Please subscribe and rate us on your favorite podcast app
YouTube - Please like and subscribe at @plrb
LinkedIN - Please follow at “Property and Liability Resource Bureau”
Send us your Scenario!
Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0).
Tree-lined residential drive in Boston, MA. The neighborhood kids were playing baseball in the street, and the big kid hit a home run; ball landed on the roof. It was a flat roof with a drain in the middle of it. The ball somehow rolled right onto the drain and completely blocked the top of it. The poor homeowner had no idea, and heavy rains came through that night, causing several inches of water to build up on the roof, eventually finding its way inside the house. This caused $20,000 in water damage to the interior of the building, and the insured is looking for coverage.
Notable Timestamps
[ 00:25 ] - The adjuster is wondering about two exclusions: (1) surface water, and (2) backup of drains. The policy is an ISO 00 03 05 11.
[ 01:33 ] - Would you give a ball back if it rolled onto your property?
[ 02:30 ] - A July 23, 2024 MA Supreme Court decision will likely be impactful on surface water issues.
[ 03:10 ] - Surface water typically applies to rain or melted snow entering a home from the yard or driveway. What about a patio 6 inches high? A deck 3 feet up? A roof?
[ 05:00 ] - Historically water on a roof was not considered surface water, but in the last decade many courts held that the surface water exclusion might apply to water on roofs. See Martinez v. Am. Family Mut. Ins. Co. 413 P.3d 201 (Colo. App. 2/09/17): "the rooftop of his home [was] a mere continuation of 'the earth's surface.'"
[ 07:30 ] - The MA Supreme Court's decision that water on a roof is not excluded as surface water only applies to MA, but other states may find it persuasive given the infrequency of major decisions on these issues.
[ 09:30 ] - The backup and overflow exclusion likely does not apply because the water never even entered the drain, much less backed up out of it.
[ 11:20 ] - The majority view of "water which backs up" terms it as water that flows in reverse.
[ 13:10 ] - Let's say the kids put the ball down the drain intentionally. Coverage A is all-risk, open peril; the loss is covered unless it's excluded. The exclusion for vandalism wouldn't apply as the home was not vacant for 60 days. That loss would likely be covered.
[ 15:00 ] - Let's say it was leaves blocking up the drain. Could faulty maintenance apply? That would be dependent on the severity of the build-up and other circumstances. Ensuing loss concerns may impact this issue. https://www.plrb.org/documents/massachusetts-ensuing-resulting-loss/
[ 17:50 ] - Tim provides a recap of the scenario and the points above.
Your PLRB Resources
Zurich American Insurance Company v. Medical Properties Trust, Inc. - https://www.plrb.org/documents/zurich-am-ins-co-v-med-properties-tr-inc-2024/
Flat Roof Drain Blockage on Commercial Building – PCQ.2024.07.26.twh.b - https://www.plrb.org/documents/flat-roof-drain-blockage-on-commercial-building-pcq-2024-07-26-twh-b/
Surface Water – “Act of Nature or Otherwise Caused” – PCQ.2021.10.31.twh.a - https://www.plrb.org/documents/surface-water-act-of-nature-or-otherwise-caused-pcq-2021-10-31-twh-a/
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
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Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0).
A claims adjuster is out at a party when they are asked: “So, what do you do for a living?” Our adjuster responds with just: “I’m in insurance claims.” That’s an “Oh no” moment. Turns out their cousin had a terrible experience on a claim and our adjuster is going to hear all about it, ending in: “You claims people are all cheaters!”
Notable Timestamps
[ 00:36 ] - Today's scenario begins as an interpersonal encounter about explaining your career in insurance, but the elevator pitch is applicable even on claims.
[ 02:05 ] - What our claims professional needed was an elevator pitch: a succinct, prepared, organized response. Whether at a party or at a claims site, our adjuster wants to know how to summarize their thoughts in a persuasive way. Ding Ding! Your elevator’s here! Are you ready?
[ 02:30 ] - Mike was asked: "what's your elevator pitch?" That was an "oh no" moment...
[ 03:35 ] - An elevator pitch is a simple presentation that you give in the time it would take to ride an elevator: around 30 seconds.
[ 04:18 ] - 1. Grab 'em at the beginning. Get their attention with a great opening.
[ 04:25 ] - 2. Tell 'em what you're gonna tell 'em. Be organized in your thought process.
[ 04:32 ] - 3. Hit 'em with your bid conclusion/sell/ask. Be brief and practiced.
[ 05:11 ] - Alissha: "So, what do you do for a living?" Mike: 1. "I allow you to take the risks to make life worth living." 2. "Without insurance, you wouldn't be able to insure your home or car." 3. "We step in when bad things happen and we hope to get people back on their feet."
[ 09:15 ] - Be prepared, be organized, be succinct.
[ 10:00 ] - Let's say an insured has suffered a casualty loss. How can an elevator pitch help? 1. "I'm so sorry that this happened." Take a moment to express sincere empathy. 2. Review the medical records / facts. 3. "I know that this has impacted your life, so how about we take care of your damages?"
[ 11:50 ] - What's the pitch for a hurricane loss? Again, start off with an emotional connection. Second, spell out the steps to get them back into the place they were before the accident. Third, conclude with the ask and what you need for the next steps.
[ 13:35 ] - Mike applies the elevator pitch to auto claims handling.
[ 15:42 ] - Mike provides a recap of the scenario and the points above.
Your PLRB Resources
Mike’s PLRB Presents presentation on this topic: https://www.plrb.org/courses/pitching-in-an-elevator-2/lessons/pitching-in-an-elevator/
Webinar: Designing & Delivering Effective Business Presentations - https://www.plrb.org/courses/designing-delivering-effective-business-presentations/lessons/designing-delivering-effective-business-presentations/
Claims Chat: Why Should You Consider Claims as a Career? - https://www.plrb.org/courses/why-should-you-consider-claims-as-a-career/lessons/why-should-you-consider-claims-as-a-career/
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
Subscribe to this Podcast
Your Podcast App - Please subscribe and rate us on your favorite podcast app
YouTube - Please like and subscribe at @plrb
LinkedIN - Please follow at “Property and Liability Resource Bureau”
Send us your Scenario!
Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0).
Mungle’s Crackers manufactures crackers shaped like exotic land and sea animals, among other food products. Apparently there was a bad batch of their latest line of Platy-Pies, because reports of moldy bags of pastries covered their social media and they had to recall many bags of the high-fructose treats. One angry customer got ill after his snack and has already filed a lawsuit against the company.
Notable Timestamps
[ 00:15 ] - Today's scenario will be Mike's debut as a host!
[ 00:37 ] - This Notice of Loss landed on the desk of our adjuster Ralph, who is relatively new to insurance and totally new to commercial lines. Ralph would like to be walked through how to approach this claim and claims in general.
[ 01:39 ] - The team agrees that today's scenario, which was drafted by the producer who also edits these show notes, is GOOD and HAS CREATIVE NAMES.
[ 02:05 ] - The acronym "DECIDE" takes the adjuster through the Declarations page, Endorsements, Conditions, Insuring agreement, Definitions, and Exclusions.
[ 05:50 ] - The policy itself can act as a checklist, and this is a helpful mnemonic can be helpful for adjusters (and numismatists).
[ 06:30 ] - A Reservation of Rights letter can mention that investigation is underway, but advise the insured of potential coverage issues.
[ 08:00 ] - Declarations page: Checking that the company insures the involved entity, that the loss fell within the effective dates, what the insured's limits are, etc.
[ 08:55 ] - Endorsements: Any food product recall coverage? Are any other parties insured? Do special limits of liability apply?
[ 09:28 ] - Conditions: Let's say the insured sent out $50 coupons to each affected customer, then sought reimbursement. The Voluntary Payments section would likely create an issue for the insured in that case.
[ 10:20 ] - Insuring agreement: It is not disputed that an accident led to bodily injury in this claim.
[ 11:05 ] - Definitions: "Occurrence", "bodily injury", "property damage" (moldy products?) are likely all defined. Endorsements can modify those definitions. Members can reach out to PLRB attorneys for guidance.
[ 12:05 ] - Exclusions: Exclusions like Recall / Sistership may apply.
[ 13:15 ] - Supervisors or even a roundtable of colleagues can be a great resource.
[ 14:00 ] - The next step is likely to examine the allegations. The duty to defend can be broader than the duty to provide coverage.
[ 15:00 ] - Mike provides a recap of the scenario and the points above.
Your PLRB Resources
Claims Chat - https://www.plrb.org/courses/can-you-help-me-walk-through-a-claim-part-1/lessons/can-you-help-me-walk-through-a-claim-part-1/
Part 2 - https://www.plrb.org/courses/can-you-help-me-walk-through-a-claim-part-2/lessons/can-you-help-me-walk-through-a-claim-part-2/
Simple Approach to Coverage Decisions (eLearning that’s a good start for anyone looking to understand a policy) - https://www.plrb.org/courses/a-simple-approach-to-coverage-decisions/
Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company.
Subscribe to this Podcast
Your Podcast App - Please subscribe and rate us on your favorite podcast app
YouTube - Please like and subscribe at @plrb
LinkedIN - Please follow at “Property and Liability Resource Bureau”
Send us your Scenario!
Please reach out to us with your scenario! This could be your “adjuster story” sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to [email protected].
Legal Information
The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate.
Music: “Piece of Future” by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0).
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