Someone who suffers an injury at a private home may be entitled to coverage under the homeowner’s insurance policy. Insurers are experts at denying claims and will frequently look for reasons why an injury did not qualify under the homeowner’s insurance policy. Policies are written to provide insurers with numerous ways of escaping liability. As a consequence the insurer may need to be sued, often along with the homeowner. In doing so the injured plaintiff can face a number of challenges. Here are two examples.
Coverage limits may not fully compensate the plaintiff
The first challenge can simply be the coverage limits built into the policy. It should be no surprise that a homeowner’s policy is deliberately designed to limit the financial exposure of the insurer to risk. Policies do this in part by placing strict caps on how much the insurer will pay out for different events. The details of these caps can draw fine distinctions between who qualifies for coverage, how much coverage will be given to specific types of injuries, and so on.
A policy will always specify how much the insurer will pay for a given injury (normally some factor of $100,000). Many policies include “umbrella” provisions that add an extra catch-all value on top of the itemized coverage. The insurer will not pay more than the maximum amount of coverage. The first challenge for plaintiffs is often that the amount available under the homeowner’s policy is simply not enough to cover all the costs associated with an injury. A policy with a coverage limit of $100,000 per incident and a $500,000 umbrella provision will not make a plaintiff whole if the plaintiff is facing $1 million in damages.
Plaintiffs may not be covered in some situations
A second challenge can arise if the plaintiff is not within the scope of coverage. Some policies may distinguish between full-time residents, guests, and contractors. It may also disclaim responsibility for specific types of injury. As a hypothetical example, a policy might specify that the insurer does not cover accidental electrocution of someone who is working on electrical systems without the appropriate professional license.
One area where this “category” problem can be important is cases where the injured person was performing services for the homeowner at the time of the injury. Many homeowners’ insurance policies disclaim responsibility for injuries to contractors, with the idea being that the contractors will already have their own insurance. If a neighbor is injured while helping a landowner clear brush, the insurer may look for ways to characterize the neighbor as a contractor. One way it might succeed in doing that is if the neighbor was being compensated in some way for the work. For example, if the neighbor is helping out as a way to repay the landowner for lending the neighbor a tractor, that might be enough to place the neighbor outside the coverage scope.
GGRM is a Las Vegas personal injury law firm
Being injured at another person’s home raises a lot of difficult questions, not least of which can be how to preserve the relationship with the homeowner despite being in a legal dispute. For more than 45 years the law firm of Greenman Goldberg Raby Martinez has helped injured clients recover compensation. We work with clients to examine the complete picture of each case to ensure that the client’s personal and financial interests are protected. Call us today for a free attorney consultation at 702-388-4476 or reach us through our contact page.
After being injured at work it’s important to follow the steps for filing a workers’ compensation claim. Ideally an employer’s workers’ comp insurer will pick up the costs of the employee’s medical care from the first visit to a doctor until the injury has healed. In reality, though, insurers work hard to limit their exposure to costs related to covered injuries. One way they try to do this is by arguing that the injury is not as significant as the employee claims. This risk can be mitigated by having an attorney present during medical exams.
After receiving a claim for benefits an insurer has the right to require the injured worker to submit to an independent medical examination, or IME. The formal purpose of the IME is to ensure that the insurer is basing its coverage decisions on a reliable and supposedly neutral diagnosis by a physician other than one with which the patient may already have a relationship. In reality insurers often request an IME because they disagree with an initial diagnosis, or have doubts about whether an injury is related to the worker’s job.
The state maintains an official list of physicians who are authorized to perform examinations of work-related injuries. Insurers are very familiar with the doctors on this list. They know who has a history of providing insurer-favorable diagnoses and will steer unwary patients to those doctors whenever possible. When a worker is told to attend an IME, the insurer may provide a limited list of doctors to choose from for the examination. The worker is required to attend the IME, but has the right to request a second opinion from another state-approved doctor if the outcome of that initial exam is not satisfactory.
The IME is potentially one of many “independent” examinations that the patient will undergo over the course of a workers’ comp claim. For example, if the injury results in a permanent partial disability the extent of the disability will need to be evaluated by a physician who is specifically trained in how to do this.
The extent to which a patient needs to have an attorney present at a medical exam will depend on the nature of the injury and the extent to which facts about the injury are in dispute. An attorney can help the patient decide whether having an attorney or other witness on-hand is advisable, but as a general rule it is better to have a witness along than to go alone. The witness can take notes about the examination and may provide important testimony in the event that the results of the exam need to be disputed in a later proceeding. Note that some physicians may claim to have a rule prohibiting others from attending these exams. This should raise concerns that the exam may not be fair, and should be disputed.
For more than 45 years the law firm of Greenman Goldberg Raby Martinez has helped injured workers get the coverage they deserve. If you have been injured at work, our experienced injury attorneys are standing by to offer advice about your case. Call us today for a free attorney consultation at 702-388-4476 or reach us through our contact page.
From a certain point of view, insurers are in the business of denying claims. Finding a way to limit the scope of benefits a claimant can receive is how insurance adjusters make their living. Naturally, an insurer is legally permitted to aggressively defend itself against the possibility of fraud or inflated damages claims. But an insurer’s aggressive posture can and often does cross the line into the realm of bad faith or, even worse, fraud on the part of the insurer. When an insurance dispute arises the insured has the option of submitting a complaint to the Nevada Division of Insurance.
What does the Nevada Division of Insurance do?
The Division of Insurance has a number of important functions, with consumer protection being among time. The Division has staff dedicated to helping resolve disputes between consumers and insurers. They will investigate cases and offer mediation services to bring the dispute to amicable resolution without involving the relatively slow and expensive court system. The Division oversees state licensing of insurance professionals, which means that it has the authority to revoke the license of a professional or even a business if it has committed serious violations.
The complaint process begins by submitting a form online, or alternatively by mail. A consumer must provide all the information the Division needs to evaluate the claim, including a signed release form to permit the Division to seek medical information from the claimant’s doctors, if necessary. The Division considers cases involving potentially improper denials of claims, improper cancellations of policies, and disputes related to the necessity or efficacy of medical treatments. Once the Division receives the complaint and provides a notice to the insurer, the insurer has a short time to respond to the complaint.
The Division of Insurance has limited power to resolve disputes
Although the Division can help a consumer in a number of important ways, its authority in disputes is limited to a mediator role. Among other things, it cannot handle complaints brought by consumers who are represented by an attorney. Essentially, the Division offers no-cost assistance to consumers who otherwise cannot find or afford the help of an attorney. The Division also cannot order an insurer to provide coverage or alter a decision.
A consumer who feels that an insurance company is acting in bad faith or unethically may find that pursuing recourse through litigation offers a greater chance of a favorable outcome. This is especially true when a case involves complicated issues that make it difficult to compile a comprehensive complaint without an attorney’s help. Speaking to an attorney needn’t foreclose submitting a complaint to the Division of Insurance. The consumer can’t be represented by an attorney in a matter that is submitted to the Division, but an attorney may be able to help the consumer determine whether it makes sense to pursue a remedy through the Division complaint process or through litigation.
GGRM is a Las Vegas personal injury law firm
For more than 45 years the law firm of Greenman Goldberg Raby Martinez has represented injured clients in cases involving personal injury, workers’ compensation, and insurance disputes. If you aren’t sure whether filing a complaint with the Division of Insurance is the right move for you, call us today for a free attorney consultation at 702-388-4476 or reach us through our contact page.