Something’s been gnawing at me lately and this past Tuesday, I was able to see it in action first hand. I attended the Citizens Property Insurance Forum held at the Dadeland Marriott in Miami Florida. It was sparsely attended, which gave me the opportunity to have some one on one time with a senior Citizens claim management person. I had originally intended to got there and express my clients frustration with the Citizens claims process, but considering the paucity of participants it seemed more productive to discuss these concerns privately.
What I can tell you from this private meeting is that the claims handling procedures in place at Citizens are profoundly dysfunctional. I have mixed feelings about this dysfunctional condition. On the one hand, I want to fix it so that the policyholder benefits. On the other hand, Citizens Property Insurance Corporation has become my Best Salesman. The policyholder who runs into the Citizens brick wall is forced to seek the assistance of a Public Adjuster or Attorney to help them resolve their issue. The Public Adjuster resolves the matter through appraisal and the Attorney files suit. The claim gets settled and the policyholder while not particularly happy is paid.
Now here’s the irony: Citizens is not happy with the outcome of the appraisals and they are not happy with the outcome of litigation. Profoundly unhappy might be a more apt description. And yet, as profoundly unhappy as Citizens is with both of these dispute resolution venues, they are not receptive to change. It is the classic Einsteinian definition of insanity: Doing the same thing over and over expecting a different outcome.
Here’s the Citizens claims adjusting process in a nut shell. We investigate the loss. We come up with a position. We proffer our opinion to the policyholder. The policyholder unquestionable accepts our position. Claim is closed. What happens if the policyholder disagrees? Simply put they are cordially invited to piss off!
Missing from this scenario is a key and fundamental aspect of adjusting: communication. Citizens’ believes it is the only party in the equation that is entitled to have any input into the claims adjustment process. This is little more than hubris.
And here we are, resolving claims through appraisal and litigation because Citizens is unwilling to listen, unwilling to talk out differences, unwilling to be flexible, unwilling to negotiate, unwilling to provide anything that even approximates customer service.
Now understand, they take this stance ostensibly because of governmental oversight to which they are supposedly subjected. I don’t buy that, because it ultimately implies that policyholder’s would have to got to their state representative to get claims paid and the representative has better things to do that mediate insurance disputes. A more likely explanation is that the majority of the time their position is simply unsupportable. Appraisal awards and litigation outcomes are evidence overwhelmingly supportive of this observation.
Thursday, September 25, 2008
Wednesday, August 13, 2008
You Will Not Pass!
I was speaking with one of the guys I work with the other day about a claim he’s handling. The loss involves black water, otherwise known as sewage. Anyway, he’s frustrated with the claims process. He’s done a lot of work and now the insurance company is pulling the rug out from beneath him.
He signed the client up and then we reported the loss to the insurance company. They claim to have not received the first report, but don’t seem to have any problems reading from the initial letter sent to them. Perhaps this is because we have the fax confirmation form showing exactly when they received the first notice.
My adjuster finally gets hold of the company adjuster and they meet out at the loss. They review the damages and agree on a scope of loss. First speed bump. The company adjuster calls and informs my guy that the company wants to send out an engineer to inspect the damage. An appointment is made, the day arrives and the engineer shows up. The engineer is puzzled about why he’s there. After a brief inspection, he confirms what everyone has known all along, The loss arises from a drain lines failure to accept the waste water discharge. It was obvious: obvious to the plumber, obvious to the insured, obvious to my guy, obvious to the engineer and that’s as far as commonsense goes.
The insurance company and the adjuster could not see the obvious. But things are clearer now. Their engineer has relayed the obvious. Second speed bump. My guy talks to the adjuster and is told that he would be ready on Friday to discuss the claims settlement. Friday comes… Friday goes. No settlement discussion.
Third speed bump. The insurance company is going to take the client’s Examination Under Oath. This is a serious development and necessitates the client retaining an attorney. It’s also little more than intimidation on the part of the insurance company trying to short cut their way out of paying the claim. There’s one minor wrinkle here: my client isn’t gong to be intimidated.
You see people buy insurance to protect them from the terrible things that never happen so that when they do, there is a financial safety net that staves off ruin. That’s the promise that’s sold. That’s the promise that’s bought. That’s the promise that reneged on after loss. In this case my client has small children. These children have been exposed to sewage and their health has been endangered. My client already works overtime to make ends meet and is really depending upon the insurance company to help in this time of need. ‘Oops, sorry about that, did we say we would pay your claim? Well yes, but that was before you were so inconsiderate as to actually have a claim. Now just run along and bother someone else.’
The insurance company’s mantra: Delay, Deny and Defend and just maybe they’ll go away. Well Mr. Insurance Company Not This Time. You see you’ve endangered the mother bears cubs with your callous disregard for the needs of your policyholder. My money’s on the mother bear.
If this were atypical I would not have much to write about. In Florida it seems that insurance companies have declared war on their policyholders and the policyholder is the only one who doesn’t know it. That is until after the loss, when the insurance company begins a process intended to limit their financial exposure. Unfortunately this process is directed towards those who are in desperate need of help, usually in times of crises.
All of us, you, me… anyone who has an insurance policy and is in need of help should remember the refrain of Gandalf the wizard when he was fighting the Balroc in Lord of the Rings. Standing on a narrow passage above the abyss, Gandalf plants his staff on the passage and declares to the Balroc “You Will Not Pass!”.
My colleague and our client have said to the insurance company just those words. They are in the fight for the long haul.
He signed the client up and then we reported the loss to the insurance company. They claim to have not received the first report, but don’t seem to have any problems reading from the initial letter sent to them. Perhaps this is because we have the fax confirmation form showing exactly when they received the first notice.
My adjuster finally gets hold of the company adjuster and they meet out at the loss. They review the damages and agree on a scope of loss. First speed bump. The company adjuster calls and informs my guy that the company wants to send out an engineer to inspect the damage. An appointment is made, the day arrives and the engineer shows up. The engineer is puzzled about why he’s there. After a brief inspection, he confirms what everyone has known all along, The loss arises from a drain lines failure to accept the waste water discharge. It was obvious: obvious to the plumber, obvious to the insured, obvious to my guy, obvious to the engineer and that’s as far as commonsense goes.
The insurance company and the adjuster could not see the obvious. But things are clearer now. Their engineer has relayed the obvious. Second speed bump. My guy talks to the adjuster and is told that he would be ready on Friday to discuss the claims settlement. Friday comes… Friday goes. No settlement discussion.
Third speed bump. The insurance company is going to take the client’s Examination Under Oath. This is a serious development and necessitates the client retaining an attorney. It’s also little more than intimidation on the part of the insurance company trying to short cut their way out of paying the claim. There’s one minor wrinkle here: my client isn’t gong to be intimidated.
You see people buy insurance to protect them from the terrible things that never happen so that when they do, there is a financial safety net that staves off ruin. That’s the promise that’s sold. That’s the promise that’s bought. That’s the promise that reneged on after loss. In this case my client has small children. These children have been exposed to sewage and their health has been endangered. My client already works overtime to make ends meet and is really depending upon the insurance company to help in this time of need. ‘Oops, sorry about that, did we say we would pay your claim? Well yes, but that was before you were so inconsiderate as to actually have a claim. Now just run along and bother someone else.’
The insurance company’s mantra: Delay, Deny and Defend and just maybe they’ll go away. Well Mr. Insurance Company Not This Time. You see you’ve endangered the mother bears cubs with your callous disregard for the needs of your policyholder. My money’s on the mother bear.
If this were atypical I would not have much to write about. In Florida it seems that insurance companies have declared war on their policyholders and the policyholder is the only one who doesn’t know it. That is until after the loss, when the insurance company begins a process intended to limit their financial exposure. Unfortunately this process is directed towards those who are in desperate need of help, usually in times of crises.
All of us, you, me… anyone who has an insurance policy and is in need of help should remember the refrain of Gandalf the wizard when he was fighting the Balroc in Lord of the Rings. Standing on a narrow passage above the abyss, Gandalf plants his staff on the passage and declares to the Balroc “You Will Not Pass!”.
My colleague and our client have said to the insurance company just those words. They are in the fight for the long haul.
Monday, August 11, 2008
More On Money
In my last entry, I touched upon the importance of reserves in getting your claim paid fairly. This can not be overstressed: if your claim is under reserved, the chances of it being under paid increase dramatically. Now you might be asking yourself why: why doesn’t the insurance company simply increase the reserves?
Typically, the reserves are readjusted early in the claims process. When the loss is first called into the company a claim is created and a provisional reserve is set aside. After the adjuster has initially inspected the loss the reserves will be readjusted to reflect the adjusters opinion of the damage and its’ value. At this point, reserves begin to solidify: like concrete it’s very hard to make changes. The reason for this is simple. The insurance company begins to believe that it has accurately assessed its’ financial exposure. The adjuster believes they have accurately relayed the extent and value of damages. And with the passage of time, both are reluctant to admit to making a mistake.
So what happens if the reserves are mismatched to the loss? If they are less than what is needed, the insurance company will begin the process of attempting to pound the proverbial square peg into the round hole. That is they try and make the loss fit the reserves. This action is different from the normal disagreements that accompany losses. This is tantamount to a constructive denial of what is to the policyholder a covered loss.
When you find yourself in this situation, it is imperative that you remain emotionally detached from the process of the adjustment. Don’t let on that you are frustrated or upset. This only encourages the adjuster to continue down the path of confrontation. Also, don’t speak to the insurance adjuster or anyone from the company, rather, put everything in writing. That way you have a complete record of what is going on.
When you write to the company, explain how their refusal to pay your claim is placing you in financial jeopardy. How you are depending upon their fair and prompt payment to ease your financial burden and how they are letting you down. Ask them to “please help you”. If they insist upon your using their contractor, ask them why they won’t pay enough to enable you to choose a market priced contractor. Ask them why they have to restrict your ability to trade with whomever you wish. So on and so forth… you get the idea.
Write often. A weekly letter imploring the insurance company to help you in your time of need is golden, if you ultimately have to litigate to get your claim paid. The weekly letter is doubly golden if they don’t respond.
It’s a lot of work to get your claim fairly paid, but it’s not impossible.
Typically, the reserves are readjusted early in the claims process. When the loss is first called into the company a claim is created and a provisional reserve is set aside. After the adjuster has initially inspected the loss the reserves will be readjusted to reflect the adjusters opinion of the damage and its’ value. At this point, reserves begin to solidify: like concrete it’s very hard to make changes. The reason for this is simple. The insurance company begins to believe that it has accurately assessed its’ financial exposure. The adjuster believes they have accurately relayed the extent and value of damages. And with the passage of time, both are reluctant to admit to making a mistake.
So what happens if the reserves are mismatched to the loss? If they are less than what is needed, the insurance company will begin the process of attempting to pound the proverbial square peg into the round hole. That is they try and make the loss fit the reserves. This action is different from the normal disagreements that accompany losses. This is tantamount to a constructive denial of what is to the policyholder a covered loss.
When you find yourself in this situation, it is imperative that you remain emotionally detached from the process of the adjustment. Don’t let on that you are frustrated or upset. This only encourages the adjuster to continue down the path of confrontation. Also, don’t speak to the insurance adjuster or anyone from the company, rather, put everything in writing. That way you have a complete record of what is going on.
When you write to the company, explain how their refusal to pay your claim is placing you in financial jeopardy. How you are depending upon their fair and prompt payment to ease your financial burden and how they are letting you down. Ask them to “please help you”. If they insist upon your using their contractor, ask them why they won’t pay enough to enable you to choose a market priced contractor. Ask them why they have to restrict your ability to trade with whomever you wish. So on and so forth… you get the idea.
Write often. A weekly letter imploring the insurance company to help you in your time of need is golden, if you ultimately have to litigate to get your claim paid. The weekly letter is doubly golden if they don’t respond.
It’s a lot of work to get your claim fairly paid, but it’s not impossible.
Saturday, July 26, 2008
It's All About Money
Insurance companies keep two sets of accounting records. No the second set is not the set that details all the money flowing into their accounts from policyholders, rather it’s the set that tells regulators how solvent the company is. While insurance companies use Generally Accepted Accounting Principals (GAAP) accounting to track money, they also use Statutory (Stat) accounting as a litmus test of their solvency. What’s the difference? Broadly speaking the two accounting methods address what can be called an asset and how the company handles liabilities. The following caveat applies for all you accountants reading this. This is a broad simplification and is not meant to be a treatise on insurance accounting.
With GAAP Accounting almost anything of value is called an asset. However when statutorily accounting for assets only those assets of high quality are counted. Liabilities in GAAP Accounting can be amortized over the expected lifetime of the liability. However with statutory accounting liabilities must be fully funded upon their recognition. This is where your claim begins to go astray.
You see insurance companies set aside money to pay claims. This money is collectively referred to as reserves and reserves are accounted for on a file by file basis, so reserves allocated to one file can not be transferred or reallocated to another file. Now you may be saying to yourself … blah, blah, blah… what does this have to do with me?
If the insurance adjuster assigned to your claim does not recognize the severity of your loss and as a consequence does not accurately report that severity back to the insurance company, not enough money gets set aside to fully reimburse you for that loss. Or to put it another way, if the insurance company under reserves your claim, chances are they are also going to under pay your loss.
Think about this. The insurance adjuster is the eyes and ears of the company. What that adjuster sees is what the company sees. What that adjuster hears is what the company hears. Now add to that a propensity towards minimizing the claim payments so as to maximize shareholder profits and you have the makings of a perfect storm. Unfortunately, you’re the one being tossed about in your time of greatest need. If you have the financial resources to repair your home and fight it out with the company great, but if you’re like most of us and need the insurance money to make repairs, this can be very intimidating.
Nothing is so difficult as to get someone the see damage when their job depends upon their not seeing damage. There are some things you can do. First and foremost, like the scouts, Be Prepared! Do your pre-loss homework: take pictures of your property, collect and save receipts for major purchases, make a home inventory. When a casualty loss occurs photo document the post loss condition of your property. As you are taking photographs try to take pictures from the same angles as your pre-loss photographs. This gives you the ability to compare and contrast the two sets of photographs. Take close ups as well to document the nature of the damage. Put together a list of everything damaged by the event and then make a copy of that list to give to the adjuster. Get the adjuster to review the list with you and document any disagreements. Get repair estimates that respond to the list you developed rather than the damages the adjuster develops. If you feel you are being ignored, don’t take it personally, get professional help. Call a Public Insurance Adjuster to assist you in the claims process. You can find on by going to your states public adjuster association. In Florida it’s the Florida Association of Public Insurance Adjusters www.fapia.net . If your state doesn’t have a public adjuster’s association go to the National Association of Public Insurance Adjusters www.napia.com
The object is to get the company to set aside sufficient money to pay your claim fully. If they don’t, chances are you’re going to need help. If you make the decision to seek assistance seek it sooner rather than later.
With GAAP Accounting almost anything of value is called an asset. However when statutorily accounting for assets only those assets of high quality are counted. Liabilities in GAAP Accounting can be amortized over the expected lifetime of the liability. However with statutory accounting liabilities must be fully funded upon their recognition. This is where your claim begins to go astray.
You see insurance companies set aside money to pay claims. This money is collectively referred to as reserves and reserves are accounted for on a file by file basis, so reserves allocated to one file can not be transferred or reallocated to another file. Now you may be saying to yourself … blah, blah, blah… what does this have to do with me?
If the insurance adjuster assigned to your claim does not recognize the severity of your loss and as a consequence does not accurately report that severity back to the insurance company, not enough money gets set aside to fully reimburse you for that loss. Or to put it another way, if the insurance company under reserves your claim, chances are they are also going to under pay your loss.
Think about this. The insurance adjuster is the eyes and ears of the company. What that adjuster sees is what the company sees. What that adjuster hears is what the company hears. Now add to that a propensity towards minimizing the claim payments so as to maximize shareholder profits and you have the makings of a perfect storm. Unfortunately, you’re the one being tossed about in your time of greatest need. If you have the financial resources to repair your home and fight it out with the company great, but if you’re like most of us and need the insurance money to make repairs, this can be very intimidating.
Nothing is so difficult as to get someone the see damage when their job depends upon their not seeing damage. There are some things you can do. First and foremost, like the scouts, Be Prepared! Do your pre-loss homework: take pictures of your property, collect and save receipts for major purchases, make a home inventory. When a casualty loss occurs photo document the post loss condition of your property. As you are taking photographs try to take pictures from the same angles as your pre-loss photographs. This gives you the ability to compare and contrast the two sets of photographs. Take close ups as well to document the nature of the damage. Put together a list of everything damaged by the event and then make a copy of that list to give to the adjuster. Get the adjuster to review the list with you and document any disagreements. Get repair estimates that respond to the list you developed rather than the damages the adjuster develops. If you feel you are being ignored, don’t take it personally, get professional help. Call a Public Insurance Adjuster to assist you in the claims process. You can find on by going to your states public adjuster association. In Florida it’s the Florida Association of Public Insurance Adjusters www.fapia.net . If your state doesn’t have a public adjuster’s association go to the National Association of Public Insurance Adjusters www.napia.com
The object is to get the company to set aside sufficient money to pay your claim fully. If they don’t, chances are you’re going to need help. If you make the decision to seek assistance seek it sooner rather than later.
Wednesday, July 23, 2008
Hurricane Dolly
Every hurricane as a similar issue: wind vs. wave. How this issue plays is determined by how much money is at stake and successful the industry believes it will be in transferring exposure from the casualty policy to the flood policy. Hurricane Katrina is the classic example. Immediately following Katrina, the industry began floating positions about the large extent of flooding associated with this storm. The mantra was flood, Flood, FLOOD and FLOOD. No amount of evidence to the contrary dissuaded them from their position. The industry hired a cadre of experts to support their position and began denying (rather successfully I might add) claims that might otherwise have been paid. Why do I say this?
Most people mistakenly believe that property insurance policies insure property. Truth is they don’t. They insure people. The property is simply the subject of that insurance. This affords the insurance company the freedom to decide which risks it wants to indemnify the policyholder against and which it does not. Guess what? Flood or should I say FLOOD is one of those risks it does not wish to insure against.
In Katrina a lot of properties were damaged by flood. A lot of those same properties were also damaged by wind. This of course raises yet another issue: chicken and egg. If flooding preceded the wind the insurance company has a very strong argument to limit the loss other wise payable. If wind is first on the scene if becomes increasingly difficult to attribute damage to flood.
The weather channel tonight stated there was a significant number of damaged roofs and broken windows. They also mentioned flooding. No comparisons were made with Katrina.
Now consider this: lets say hypothetically that Hurricane Dolly damages a roof and breaks a window or two or three. Water enters the house through the damaged roof and broken windows: a lot of water. Imagine a fire hose pointing at your house in a hundred mile per hour wind. How much water to you think would enter a broken window.
That water is going to saturate the property in short order. Much if not all of the interior finishes, fixtures and personal property are going to be significantly damaged if not considered a total loss. Now flooding occurs. My question is this: how has the flooding caused any more damage?
It hasn’t. The proximate cause of the damage is wind and the insurance company not Federal Flood should be paying the loss.
If your home was damaged by Dolly, take good photographs. Pay particular attention to broken windows and damaged roofs. Inside your home document any damage that appears to originate above the water line. Be sure to document the water line as well. Use a tape measure to capture the exact height of the water. Remember the burden is on the policyholder to prove their loss. If you have questions email be at bill@sasclaim.com I’ll do my best to help you out. Good luck!
Most people mistakenly believe that property insurance policies insure property. Truth is they don’t. They insure people. The property is simply the subject of that insurance. This affords the insurance company the freedom to decide which risks it wants to indemnify the policyholder against and which it does not. Guess what? Flood or should I say FLOOD is one of those risks it does not wish to insure against.
In Katrina a lot of properties were damaged by flood. A lot of those same properties were also damaged by wind. This of course raises yet another issue: chicken and egg. If flooding preceded the wind the insurance company has a very strong argument to limit the loss other wise payable. If wind is first on the scene if becomes increasingly difficult to attribute damage to flood.
The weather channel tonight stated there was a significant number of damaged roofs and broken windows. They also mentioned flooding. No comparisons were made with Katrina.
Now consider this: lets say hypothetically that Hurricane Dolly damages a roof and breaks a window or two or three. Water enters the house through the damaged roof and broken windows: a lot of water. Imagine a fire hose pointing at your house in a hundred mile per hour wind. How much water to you think would enter a broken window.
That water is going to saturate the property in short order. Much if not all of the interior finishes, fixtures and personal property are going to be significantly damaged if not considered a total loss. Now flooding occurs. My question is this: how has the flooding caused any more damage?
It hasn’t. The proximate cause of the damage is wind and the insurance company not Federal Flood should be paying the loss.
If your home was damaged by Dolly, take good photographs. Pay particular attention to broken windows and damaged roofs. Inside your home document any damage that appears to originate above the water line. Be sure to document the water line as well. Use a tape measure to capture the exact height of the water. Remember the burden is on the policyholder to prove their loss. If you have questions email be at bill@sasclaim.com I’ll do my best to help you out. Good luck!
Tuesday, July 22, 2008
So Good
The other day I met with an adjuster out at a loss. I had heard of this adjusters reputation through the grapevine and the grapevine did not have much good to say about him. Anyway this adjuster shows up with the usual insurance adjuster repertoire of tools: tape measure and camera. This guy was so good that it only took one “o” to spell it and you started with a capital G.
My point in telling this story is not to rant and rail at every adjuster with whom hubris is a personality trait, but rather to point out as I’ve done before that some times losses are not open and obvious. Yet adjusters routinely show up without the tools necessary to do their job beyond what is obvious. The village idiot can see damage that is open and obvious; it takes a professional to see damage that is not.
Here’s the rub: the policyholder depends upon the insurance company to send out a professional adjuster. Those sent out however by and large are not professionals. I know it, you know and the insurance company knows it.
I say the insurance company knows it because they don’t trust these people with authority to agree on scope or price. They don’t trust them! Now here’s my question: if the insurance company doesn’t trust the adjuster they send out to adjuster your loss, why should you?
My point in telling this story is not to rant and rail at every adjuster with whom hubris is a personality trait, but rather to point out as I’ve done before that some times losses are not open and obvious. Yet adjusters routinely show up without the tools necessary to do their job beyond what is obvious. The village idiot can see damage that is open and obvious; it takes a professional to see damage that is not.
Here’s the rub: the policyholder depends upon the insurance company to send out a professional adjuster. Those sent out however by and large are not professionals. I know it, you know and the insurance company knows it.
I say the insurance company knows it because they don’t trust these people with authority to agree on scope or price. They don’t trust them! Now here’s my question: if the insurance company doesn’t trust the adjuster they send out to adjuster your loss, why should you?
Wednesday, July 16, 2008
Causation Disputes
Lately it seems that insurance companies have been taking issue with losses by asserting a difference of opinion as to causation. For example, take an insured who reports wind damage to their home. The insurance company hires an “expert” to examine the home. This “expert” (I put “expert” in quotation marks because I find that many of them have a predetermined opinion as to causation) comes out and following a casual inspection of the property opines that the home suffers from a variety of ills relating to deferred maintenance or some such argument that is similar in nature.
The insurance company in turn takes exception to the claim citing the wear and tear, deterioration, inherent vice and latent defect exclusions or the improper maintenance language under the concurrent causation section of the policy. The insured is left blinking like the proverbial deer in the headlights.
Understand this is little more than a tactic. Most houses suffer from maintenance related damages. Whether it’s a broken roof tile from someone walking on the roof or a pipe under the sink that leaked for a few days before anyone noticed it, every house has some blemish, some flaw. The question here is whether the maintenance is responsible for the loss or some casualty is responsible such as the wind in our example.
Insurance policies are unilateral contracts between the policyholder and the insurance company. The policyholder is given the option of accepting the policy as written or going somewhere else. Because it is a unilateral contract any ambiguity is automatically decided in favor of the policyholder. Unfortunately, many insurance companies are using “experts” to try and remove ambiguity from the claim adjustment process.
Now in our example, even though the house may suffer from wear and tear or deterioration or latent defects etc… when those conditions serve to weaken the structure and make it more susceptible to wind, the proximate cause of the loss becomes wind not wear and tear and the loss should be covered. In reaching this conclusion I ask myself a simple question: did the loss occur absent the casualty. If the answer yes, then wear and tear may be responsible. If the answer is no, then the casualty (in our example wind) is responsible and the merits of the claim should be considered in the context of the cause of loss.
A repositioning of the loss as wear and tear is improper and you should take a stand against the company when they attempt to do this.
The insurance company in turn takes exception to the claim citing the wear and tear, deterioration, inherent vice and latent defect exclusions or the improper maintenance language under the concurrent causation section of the policy. The insured is left blinking like the proverbial deer in the headlights.
Understand this is little more than a tactic. Most houses suffer from maintenance related damages. Whether it’s a broken roof tile from someone walking on the roof or a pipe under the sink that leaked for a few days before anyone noticed it, every house has some blemish, some flaw. The question here is whether the maintenance is responsible for the loss or some casualty is responsible such as the wind in our example.
Insurance policies are unilateral contracts between the policyholder and the insurance company. The policyholder is given the option of accepting the policy as written or going somewhere else. Because it is a unilateral contract any ambiguity is automatically decided in favor of the policyholder. Unfortunately, many insurance companies are using “experts” to try and remove ambiguity from the claim adjustment process.
Now in our example, even though the house may suffer from wear and tear or deterioration or latent defects etc… when those conditions serve to weaken the structure and make it more susceptible to wind, the proximate cause of the loss becomes wind not wear and tear and the loss should be covered. In reaching this conclusion I ask myself a simple question: did the loss occur absent the casualty. If the answer yes, then wear and tear may be responsible. If the answer is no, then the casualty (in our example wind) is responsible and the merits of the claim should be considered in the context of the cause of loss.
A repositioning of the loss as wear and tear is improper and you should take a stand against the company when they attempt to do this.
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