Insurance Policy Conditions (a/k/a/ Land Mines): Part 18 - Who Is "You"?

My previous seventeen posts in this blog series have discussed what you are required (or not required) to do under various post-loss / pre-suit insurance policy conditions. This post discusses the extent of “you.” Is “you” just you, or does “you” include your spouse, your family members, your public adjuster, and others? Who is “you” largely depends on the language of the insurance contract.

The “Conditions” section of most policies has a subsection entitled “Your Duties After Loss.” Most policies define “you” and “your” as “the ‘named insured’ shown in the Declarations and the spouse if a resident of the same household.” Take note of the oft-overlooked latter half of that definition and cooperate with the insurer (despite knee jerk reactions to the contrary) when it burdens your spouse with post-loss / pre-suit conditions … the machismo or chivalry can wait for car doors, water puddles, and restaurant bills.

Are we there yet? Is it just you and your spouse that the insurer gets to pick on? Not necessarily – more and more policies these days are pulling others into the post-loss / pre-suit conditions mix. For example, some policies include language like this: “Anyone you hire in connection with your claim ... must … [s]ubmit to examinations under oath and recorded statements, while not in the presence of any other ‘insured,’ and … sign the same.” This could include the likes of public adjusters, damage mitigation specialists, and contractors.

Are we there yet? Is it just you, your spouse, and anyone you hire in connection with your claim that the insurer gets to pick on? Not necessarily – some policies require any “insured” to comply with various post-loss / pre-suit conditions. And “insured” is sometimes defined to include “residents of your household who are: a. Your relatives; or b. Other persons under the age of 21 and in the care of any person named above.”

In sum, think twice (maybe even thrice) before telling an insurer to “take a hike, only I am subject to post-loss / pre-suit policy conditions.”

To read previous posts in my series on insurance policy conditions, click here.

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Comments (3) Read through and enter the discussion with the form at the end
William S Cook - March 2, 2013 8:18 AM

Mr. Greyber

More inportant to the PA industry..."WHO IS WE"?
Many adjusters define "WE" as anybody that I select to send to the property to opine on loss issues, always with the statement "WE" have the right to inspect as often as may be reasonably required. I have never disputed licensed adjusters coming for an inspection. I maintain that the bolded definition of "WE" is a clearly defined term in a policy. "WE" does not include an engineer, roofing consultant, tile expert, mold expert, cabinet expert, cause an origin expert, contents expert, construction consultant,or any other pseudo professional person that may be sent to usually discover that in the expert's opinion, insuerers win the day. Many times when the expert injects his thoughts the claim is then denied and a major hurdle must now be overcomed to prevail on a loss. The experts are often self-appointed experts absent any oversite or licensing authority.

I always protest the above practices, please comment!

William S Cook
Public Adjuster

Jeffrey Greyber - March 4, 2013 1:26 PM

Mr. Cook,
Thank you for your comment. I will provide a substantive response upon my return from my honeymoon.

Thanks,
Jeff

Jeffrey Greyber - March 27, 2013 6:25 PM

Mr. Cook,
Here are my general thoughts regarding an insurer's use of gatekeeping "experts":
http://www.propertyinsurancecoveragelaw.com/2012/08/articles/insurance/is-your-valuable-premium-paying-for-valuable-claim-adjustment/index.html

As for the definition of "we," most policies that I'm aware of define "we" along these lines: "'We', 'us', and 'our' refer to the Company providing this insurance." But, then, most insurance policies that I'm aware of do not define "Company." Read literally, I would agree with you that an engineer, tile expert, mold expert, or etc. retained by the insurance company is not the Company. But I have my concerns with that literal approach: (1) Those on our side of the V often wish to send out an engineer, tile expert, mold expert, or etc. In my opinion, under those circumstances, I do not believe a judge would take kindly to the insured (or the insured's representative) stymying the insurer's efforts to do the same. (2) Policyholder attorneys often argue (correctly so) that the insurer's minions are the insurer for liability purposes. In my opinion, one who prescribes to that theory would be hard-pressed to endorse the insured's (or the insured's representative's) belief that "we," "us," or "our" does not contemplate third parties retained by the insurer.

Do you have any authority that dispels my opinions? If so, please share: (305) 448-4800. Then, I'll dedicate an entire blog article to such authority.

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