As I am writing this blog, most of the country is in the middle of a deep freeze. Here in New Jersey, the forecast doesn’t show any signs of warming up:
So naturally, my mind turned to more temperate climates and so today we are going to chat about the claims handling guidelines in California.
California property insurers must follow the Fair Claims Settlement Practices Regulations. The regulations define their purpose as being “[t]o delineate certain minimum standards for the settlement of claims” and to “promote the good faith, prompt, efficient and equitable settlement of claims on a cost-effective basis.”1
A California insurance carrier must acknowledge the notice of claim, provide all necessary claim forms and instructions and begin the investigation of the claim within 15 calendar days of receipt of the notice of claim.2 The investigation must be thorough, fair and objective and the carrier must not request information not relating to the claim.3 The carrier must appropriately reply to all communications from a claimant regarding the claim where a reasonable person would expect a response.4 They must immediately (but no later than 30 calendar days) pay the portion of the claim not in dispute.5 The carrier must advise as to the acceptance or rejection of the claim in whole or in part within 40 days of their receipt of the notice of the claim.6 They must give the insured updates as to the status of the claim every 30 days that it remains open.7 Any denial must be in writing detailing the factual and legal basis therefore.8
No California insurance carrier make an offer to settle a claim that is unreasonably low.9 Needless to say, the insurance carriers must not discriminate against their insured based on, among other things, age, race, religion, or sexual orientation.10 Finally, the insurance carrier must advise unrepresented first party claimants that a statute of limitations or other time limit is going to expire no less than 60 days before the expiration of the time limit.11
California has additional standards for first-party residential and commercial property insurance policies:12
(1) When a loss requires repair or replacement of an item or part, any consequential physical damage incurred in making the repair or replacement not otherwise excluded by the policy shall be included in the loss. The insured shall not have to pay for depreciation nor any other cost except for the applicable deductible.
(2) When a loss requires replacement of items and the replaced items do not match in quality, color or size, the insurer shall replace all items in the damaged area so as to conform to a reasonably uniform appearance.
(b) No insurer shall require that the insured have the property repaired by a specific individual or entity.
(c) No insurer shall suggest or recommend that the insured have the property repaired by a specific individual or entity unless:
(1) the referral is expressly requested by the claimant; or
(2) the claimant has been informed in writing of the right to select a repair individual or entity and, if the claimant accepts the suggestion or recommendation, the insurer shall cause the damaged property to be restored to no less than its condition prior to the loss and repaired in a manner which meets accepted trade standards for good and workmanlike construction at no additional cost to the claimant other than as stated in the policy or as otherwise allowed by these regulations.
(d) If losses are settled on the basis of a written scope and/or estimate prepared by or for the insurer, the insurer shall supply the claimant with a copy of each document upon which the settlement is based. The estimate prepared by or for the insurer shall be in accordance with applicable policy provisions, of an amount which will restore the damaged property to no less than its condition prior to the loss and which will allow for repairs to be made in a manner which meets accepted trade standards for good and workmanlike construction. The insurer shall take reasonable steps to verify that the repair or rebuilding costs utilized by the insurer or its claims agents are accurate and representative of costs in the local market area. If the claimant subsequently contends, based upon a written estimate which he or she obtains, that necessary repairs will exceed the written estimate prepared by or for the insurer, the insurer shall:
(1) pay the difference between its written estimate and a higher estimate obtained by the claimant; or,
(2) if requested by the claimant, promptly provide the claimant with the name of at least one repair individual or entity that will make the repairs for the amount of the written estimate. The insurer shall cause the damaged property to be restored to no less than its condition prior to the loss and which will allow for repairs in a manner which meets accepted trade standards for good and workmanlike construction at no additional cost to the claimant other than as stated in the policy or as otherwise allowed by these regulations; or,
(3) reasonably adjust any written estimates prepared by the repair individual or entity of the insured’s choice and provide a copy of the adjusted estimate to the claimant.
(e) Once the appraisal provision under an insurance policy is invoked, the appraisal process shall not include any legal proceeding or procedure not specified under California Insurance Code Section 2071. Nothing herein is intended to preclude separate legal proceedings on issues unrelated to the appraisal process.
(f) When the amount claimed is adjusted because of betterment, depreciation, or salvage, all justification for the adjustment shall be contained in the claim file. Any adjustments shall be discernable, measurable, itemized, and specified as to dollar amount, and shall accurately reflect the value of the betterment, depreciation, or salvage. Any adjustments for betterment or depreciation shall reflect a measurable difference in market value attributable to the condition and age of the property and apply only to property normally subject to repair and replacement during the useful life of the property. The basis for any adjustment shall be fully explained to the claimant in writing.
(1) Under a policy, subject to California Insurance Code Section 2071, where the insurer is required to pay the expense of repairing, rebuilding or replacing the property destroyed or damaged with other of like kind and quality, the measure of recovery is determined by the actual cash value of the damaged or destroyed property, as set forth in California Insurance Code Section 2051. Except for the intrinsic labor costs that are included in the cost of manufactured materials or goods, the expense of labor necessary to repair, rebuild or replace covered property is not a component of physical depreciation and shall not be subject to depreciation or betterment.
Reviewing the above regulations that offer protections to policyholders and freezing in the frozen tundra of New Jersey has me dreaming of California…
1 Cal. Code Regs. Tit 10 § 2695.1.
2 Cal. Code Regs. Tit 10 § 2695.5(e).
3 Cal. Code Regs. Tit 10 § 2695.7(d).
4 Cal. Code Regs. Tit 10 § 2695.5(b).
5 Cal. Code Regs. Tit 10 § 2695.7(h).
6 Cal. Code Regs. Tit 10 § 2695.7(b)(1).
7 Cal. Code Regs. Tit 10 § 2695.7(c)(1).
8 Cal. Code Regs. Tit 10 § 2695.7(b)(1).
9 Cal. Code Regs. Tit 10 § 2695.7(g).
10 Cal. Code Regs. Tit 10 § 2695.7(a).
11 Cal. Code Regs. Tit 10 § 2695.7(f).
12 Cal. Code Regs. Tit 10 § 2695.9.