Imagine you are walking around your house one night, and the lights suddenly flicker. You immediately investigate the issue, open a living room wall, and determine that the electrical wiring behind the wall is burned due to water leaking down from the bathroom above. You shut the main valve to the bathroom right away and call an electrician. Prior to this, there were no signs of any plumbing or wiring issues that would have tipped you off that you had a problem in your home. It is subsequently determined that the wax ring on your toilet, which is hidden and not visible, failed and has been leaking. You submit an insurance claim only to be told that the loss is excluded.
Continue Reading Merlin Law Group Overturns Coverage Denial Over Interpretation of the Term “Sudden”

Greene v. USAA1 is probably the most cited case by first-party insurance carrier attorneys in Pennsylvania. It is an appellate level case that centered on whether an insurance carrier is required to replace a roof when the existing shingle is no longer in production, but shingles of “similar color, texture, function, and shape” are available. In Greene, the Superior Court of Pennsylvania (appellate) held that using shingles similar to the damaged shingles in function, color, and shape satisfied the insurer’s obligation to pay for repair or replacement with like construction.
Continue Reading Repair vs. Replacement in Pennsylvania

The Professional Public Adjusters Association of New Jersey is having its Spring Event on May 12, 2021, at the Hotel LBI in Long Beach Island, New Jersey. As per the usual structure of these events, attendees are eligible for up to four credit hours of Continuing Education recognized in New Jersey, New York, and Pennsylvania.
Continue Reading Register Now for the PPAANJ Spring Educational Meeting Being Held on May 12, 2021

Below is testimony I elicited from a Nationwide Insurance representative during a recent deposition:

Q. Are you familiar with Overhead and Profit?

A. Yes.

Q. Okay. And when does Nationwide include overhead and profit in its estimates?

A. When it is reasonably necessary to assume that a general contractor is needed to facilitate the repairs.

Q. Okay. Now, going to the back of this estimate, it appears that Nationwide did not apply overhead and profit in terms of the estimate that It produced. Can you explain why Nationwide decided not to include overhead and profit on this estimate?
A. Can we – can I talk to counsel a second?

(A discussion between the attorneys was had wherein the witness was instructed to answer the question)

A. Okay. All right. It appears that we missed it.

Q. Okay.

A. Yeah There’s – there’s no reason why profit and overhead would not have been included on this estimate.


Continue Reading A Refresher on Overhead and Profit in Pennsylvania: Mee v. Safeco

Below is a conversation I have all too often with insureds:

Insured: I just received a letter from the carrier that they are denying my claim.

Attorney: I am sorry to hear that. What was the basis for the denial?

Insured: The basis for the denial was _____. However, the insurance adjuster told me that this would be covered when he was at the property.

Attorney: Great. Did you document the representation in writing?

Insured: . . . . .


Continue Reading Documenting Your Claim: Preparing for Litigation During Claims Handling

The Middle District of Pennsylvania recently denied a Motion for Summary Judgment filed by Allstate Insurance Company (“Allstate”) against its insured for the insured’s alleged failure to reside at the property. Merlin Law Group attorney Jason Cieri blogged on the Court’s Denial of Allstate’s Motion for Judgment on the Pleadings last November which you can access here. Now, after consideration of the expert reports and facts obtained during discovery, the court has ruled that this matter can move to trial.
Continue Reading Question of Residency is Determined by Jury

Shawnee Tabernacle Church (“Shawnee”) is a Congregation located in Monroe County, Pennsylvania. The church was insured by GuideOne Insurance (“GuideOne) with a policy that included the following language under the title “Pennsylvania Changes”:

Notice of Acceptance or Denial of Claim

Except as provided in 3 below, we will give you notice, within 15 working days after we receive a properly executed Proof of Loss that we:

A.) Accept your claim.

B.) Deny your claim; or

C.) Need more time to determine whether claim should be accepted or denied.

1) If we deny your claim such notice will be in writing and we will state any policy provision, condition or exclusion used as a basis of denial. If we need more time to determine whether your claim should be accepted or denied, the written notice will state the reason why more time is required.

2.) If we have not completed our investigation, we will notify you again, in writing, within 30 days after the initial notice as provided in i.e., above and thereafter every 45 days. The written notice will state why more time is needed to investigate your claim and when you may expect us to reach a decision on your claim.

3.) The notice procedures in 1 and 2 above do not apply if we have a reasonable basis, supported by specific information, to suspect that an insured has fraudulently caused or contributed to the loss by arson or other illegal activity; under such circumstances, we will notify you of the disposition of your claim within a period of time reasonable to allow full investigation of your claim, after we receive a properly executed Proof of Loss.


Continue Reading Pennsylvania Bad Faith Archives: Shawnee Tabernacle Church v. GuideOne Insurance

Join us tomorrow for a public adjuster webinar. Jason Cieri and I, from the Merlin Law Group Red Bank, New Jersey office, will be presenting two courses starting at 2:00 pm (Eastern Time). Jason’s course will cover a very common issue up in the Northeast: Frozen Pipes and Sewer Backups.

I will discuss the

Occasionally, an attorney representing an insured will run into a Motion to Compel Appraisal filed by the carrier’s attorney. Upon receipt of the motion, a few considerations must be made with the most important being:

  1. Is the demand for appraisal timely? and
  2. Is appraisal proper considering the “amount of loss”?
    Continue Reading Amount of Loss: Appraisal Considerations in New Jersey