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Avoid Agent E&O When Handling Problem Claims
Avoid Agent E&O When Handling Problem Claims
By Brent Winans of Clear Advantage Risk Management
Insurance agents—be careful about advocating for your clients when the insurance company has denied their claim. Insureds—understand that your insurance agents may be more hesitant to "go to the wall" for you on a claim than in the past for fear that you may end up suing them.
Most agents tell their insureds that one of the prime benefits they provide for their clients is that they will advocate for them with the insurance company when there is a claim. So, I was surprised recently to hear advice from one of the nation's leading providers of insurance agents' errors and omissions (E&O) coverage that agents should be very careful about advocating for a client when there is a claim denial. Their bottom line was that agents need to take due precautions about when and how they advocate for their clients so they do not end up on the wrong end of a lawsuit themselves. As a result of that shift, I believe insureds may need to take more responsibility to advocate for themselves.
The Dangers of Agents Trying To Be Coverage Attorneys
Recently, a group of highly experienced agent E&O defense attorneys were asked what practices were most likely to result in an E&O claim against the agent. One of their top picks was, "Advocating in writing on behalf of the customer once a claim has been submitted and denied by the carrier."
Why is that such a problem? Isn't that just what good agents do for their clients? One defense attorney explained to me that if an agent writes a letter insisting that a claim should be paid and then the insurer successfully upholds its denial in court, the agent may have just demonstrated that he did not understand the policy he sold. The attorney for the insured can then use the agent's letter as "Exhibit A" to prove that the agent misled the insured about the coverage he was buying.
Here is an example that shows how that scenario might play out in real life.
A friend of Ben's had recently opened one of the increasingly popular indoor trampoline parks. After an extensive marketing effort, Ben was able to place the coverage with a leading excess and surplus lines insurer. Among several other exclusions, the policy contained one that deleted coverage for participants in organized teams. Not long after the policy was written, a 17-year-old boy suffered a paralyzing neck injury while playing trampoline dodge ball. It came to light that several churches in the area had organized a trampoline dodge ball league, and the boy was playing on one of them when he was injured. The insurer denied coverage based on the exclusion.
Ben wrote a strongly worded letter to the insurer insisting that the claim should be covered since the "league" was not incorporated and was really just a bunch of church kids having a good time. The court found for the insurance company, reasoning that the policy unambiguously excluded participants in organized teams, whether their organizations were incorporated or not. The insured then sued Ben's agency, alleging that Ben had misled him about the coverage provided, using Ben's letter as evidence.
As with many E&O cases, whether a client would be likely to win such a suit would be highly dependent on the state law that applied and the facts of the case, but a letter like Ben's would rarely be helpful to an agent's defense. A highly respected defense attorney told me, "I have been litigating coverage cases for decades, and I still cannot tell what a particular court will rule in a particular case. How can agents be so sure? During a claim, agents should provide information, facilitation, and communication, not try to make a coverage determination. And, if agents insist on doing so, they certainly should not do it in writing."
If You Can't Stand the Heat, Stay Out of the Kitchen
Agents should understand that anything they do that encourages an insured to sue its insurance company may increase the chances that the agent will be sued, too. A policyholder attorney explained it to me this way:
Let's say that the insurance company is based in New York, but my policyholder client is in Georgia. That situation is referred to as diversity of citizenship, since the two parties are based in two different states. If the amount of the claim is also over $75,000, those two factors usually make the case eligible to be heard in federal court. Attorneys know that federal judges are generally less likely to send a case to a jury than state judges. So the insurance company would usually try to have the case tried in federal court, since they often don't want to face a jury, which is commonly pro-policyholder. But because I do want to try the case in front of a jury, I want to keep the case in state court. If the agency is also located in Georgia, and I have a legitimate basis to bring the agency into the suit along with the insurance company, I have a better chance of keeping it in a Georgia state court. So, if I can reasonably bring the agent into the suit in that situation, I am going to.
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