Every time a claim is denied, there is always a concern that the claimant will sue for insurance bad faith. Claims denials should not be taken lightly. Even if it is clear to you that the claim is not covered, I suggest doing the following to make it difficult, if not impossible, for a claimant to prevail in a bad faith claim against your company following your denial. (I cannot say that the following will prevent a bad faith claim; if a monkey pays the requisite filing, that monkey can at least file suit in California. The goal here is to discourage reputable counsel from pursuing bad faith claims, and that’s worth avoiding.)
First, make sure you’ve looked at all the insured’s coverages with your company, not just the policy the insured tendered under. If the insured has other coverages with your company that may cover the claim, advise the insured in writing that the company is still evaluating the claim for coverage. Do not deny the claim out of hand. You are entitled to conduct a reasonable investigation before denying coverage. So conduct a reasonable investigation first.
Second, respond to the claim within 15 days of your receipt of the claim in writing to the insured. California Department of Insurance Regulations regarding liability carriers to advise the insured in writing within 15 days the status of the claims. (10 Calif. Code of Regs., § 10 CCR § 2695.5, subdivision (b).) You don’t have to accept or reject the claim within 15 days, just acknowledge you’ve received the claim and are evaluating. If the insured inquires about the status of the claim, you need to respond within 15 days with what you know about the claim and what you’re doing about, such as evaluating it, investigating, etc. The insurance regulation above notes that you can just make a note in your claims file when the claim came in, but it is a better practice to both note your file and tell the insured in writing that you are considering the claim. Why, because the insured has tendered and is wondering what, if anything, the insurer is doing with the claim, and will be much more patient knowing someone is working on the claim.
Third, provide the claimant any necessary forms, instructions, and reasonable assistance the claimant needs to properly make the claim, which includes telling the insured if there is missing information necessary to make a valid proof a claim. This also required under the same insurance regulation cited above at subdivision (e). Failing to tell the insured what the insured needed to do in order to submit a valid claim will not make the claim go away. It will most likely encourage the insured to get an insurance bad faith lawyer or encourage the insured to complain to the California Department of Insurance—results you are trying to avoid.
Fourth, investigate the claim. Some claimants won’t have counsel. Some claimants who have counsel don’t have legal counsel knowledgeable about insurance practices. You shouldn’t just rely on the insured’s tender to tell you everything you know about a claim. On receipt of a claim, you should verify with the insured that insured and insured’s counsel, if any, have provided you with all information relating to the claim, including copies of any pleadings or discovery. If you know who the attorney representing the party suing the insured, call that attorney and ask for information about the claim. You could also retain coverage counsel to assist with your investigation if necessary. The point is you want to document your file that you made reasonable efforts to gather information about the claim before denying it. In California, an insurer can be liable for insurance bad faith for failing to reasonably investigate a claim. Note too that the same California insurance regulation cited above also requires “any necessary investigation of the claim.” Here, “necessary” and “reasonable” are synonymous. What you want to avoid is having an empty claims file that shows little or no effort went into investigating the insured’s claim. If you deny without conducting a reasonable investigation, you are encouraging an insurance bad faith lawyer to take the claimant’s case.
Fifth, if its close to being a “close call” about whether coverage exists, get a second opinion. Even better two. Run the claim by a more experienced and knowledgeable adjuster at your company, and not your file that you did this. Get an opinion from coverage counsel too, and make sure you note that in your file.
Sixth, when denying the claim, carefully explain to the insured the coverages the insured had, what your understanding of the claim is, and what you did to investigate the claim. Then explain why there is not coverage under the policy for the claim that the insured submitted. Most insureds are not insurance experts and many lawyers do not practice insurance law. A well thought out, thoughtful, and professional denial letter is perhaps the best talisman to ward off bad faith claims. Why? Because the letter should should the good faith consideration the company undertook to evaluate the claim. It would be Exhibit “1” to your company’s defense. The importance of such a letter cannot be understated. If there is something you missed, or if your information is incomplete, you’ve not put the ball in the insured’s court to respond. Even in California, insurers are not liable for mistakes or even ordinary negligence in claims handling.
Following the above six steps creates an evidentiary record showing good faiths claims handling. It will help your defense counsel immensely if you followed these steps, and will both ward off potential bad faith claims or certainly make the resolution of such a claim more favorable for your company.