tuesday april 29 2014 1 45 3 45 david goodwin tracy jurusik barbara miller n.
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Why Won’t They Pay My Claim? (CLM 018) PowerPoint Presentation
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Tuesday, April 29, 2014, 1:45-3:45 David Goodwin Tracy Jurusik Barbara Miller. Why Won’t They Pay My Claim? (CLM 018). Introduction. Meet the panelists What we’re going to discuss Identifying and presenting a claim What happens after the claim arrives at the insurance company

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Why Won’t They Pay My Claim? (CLM 018)


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Presentation Transcript
introduction
Introduction
  • Meet the panelists
  • What we’re going to discuss
    • Identifying and presenting a claim
    • What happens after the claim arrives at the insurance company
    • What happens if the insurer disputes the claim
  • A case study
what is a claim
What is a claim?
  • Ordinary meaning – demand for money
  • Common definitions of “claim”
    • Lawsuit
    • Written demand for money
    • Tolling agreement request?
    • Investigation?
    • Subpoena?
identifying and presenting a claim
Identifying and Presenting a Claim
  • Set up process with law department to receive threats/lawsuits (prior to claims being presented)
  • Review threat/lawsuit for potential coverage
  • Review reporting requirements for every potential policy
  • Report threat/lawsuit to broker(s)
identifying and presenting a claim1
Identifying and Presenting a Claim
  • Ensure broker follows reporting guidelines outlined in policy and timely reports claim
      • Form of reporting (letter; email; bordereaux)
      • Content of notice
  • Follow up for acknowledgments from insurers
  • Notify law department of potential involvement of insurers and consent provisions
what happens after the claim reaches the broker
What happens after the claim reaches the broker
  • Review the materials received from the Insured – from the perspective of a claim adjuster
  • Does the information appear to be related to anything that was previously reported?
  • Do we have a “Claim” as defined in the Policy?
what happens after the claim reaches the broker1
What happens after the claim reaches the broker
  • If we have a “Claim” what is the date the “Claim” was first made?
  • Which type of policy is triggered based on the alleged wrongful acts in the “Claim”?
  • Which policy period is implicated and do we have any late notice issues?
  • Do the allegations in the “Claim” trigger more than one Policy?
what happens after the claim reaches the broker2
What happens after the claim reaches the broker
  • If more than one Policy is implicated – how do the “other insurance” clauses in each Policy operate?
  • Are there any applicable exclusions in the Policy that may come into play?
  • Once we know which Policy and policy period, report the matter to the entire applicable tower
what happens after the claim reaches the broker3
What happens after the claim reaches the broker
  • What are the choice of counsel provisions in the Policy?
  • Does the insurer or the insured have the “duty to defend”?
  • Does the applicable Policy have a panel counsel requirement?
  • Does the Insured’s choice of counsel comply with the Policy’s counsel requirements?
what happens after the claim reaches the broker4
What happens after the claim reaches the broker
  • If we don’t have a “Claim” should we consider reporting a “notice of circumstances” if allowed under the Policy?
  • Factors to consider in a submitting a “notice of circumstances”
  • Once a “Claim” or “circumstances” reported, review acknowledgment and reservation of rights letters for accuracy and response
what happens after the claim reaches the broker5
What happens after the claim reaches the broker
  • Understand the Policy’s consent provisions and confirm compliance
  • Insurer responses to claim
      • Acknowledgement of coverage
      • Reservation of rights/request for information
      • Denial
      • Silence
what happens after the claim reaches the broker6
What happens after the claim reaches the broker
  • Broker response to reservation of rights
  • Broker response to silence
  • Broker response to coverage denial
      • Typical process following denial
      • What you can and cannot do
      • What your broker can and cannot do
what happens after the claim reaches the broker7
What happens after the claim reaches the broker
  • Facilitate the flow of information between Insured’s counsel and the Insurers
  • How to communicate with insurers
      • Confidentiality issues/will agreements help?
      • Disclosing privileged information?
      • Avoiding waiver
    • Periodic calls and meetings
    • Identify and head off problems
what happens if the insurer refuses to pay1
What Happens If the Insurer Refuses to Pay?
  • Evaluate insurers’ reasons for refusing
      • Insurer definitely right?
      • Iffy?
      • Arguable?
      • Insurer wrong
  • Legal issues or factual questions?
  • How do you tell who is right?
what happens if the insurer refuses to pay2
What Happens If the Insurer Refuses to Pay?
  • Do you need outside assistance?
      • Broker
      • Consultant
      • In-house counsel
      • Outside counsel
  • Process of evaluating the claim
      • Legal uncertainties
      • Factual uncertainties
what happens if the insurer refuses to pay3
What Happens If the Insurer Refuses to Pay?
  • First steps
      • Gather policies
      • Learn facts
  • Process of evaluating the claim
      • Legal uncertainties
      • Factual uncertainties
  • Respond to insurer
what happens if the insurer refuses to pay4
What Happens If the Insurer Refuses to Pay?
  • Negotiate
      • Informal negotiation
      • Broker and insurer?
      • Client and insurer?
      • Counsel and counsel?
      • Effective negotiation strategies
  • What if negotiation doesn’t work?
what happens if the insurer refuses to pay5
What Happens If the Insurer Refuses to Pay?
  • Does policy have an “ADR” clause?
      • Mandatory choice of mediation or arbitration?
      • Mandatory arbitration?
  • What is mediation?
      • How a mediation works
  • What is arbitration?
      • How an arbitration works
      • Pitfalls of an insurance arbitration
      • What if you have a multi-policy program?
what happens if the insurer refuses to pay6
What Happens If the Insurer Refuses to Pay?
  • Litigation
      • Where do you file?
      • What do you allege?
  • Litigation – how it works
      • Litigation process
      • Discovery – documents; written discovery; depositions
      • Motion process
      • Settlement conference/mediation
      • Trial/appeal