Insurance Claim Terms – Jargon and Definitions

Post Insurance Claim Terms Question (below)

Normally boring insurance claim terms and jargon are defined below and spiced up with editorial by contributor Ron Cercone, a semi retired licensed public adjuster and owner of UClaim.com (where there is currently a free 2nd Insurance Claim Advice eBook offer).

These insurance claim terms, jargon and definitions are in layman terms and from the consumer advocate perspective. They will help you command the adjusters respect and build your confidence.

These definitions are only intended as a quick reference and may not be fully defined or all inclusive or “guaranteed”. They may also include biased and sarcastic editorial opinions to add interest to an otherwise boring topic. Use of these definitions in pursuit of your claim should be confirmed by you with other sources such as your policy, attorney, law library, etc.

You may find varying legal definitions of these terms based on your geographic location (ACV for example). A major problem with insurance in the USA is the lack of uniformity throughout the 50 states. In some claims, coverage for the entire claim may hinge on the definition or meaning or ambiguity or lack of clarity of one word in your policy.

The intent of these definitions is to take away a little of the intimidation factor used by some insurer’s adjusters and attorneys who would use insurance and legal jargon to intentionally confuse and discourage you. These “free” definitions are not intended to give new or novel meaning to that one word in dispute in your policy that may make or break your case.

More detailed discussions of some of the following terms and concepts are available in the eBook products section at UClaim.com.

 

ACV – Abbreviation, see Actual Cash Value.

Actual Cash Value – In layman’s terms “Depreciated Value” or “Market Value” depending on whether it is applied to building structure or contents. This will further depend on a state’s or local jurisdiction’s legal definition. In California, ACV on buildings is “Fair Market Value”, not replacement cost less depreciation. In Pennsylvania, ACV on buildings is replacement cost less depreciation. In California ACV on contents/furnishings/personal property is current replacement cost less depreciation. Note – adjusters very often use the incorrect methods to calculate ACV. How to use this to your advantage is covered in the eBooks available for purchase at Uclaim.com.

Actual Damages – (See also Damages for other kinds of damages) Also referred to as Special Damages. Damages that have a dollar cost attached such as property value or cost to repair or replace personal, business or real property, medical bills, towing costs, lost wages, additional living expense, extra business expense.

ACV of the Repairs – Depreciated value of the repairs. For example, if the cost to paint your house is $1,000.00 and the paint is 40% worn, then the ACV of the Repairs is $600.00. This is the amount most insurers and policies will pay after their investigation or inspection is complete. If you have RCV, Replacement Cost Value, as most people do, you will get the other $400.00 after the repairs are completed. For advice on how to minimize the amount of depreciation that an insurer deducts, see the Uclaim.com product section on Homeowner, Landlord and Businessowner Loss eBooks.
ACV of the Total Value – Actual Cash Value of the value of the entire structure or vehicle. This figure is useful even if the item is only partially damaged in order to decide whether the item is worth repairing. (See ACV). Adjusters sometimes neglect to consider this figure in their haste to close their claim file and it can work to the policyholder’s advantage.

Additional Coverage – Generally, this term can be used to refer to sections of your policy entitled “Additional Coverages” and “Extensions of Coverage” as well as to endorsements. The typical small percentages of 5% here and 10% there can add up to a lot of extra dollars.

Additional Living Expense – (See also Fair Rental Value) The part of a homeowners or renters policy that pays the additional expenses incurred to maintain your standard of living after being displaced from your insured dwelling while you repair or replace the damaged dwelling. It is usually limited to 12 months and a stated dollar limit shown in the declarations. Normal expenses are deducted first. Insurance claim advice eBooks on how to maximize this coverage and not to get burned are in the product section of Uclaim.com.

 

Adhesion – (See “Contract of Adhesion”)

Adjuster – (See also Staff Adjuster, Company Adjuster, Independent Adjuster, Claim Analyst and Public Adjuster) Literally, one who adjusts or alters the claim. Except for Public adjusters, the others are paid by the insurance company. They usually adjust the claim downwards. They are trained to believe that the average claim is inflated anyway. Most adjusters handling claims by phone are entry level robots. Most have never experienced a claim themselves and most have never owned a home. Most of the office adjusters’ supervisors lack higher education and started in the mail room or at a clerk level. The supervisors are “super robots”. Most field adjusters have a couple years experience and are on an ego trip because they have a company car and a “flexible” schedule. A “good seasoned adjuster” from the insurance perspective is forty to sixty years old and gives you three items when you only claimed two items and he knew of another seven items he could have paid you for, but kept his mouth shut. He also has a GCA, CPCU or some other impressive initials after his name. Despite the commentary, these are not bad people. They are just doing what is expected of them (for the most part).

Within these categories are “office adjusters” who handle small claims or manage larger claims with the help of “field adjusters” or independent adjusters. Office adjusters sit behind a desk all day. Field adjusters get a car and make inspections of damaged property in person. Some field adjusters only write estimates and take photos for the office adjuster, while others will handle the claim start to finish.

Like attorneys, adjusters have specialties. The three most common types are automobile (repair cost and valuations), liability (injuries) and property (buildings and contents).

ADP AUTOSOURCE – One of the two major computerized appraisal companies used by most US insurers (their main competitor is CCC, see below). These two companies are responsible for probably over 99% of valuations placed on total loss vehicles. They are also used for valuations of other insurable motorized property such as boats, motor homes, motorcycles, aircraft, trucks and equipment. Their reports look bullet proof, scientific, intimidating and are full of jargon. They boldly claim to adhere to insurance laws when in fact they are full of legal violations as well as errors. They are truly controlled by the insurers who pay for their reports. For guidance in how to successfully unravel and discredit their reports, see the product section of Uclaim.com.

Agent – (See also “Captive Agent”, “Independent Agent” and “Broker”) Generally, one who represents another. Most people incorrectly think that the insurance agent who sold them their policy is “their insurance agent”. From a legal standpoint, that agent represents the interests of the insurer who signs his/her paycheck. However from a practical standpoint, if the agent wants to continue to earn commissions from your renewal premium dollars, he will try to satisfy you as well, without getting himself fired by his employer, your insurance company.

ALE – See Additional Living Expense

“All Risk Policy” – This is only a general descriptive term used by insurers. There is no such thing as a truly all risk policy since all policies have conditions and provisions. What this term signifies is the general structure of a policy. A policy which begins the section entitled “Perils Insured Against” with wording such as “We insure against everything except the following excluded items …” is referred to as an “All Risk” Policy. (This is in contrast to the other policy format called “Named Perils Policy” , which has wording such as “We insure for damage against the following named items only”). Most home and business policies today are insured as “All Risk” on structure and “Named Perils” on contents. Homeowners are often upset when they discover that the supposedly “All Risk” Policy their agent sold them is not really “all risk.” One cannot buy a true all risk policy. Not even the best floaters come without conditions.

Assumption of Risk – legal liability doctrine that if a person knows ahead of time that they could get injured and also agree not to hold anyone other than themselves responsible if they are injured, there can be no negligence and therefore a liability insurer will resist payment.

Assignee – The party who receives an assigned policy or assigned claim benefits.

Assignor – The party who assigns or gives his policy or claim benefits to another party.

Assignment of Policy contract – The insured gives ownership of his policy to another person. It requires the insurer’s approval since the person insured may present a higher risk of loss. This can be before or after a loss.

Assignment of Claim proceeds – The insured gives the right to the proceeds of a claim to another person. It does not require the insurer’s approval since the loss already occurred. However the original policy holder may still have some duties to cooperate, within reason and if relevant to coverage, with the insurer’s investigation. For example, submit to recorded statement, Examination Under Oath, supply proof of purchase and ownership, etc.

Attorney – (See Defense Attorney, Plaintiffs Attorney) “The good, the bad and the ugly”, pretty much says it all, right? Most attorneys are in their profession only for the money (ask any attorney or law student why they went to law school). Most attorneys dislike their profession. See “Special Commentary” under “Law” to better understand why the US legal system is rampant with “unscrupulous” attorneys.

“Basic Form” – One of the three property policy types: Basic Form, Broad Form and Special Form. Basic Form was one of the first policy types and is used today only by people who want the least expensive policy (some land lords), or by government agencies and high risk insurers for high risk properties, such as substandard buildings or locations in high crime areas. Basic Form covers only three perils on structure and contents: “fire, lightening and removal”. It also only pays ACV (depreciated value) as opposed to RCV (Replacement Cost Value). Endorsements can be added for more coverage. The number “1” in the policy form number often designates Broad Form, e.g. DP1, DF1, HO1.

BI – see “Bodily Injury” or “Business Interruption” or “Business Income”.

Blanket Coverage – (versus “Scheduled Coverage”) Description for an endorsement which has an agreed dollar limit of coverage for a category of items. For example, $15,000 for “miscellaneous farm hand tools”, $10,000 for “miscellaneous irrigation pipe”, $10,000 for “business personal property” or $30,000.00 on silverware (on a homeowners policy).

“Blue Book” – See Kelly Blue Book

Bodily Injury – “Bodily Injury Coverage”. Term used to express insurance coverage to pay for bodily injuries and compensation to others caused by an insured. It also pays the cost of a legal defense. In auto insurance it is usually expressed as a per person and per accident limit, 15k and 30k. Not to be confused with “Med Pay” and Property Damage insurance.

BOP – Abbreviation, see Business Owners Policy.

Branch Office – local insurance claims office vs. “Regional Office” and “Home Office.”

“Broad Form” – One of the three property policy types: Basic Form, Broad Form and Special Form. Broad Form began to be offered after Basic Form. It is also used today only by people who want a less, but not least, expensive policy (some land lords), or by government agencies and high risk insurers for high risk properties, such as substandard buildings or locations in high crime areas. Broad Form covers sixteen named perils on structure and contents. It also only pays ACV (depreciated value) as opposed to RCV (Replacement Cost Value). Endorsements can be added for more coverage. The number “2” in the policy form number often designates Broad Form, eg. DP2, DF2, HO2.

Broker – See Insurance Broker.

Business – As defined in a homeowners policy, it is intended to exclude coverage for property used in a business. The definition varies in different policies as well as in different editions of the same policy. It is a huge area of abuse by insurance adjusters. For insurance claim advice on how to fight a denial of business property in a homeowners policy, see the products section of Uclaim.com.

 

Business Income Coverage – Usually listed under “additional coverages” in a BOP policy and shown as “Business Income (And Extra Expense) in a CP policy. It appears to cover lost profits during the “period of restoration” usually up to 12 months. Contrary to appearances, this is not a simple or self explanatory coverage. You can very easily get “burned” or knifed in the back by your insurer on this and Extra Expense coverages. Don’t go through a business loss without one of the appropriate business owners loss eBooks in the product section of Uclaim.com.

Business Interruption Coverage – This is an insurance coverage concept which includes “business income lost” due to a covered loss and “extra expenses” necessary to continue business after a covered loss.

Business Owner’s Policy – (also referred to as “BOP”) A package type policy in one booklet that includes various common coverage parts such as for property damage, liability, loss of income and extra expenses. It can still have endorsements attached for additional coverages unique to your business. The booklet may discuss coverages which you may not actually have. Your declarations page will specify which parts of the booklet apply to you. The BOP is in contrast to the older form “Commercial Policy” which is like a loose leaf binder full of individual parts, similar to a-la-carte menu.

Cancellation (of the policy) as opposed to “non renewal.” It is more difficult for an insurer to cancel your policy mid term than to just non renew it. Certain specific reasons must be given by the insurer to cancel your policy mid term whereas no reason at all need be given to non renew, or, allow the policy term, usually 12 months, to expire. Reasons for cancellation would be things such as major change in the condition of the property insured increasing the chance of a loss or a change in the person insured, such as a criminal felony conviction or misrepresentation in the policy application. Turning in a claim is not a valid reason to cancel a policy mid term. However, many insurers will surprise you with a non renewal notice two weeks before your policy expires after you have had a claim. It is therefore advisable for insureds who have had a loss to apply for insurance with another insurer and get approved just in case their original insurer surprises them with a non renewal notice two weeks before the policy comes up for renewal. It is also advisable for insureds to keep their policy in force even if the structure burned to the ground, since there may still be a need for liability insurance, especially if there are kids in the neighborhood.

If you think your policy was wrongly canceled or non renewed, or you never got a notice, you should start with one of the eBooks on denied claims in the product section of Uclaim.com.

Cancellation Notice – A mailed notice that your insurance is about to cancel. Insurers must follow certain procedures in the mailing of the cancellation notice itself. If you think your policy was wrongly canceled or non renewed, or you never got a notice, you should start with one of the eBooks on denied claims in the product section of Uclaim.com.

Captive Agent – (See Independent agent for comparison) An insurance sales agent who works only for one company or “insurance group” under one roof, for example, Allstate, State Farm and Farmers Insurance Group. He is under more pressure to back up the insurer against you. Legally, he is an “agent” for the insurer, not you, since he is paid commissions by the insurer. A Broker by contrast, is legally, your agent.

Case Law – (See also Law) A decision/s reached in an appellate court becomes law in that jurisdiction, a US state for example. If you win a case in a trial court, but the loser appeals to a higher court (the appellate court), whatever decision the higher court makes becomes law for all lower courts, trial courts, in that state. If you win a case in trial court and the loser accepts the decision, then that case does not become law for other trial courts and anyone else who wants to sue will have to bring a whole new case and it could conceivably have a decision completely the opposite as in your case, even with the same set of underlying facts.

Insurers like the case law system because it is less expensive to pay for a few lost cases in a state and continue with whatever it was they were doing wrong than to risk a loss in an appellate court and have the unfair practice totally shut down. Most of the cases that insurers settle the day before trial are also with a confidentiality agreement. So the details of the case are never made public.

In order for case law to be binding on your case and your judge or jury, it must have substantially similar underlying facts and issues and be in the same context as your case. While no two cases are ever exactly the same, there may be enough relevant similarities to make it applicable to your case. It is our experience that 99% of cases cited by insurance attorneys are misrepresented to fit their own needs (and sadly, in the US, this misrepresentation is called “right to free speech”). This is one reason why most US judges have “research attorneys” on staff, to verify or nullify written citations in papers to the court. (It’s no wonder US courts are clogged up!).

Cause of Loss – (See also Concurrent, Efficient and Proximate cause of loss). The “cause of loss” is not covered by property insurance because wear and tear, defective and malfunctioning property are not covered. For example, if a television overheats, catches fire and the building burns down, the insurance adjuster will tell you the house and contents are covered, but he will not cover the television. If a water pipe breaks and floods your house, the adjuster will not pay the plumber’s $500.00 bill to fix a water pipe under a slab. If a $20,000.00 appliance starts a fire and the insurer denies coverage for that appliance, then that is hard to accept. However, insurance claim advice on how to get payment for most of the cost to repair or replace the item which caused the loss is covered in eBooks for sale in the product section of Uclaim.com. You may learn enough from these eBooks to get your claim covered in whole or in part.

Simply put, the cause of loss is that which caused the damage for which the claim is made. Most property insurance policies now say they cover damage caused “directly”, not concurrently or otherwise. Although insurers have loaded up their policies with specific exclusions designed to close loopholes for creative legal causation arguments, policies may be overridden by state laws which may give coverage based on cases and legal arguments of concurrent, efficient and proximate causation. Examples of recent exclusions would be for mold, mudslide, contractor or third party negligence and terrorism. As long as insurers continue to issue “all risk/peril with named exclusion” policies, there will always be an opportunity to find a new non excluded cause of loss.

In reality, in some claims, the cause of loss may be complex. It may be a chain of events leading to the final damage. For example, a fire may have been started by an arsonist who was taught by someone in his childhood to enjoy setting fires who himself read a book on setting fires by someone else. The book writer might be considered a “remote cause” of loss. The fire that damaged the property might be considered the “proximate cause” of loss. There may also be two unrelated causes which occur at the same time (“non-concurrent causes”). For example a wood floor may be wet from a slow drip drip drip pipe leak, and also from a washing machine that just overflowed or a leaking roof after a rain. There may be a cause not part of a chain of causes that intervenes during the chain of events to cause damage on its own (“efficient intervening cause”).

If you come across terms such as Proximate Cause, Efficient Cause, Concurrent Cause, then an insurer’s attorney is probably trying to deny all or part of your claim. Legal definitions and treatises of various types of causes of loss vary from author to author, state to state and from case to case. There are often confusing and conflicting definitions, court rulings and hair splitting definitions. Dissenting opinions by judges on the same panels or higher courts also point to the difficulty in defining and applying some of these terms to insurance policies which often do not give clear definitions. For example, Blacks Law Dictionary (6th edition) defines proximate cause as “that which stands next in causation to the effect, not necessarily in time and space, but in casual relation.” To further complicate it, definitions of the various types of cause of loss can also vary within the various categories of insurance claims such as property, casualty, liability, workers compensation, life, health and disability insurance. Whether or not your claim gets covered may depend on yours or your representative’s power of persuasion with an insurer’s adjuster or judge or jury.

A good place to start may be with an eBook in the product section at Uclaim.com to get some basic advice on how to deal with some types of denied or reduced claims based on various “cause of loss” exclusions.

CCC “Certified Collateral Claims” – One of the two major computerized appraisal companies used by most US insurers (their main competitor is ADP, see above). These two companies are responsible for probably over 99% of valuations placed on total loss vehicles. They are also used for valuations of other insurable motorized property such as boats, motor homes, motorcycles, aircraft, trucks and equipment. Their reports look bullet proof, scientific, intimidating and are full of jargon. They boldly claim to adhere to insurance laws when in fact they are full of legal violations as well as errors. They are truly controlled by the insurers who pay for their reports. For guidance in how to successfully unravel and discredit their reports, see the product section of Uclaim.com.

Certificate Holder – (See also Forced Placed Insurance) A term used by “forced placed insurers” to designate the homeowner or vehicle owner. The mortgagee and insurer use this term to try to make you believe you have almost none of the rights of “the insured” who they allege is the mortgagee. It’s a huge loophole in the law and a deceptive practice. The fact is that if you are paying the premiums, you should be treated as an insured. This means you should get to see the policy that covers your house. In 2006, Balboa/Newport Insurance was telling certificate holders they had to drive to Texas, USA if they wanted to see the policy at Countrywide Home Loans office. All they would give to the certificate holder by mail was a one paragraph summary of their policy. Outrageous.

Claim Analyst – A term used mostly by medical claim adjusters who process medical and dental claims with health insurers. The term is also used by some auto and homeowners insurers for office adjusters who work at a desk all day and oversee claims that are assigned out to independent adjusters for the field work.

Claimant – (see also Claimant, First and Third Party) This term by itself is most commonly used by auto, homeowners liability, and workers compensation adjusters in referring to “Third Party Claimants”, that is, the other party who their own insured was involved in an accident with or any other party who is making a negligence claim against their insured for bodily injury or property damage. When claimants are referred to as “First or Third Party Claimant” it is usually in a legal document of some sort.

Claimant, First Party – In insurance contracts, a person, the “insured”, who makes a claim against his own insurance company, the “second party”. In non insurance contracts, one of the two parties to a contract.

Claimant, Third Party – In insurance claims, a person who makes a claim against someone else’s insurance company. In non insurance contracts someone who makes a claim for negligence against one of two parties who have a contract.

Claims Made Coverage – (See also Retroactive Date) A term used in liability insurance for insurance that will cover the insured for claims made during the current policy year, even if the damage a results from a negligent act that occurred in years prior to the current policy year and even if the insured was with a different insurer when the negligence occurred. Most claims made policies will cover prior years acts only if there was insurance in those prior years and as long as it was continuous with no lapses in coverage, not even by one day.

This is an important feature to make sure your liability coverage includes if you are in a business where your clients or customers are people who could sue you years after you have completed your product or service.

Claims Occurrence Coverage – (Compare to Claims Made Coverage) – The insurer has responsibility for claims that occurred during its own policy coverage period, even if the claim was filed after the policy lapsed and the policy holder has a new insurance company or no insurance company. However keep in mind that claims must still be turned in as soon as reasonably possible or becomes known, or the insurer can deny the claim.

Collision Coverage – (Compare to Comprehensive Coverage) A term used in automobile insurance that covers you by your own insurer for physical damage to your own vehicle by an impact as opposed to “comprehensive” damage such as theft, flood, vandalism or fire.

Commercial Property Policy – (also referred to as “CP”) An a-la carte policy in a loose leaf binder format with various coverage parts such as for property damage, liability, loss of income and extra expenses. It can have endorsements attached for additional coverages unique to your business. The declarations page will specify the dollar amounts of the parts. The CP is in contrast to the BOP older form. The CP policy is better suited to large businesses and unique businesses of any size.

Company Adjuster – The same as a “Staff Adjuster”. An adjuster who is a salaried employee of one insurer or “insurance group” (such as Farmers Insurance Group) and handles claims for that company only. While they cannot be paid commissions on how much they cut a claim, it is an unspoken condition for promotions and keeping your job.

Comparative Negligence – (as opposed to Contributory Negligence and No-Fault Insurance) This refers to a legal and insurance method used by most states, including California, to apportion liability by the various parties, such as in an auto accident, by percentage of negligence. Each party or their insurer pays the other party’s damages based on the percentage of negligence by their own insured. If you were 30% at fault in an accident and the other drivers vehicle had $1,000.00 worth of damage, then you or your insurer would owe the other driver $300.00.

Note, while most claims are settled without any litigation or lawsuits ever being filed, the motivation for insurers to settle liability claims is to save the extra expense that litigation would cost and the predictability of the outcome of most accident related litigation. Technically and legally, a negligent party and/or their insurer do not have to pay one penny until and unless a judgment is entered by a judge or jury.

 

Compensatory Damages – (See also Damages for other kinds of damages) These damages include all the elements of the other forms of damages (special and general) except punitive and exemplary damages.

Comprehensive Coverage – (Compare to Collision Coverage) A term used in automobile insurance that covers you by your own insurer for non collision claims such as theft, fire, vandalism and flood. Collision with an animal is considered as comprehensive coverage in most auto policies.

Coinsurance Clause – You are most likely to encounter this term in a homeowners or business owners property claim and get burned by it before you ever knew what hit you. Property policies (aka Fire policies) contain a clause which says that if you were under insured on the structure portion of your policy by more than 20% (or not insured to 80% of value), you will pay a penalty, the “Coinsurance Penalty” , based on a formula in that clause. Some people, at least in theory, know that most claims will not be major and that they can get lower premiums by choosing a smaller policy limit. However in practice, it is the average unwitting person, who had no intention of being underinsured using this strategy, that gets his claim slashed by surprise.

Concealment – intentional withholding of information relevant to an insurance claim or application for insurance. It is grounds for denying the entire claim, even if the concealment only applied to a small portion of the claim. Claims denied for concealment are not always justified and are usually put together by insurer’s attorneys who use bully methods and letters to intimidate and scare you away. For insurance claim advice on how to fight a claim denied for concealment, see the section on denied claims in the products section of Uclaim.com.

Concurrent Cause – (See also Cause of Loss) The common sense definition of concurrent means “at the same time as” and not necessarily related to each other as in the example given in “Cause of Loss” above. However a legal definition can be different. Based on a reading of the Blacks Law Dictionary definition (6th edition) “causes acting together causing injury, which would not have resulted in the absence of either”, for example, in a fire which melts water pipes, which flood a building and damages a structure, the fire and water would be concurrent causes.

Concurrent cause issues in insurance claims usually involve damage by one peril that is covered and another peril that is excluded, fire and earthquake for example. Courts have generally held that there will be coverage if any of the causes are covered, unless there is a specific exception or provision to the exclusion. For example, if a policy says “we will not cover landslide, earth movement … , however if a fire breaks out during the mudslide, the fire damage will be covered”. For in depth discussion of the recent “concurrent cause not covered” exclusion and how to argue against it, see the eBooks on denied home and business claims in the products section of Uclaim.com.

Conditions – (See also DICE) One of the original four basic parts of an insurance policy contract. Conditions have two main parts: “Your Duties After Loss” and “Settlement Provisions”.

Consequential Loss – (as opposed to direct loss) water damage from melted pipes or fire hose water during a fire and its suppression. It may or may not be excluded in a policy. Often the subject of case law and lawsuits. See also “Concurrent Cause.”

Constructive Total Loss – (See also Total Loss) When the repair cost exceeds the value of the item or the cost to replace the entire item, whether new (RCV policy) or used (ACV policy). A constructive total loss may only have minor physical or cosmetic damage and have an appearance of being repairable. A motorcycle with cosmetic scratches may be enough to make it a total loss, even though it may be a fully functioning machine.

Contract of Adhesion – A contract that is written by one party and presented to the other party to “take it or leave it” with no opportunity to make any changes or additions by the non writing party. Insurance policies are contracts of adhesion. You cannot tell your agent take out a line or clause or add a clause.

The advantage to you as a policy holder is that if there is any unclear or ambiguous language in the policy, a court should rule in your favor. This is probably for the best since the average person would not know how to negotiate an insurance policy anyway, much less even read the policy.

Contractor – See General Contractor and Subcontractor

Contributory Negligence – (as opposed to Comparative Negligence and No-Fault Insurance) Refers to a legal and insurance method used by a few states to apportion liability by the various parties, such as in an auto accident, by percentage of negligence. You or your own insurer pays 100% of the other party’s damages only if you were at fault by more than 51%. On the other hand, if you were 49% or less at fault, you or your insurer pays no part of the other party’s damages.

Note, while most claims are settled without any litigation or lawsuits ever being filed, the motivation for insurers to settle liability claims is to save the extra expense that litigation would cost and the predictability of the outcome of most accident related litigation. Technically and legally, a negligent party and/or their insurer do not have to pay one penny until and unless a judgment is entered by a judge or jury.

Contributory Negligence is not our favored method since it makes the claims process more like a game of chance, like “winner take all or nothing.” On the surface, it may appear like it would not matter which insurer paid, as long as both parties had insurance. The total dollars paid out by insurers at the end of the year for the material damage portion of claims might be the same as in comparative negligence states. However the total dollars paid out for bodily injury claims would be substantially less in a Contributory Negligence state since individual policy holders would be limited to the low limits of “Medical Pay” coverage under their own auto policy. And there would be no coverage for general damages such as pain and suffering, emotional distress, loss of companionship or sex, lost wages from time off work, etc. under their own policy. The other drawback would be for uninsured drivers who could recover nothing for their damages unless they were less than 50% at fault. Nobody likes uninsured drivers because most of them are perceived as illegal immigrants (and maybe they are mostly illegal immigrants) but the fact is that plenty of people are “self insured” if not on all but at least some of their vehicles (and how can an insurer justify a lousy 10% discount on premiums for two, three or more vehicles owned and driven by only one person?). Anyway, if it happens that you are 60% at fault in an accident driving that vehicle you only take out of the garage a few times a year, you would not only owe 100% (not 60%) of the other drivers damages, you would not get the 40% of the damages to your vehicle caused by the other driver.

Contributory negligence states definitely favor big business, insurance companies and their campaign contributions, over the best interests of the common man. It is furthermore unlikely that premiums are significantly less in those states.

“Coverage A” – The section of a personal lines fire policy, such as a homeowners or rental house policy, which covers the main building structure. The total dollar amount of coverage is shown on the Declarations page.

“Coverage B” – The section of a personal lines fire policy, such as a homeowners or rental house policy, which covers the smaller detached or “appurtenant” or “other” structures. It is usually 10% of Coverage A. The total dollar amount of coverage is shown on the Declarations page.

“Coverage C” – The section of a personal lines fire policy, such as a homeowners or rental house policy, which covers the contents and furniture. It is usually 70% of the Coverage A amount. Some older policies only cover 50% of Coverage A. The total dollar amount of coverage is shown on the Declarations page.

“Coverage D” – The section of a personal lines fire policy, such as a homeowners or rental house policy, which covers Additional Living Expense or Rental Value. It is usually 20% or 30% of Coverage A. The total dollar amount of coverage is shown on the Declarations page.

“Coverage E” – The section of a personal lines fire policy, such as a homeowners policy, which covers personal liability for bodily injury and property damage. It is usually $100,000 to $300,000. The total dollar amount of coverage is shown on the Declarations page.

“Coverage F” – The section of a personal lines fire policy, such as a homeowners policy, which covers medical payments. It is usually $1,000 per person. The total dollar amount of coverage is shown on the Declarations page.

“CP” – Abbreviation, see Commercial Property Policy.

Damages – (See Punitive, Exemplary, General, Special, Actual and Compensatory Damages) The dollar sum total of damages. In property claims with your own insurer, “damages” is usually the cost of repair or replacement or the value of lost property. If your house burns down, the policy gives no compensation for injury, pain and suffering, emotional distress or sentimental value.

Defense Attorney – In property insurance claims, usually the attorney who represents and defends the insurer against the policyholder. In liability insurance claims, the attorney who is hired by the insurer to defend a policyholder who is sued by some other “third” party. They are usually paid on an hourly basis and give discounts to insurers (However they make up for discounts when they “build the bill”). Most insurer’s property claims attorneys will misrepresent and lie to whatever degree necessary to get a policyholder to drop a claim against an insurer.

“DICE” – (See also Declarations, Insuring Agreement, Conditions and Exclusions and Endorsements) Insurance jargon for the original four basic parts of an insurance policy: Declarations, Insuring Agreement, Conditions and Exclusions. If it is a “package policy” (usually in one preprinted and single bound booklet) for example a homeowner’s policy that contains property and liability sections, each section will have its own set of DICE with a common part at the end and a common Declarations page at the beginning. A commercial custom policy (usually in a “loose leaf like” binder) may have “sub-declarations” pages for each property location. As policies became more complex over the last 75 years, various parts were added (see Insuring Agreement). Endorsements are not included in the DICE sections.

DOL – Abbreviation and adjuster jargon for “Date of Loss.”

Declarations – Also referred to as “Declarations Page” and/or “Cover Sheet”. Usually the single sheet of paper attached to your policy booklet that has your name, address, basic policy description and dollar limits for Coverages A, B, C, D, etc., endorsement titles and numbers. While the policy booklet and endorsements will usually only be mailed to you when you first buy a policy, a Declarations Page and any new endorsements should be mailed to you with every annual or semiannual bill. Commercial policies may have several “sub-declaration sheets for various property locations and coverage types.

Declaratory Relief – This describes a legal court procedure whereby one party to the insurance contract, usually the insurance company, asks a local court to determine if the insurance should cover a claim or not. It’s a great concept, but unfortunately it has become an abusive tool used by some low quality insurers to intimidate and trick policy holders into giving up their claim. Because an answer must be filed and a defense mounted, which usually costs money to hire a lawyer and court costs, most policy holders fail to file a written answer before the hearing date. They don’t know the “rules of civil procedure” and that a “tentative ruling” is made the day before the hearing and that if no request is made the day before the scheduled hearing for “oral argument” on the day of the hearing, there will be no hearing and they will walk into an empty court room on the day of the hearing. They will have lost by default.

The other abusive part of this procedure is that it forces a full blown lawsuit if an informed policy holder wants to protect their legal rights. If the policy holder does not file a “Cross Complaint” back against the insurer for damages and “Bad Faith” along with their answer to the Declaratory Relief within 30 days of being served, they forever lose the right to do so. For advice on how to deal with this if you are served with Declaratory Relief papers, see the product section of Uclaim.com.

Depreciation – The loss in value of a building or personal property mostly due to physical wear and tear. This is affected by age and severity of use. Other less significant factors can be obsolescence and location for certain types of property. How to reduce depreciation taken by adjusters and how to easily figure your own depreciation (it is actually your right to figure it yourself if you want to) is covered in eBooks available for purchase at Uclaim.com.

Efficient Cause of Loss – (See also Cause of Loss) Often used interchangeably with proximate cause and efficient proximate cause. Simply stated, the most direct or closest cause of loss to the damage. For example, if fluid in a glass test tube is lost because the tube breaks due to freezing because someone bumped the thermostat down accidentally, the efficient cause or efficient proximate cause would be the glass breaking, since the fluid would not have been lost it was in a metal tube. This is a legal concept that will not be mentioned in most policies. There may be a cause, not part of a chain of causes, which intervenes during the chain of events to cause damage on its own (“efficient intervening cause”). The main distinguishing factor is that, according to Blacks Law Dictionary, the person or action at the beginning of the chain of causes is not responsible.”

Endorsement – (See also “Rider” and “Floater”) An endorsement can be any piece of paper, including letters and notices of non dollar related issues such as privacy rights, added to your policy when and after you receive it. Most floaters will have a number and brief word description shown on the Declarations page.

Within weeks after the Coalinga, California earthquake of 1981, most insurers had sent out a notice to policy holders that they would no longer cover “third party negligence”, which included negligence by building contractors and public building inspectors. This became an endorsement every year until it was eventually included in the policy booklet itself.

Endorsements can add or take away or limit coverage features, perils, conditions, exclusions and dollar limits on various categories of items. While most policies don’t have over five or ten endorsements, there are literally hundreds, if not thousands, of endorsements available to customize your policy. For example if your policy has a limit of $5,000 for theft of jewelry, you can get an endorsement to kick up that dollar limit. You can also get an endorsement that covers jewelry if it gets scratched or broken by a non covered peril, dropping it for example, (something a normal homeowners policy would not cover).

Estoppel – A legal principal that says that one party cannot change its mind after it has acted in a certain way or led another party to believe it would act in a certain way. For example, in insurance, if an insurer sends a letter stating they would cover your leaking roof water damage claim, they cannot come back at a later time and say “oh, we made a mistake it was a new adjuster”, or, for whatever reason, they will not cover that same claim. The insurer is “estopped” from denying the claim. The estoppel would be held even more valid as more time and actions had taken place which relied on that original statement or promise to pay.

Exclusions – (See also Dice) Losses or causes of losses not covered by your insurance policy. This section is one of the original four basic parts of an insurance policy contract. Exclusions have two main parts: the first section is a list of excluded causes of loss and the second section is a list of “exceptions to exclusions”.

EUO – See Examination Under Oath

Examination Under Oath – (Compare to Recorded Statement) It is sign of mistrust when your insurer demands an EUO (if you have nothing to hide, then welcome it as a way to get the claim over with). This is a much more formal question and answer session where the insured is asked questions about a claim and him/herself by an attorney (as opposed to the insurance adjuster in a recorded statement) with a court reporter present. It is required by the policy if the insurer insists on it. Some insurance attorneys are overly abusive during the process. For advice on how to deal with EUO and avoid common pitfalls, see the products section of Uclaim.com which has comprehensive eBooks dedicated to the process.

Exemplary Damages – (See also Damages for other kinds of damages) Damages intended to punish a wrong doer and make an example of them to discourage others from doing the same thing. The dollar amount is calculated as with punitive damages (see below). These damages usually coincide with punitive damages and are not “in addition to” punitive damages.

Extra Expense Coverage – Usually listed under “additional coverages” in a BOP policy and shown as “Business Income (And Extra Expense) in a CP policy. It appears to cover extra expenses to keep your business going and or to relocate temporarily during the “period of restoration” usually up to 12 months. Contrary to appearances, this is not a simple or self explanatory coverage. You can very easily get “burned” or knifed in the back by your insurer on this and Business Income coverages. Don’t go through a business loss without one of the appropriate business owners loss eBooks in the product section of Uclaim.com.

Fair Market Value – the value of a building or personal property as agreed to by a reasonable and willing buyer and seller. It is most often estimated by appraisers by taking an average of “comparable past sales.” It is not necessary to calculate construction cost or depreciation with this method. Most insurers’ appraisers will low ball the Fair market Value to your disadvantage. For advice on how to deal with this situation, see the product section at Uclaim.com.

Fair Rental Value – (See also ALE) An option to ALE offered in some homeowners policies. Instead of paying ALE, it pays you what your house would rent for and you take care of your own ALE. You do not have to incur expenses. You can pocket the money if you want to live with a relative or in a tent.

First Party – See Claimant, First Party

FC&S Bulletins – Abbreviation for Fire Casualty and Surety Bulletins

Fire Casualty & Surety Bulletins – Several volumes of loose leaf bulletins published by “National Underwriters” for the insurance industry which gives the latest in legal trends and case law in regard to particular claims issues. Many local branch claims offices even have a set of these on hand (although they are usually gathering dust under a counter).

Other than having some familiarity with the unfair claims practices regulations for their particular state, most insurer’s claims adjusters will have never gone beyond looking at the FC&S bulletins, so if you can support your side of a claims issue using this source, you are less likely to have to battle with your insurer and their attorney. If you want to learn how to do some legal research to support your side of a claim issue, see the product section of Uclaim.com.

First Party – The “First Party” to an insurance contract (the policy) is “the policy holder”, or “the insured”. The “Second Party” is always the insurance company. The “Third Party” would be anyone outside of the contract making a liability claim for damages caused by the First Party. For example, a person who you rear ended in an auto accident is called a Third Party when he deals with your insurer. When dealing with his own insurer, that person you rear ended would be called a First part

First Party Claimant – See Claimant, First Party

Floater – a type of endorsement, most commonly on certain kinds of homeowner’s personal property, which has a predetermined dollar value and covers more perils. Its value is usually set before a loss by a professional appraisal which the policyholder pays for. It may cover property being lost or scratched (such as a ring) whereas the normal homeowner policy would only cover theft and not accidental scratching.

Forced Placed Insurance – (See also Certificate Holder) If you have a loan on a house or vehicle and you allow your insurance to expire, the mortgagee or lien holder will procure insurance to the amount of their interest and add the premium payments to your loan payments. The premiums are usually two to three times the cost of what you were paying to your insurer. Yes, it’s a huge rip off and all you get is structure coverage for the loan amount, no contents or other stuff.

General Contractor – In insurance, this usually refers to a general building contractor who may write a repair estimate or do the actual repair work to a damaged building. The General contractor can perform any trade (such as electrical, framing, etc.) during construction. He can also hire subcontractors for the various trades. Your state should have publications on how to select, hire and manage a contractor. There are advantages, but mostly disadvantages to using the insurer’s contractor to do your repairs.

The most important thing for you to understand is that your insurer will have their own favorite contractors who will in effect help your insurer low ball your claim. You can also get advice on how to handle both the insurer’s contractor and your own contractor and how to act as your own contractor to repair your damaged house and not get back-stabbed by your insurer for doing so in the product section of Uclaim.COM.

General Damages – (See also Damages for other kinds of damages) These damages are more difficult to place value on and are subjective. For example, pain and suffering, emotional distress, scarring and disfigurement are general damages. A scar may be worth more monetary compensation on a beauty queen than on a construction worker. For example, a general rule of thumb in injury claims is two to four times the medical bills to compensate for pain and suffering. A lost hand on a piano player would be worth more than for a car salesman.

“Gold Book” – See NADA.

Independent Adjuster – (See also Adjuster). An independent adjuster is not an employee of the insurance company. He is hired on a per claim basis and usually bills the insurer at an hourly rate plus expenses. He may be self employed or he may work for a large independent claims company such as Crawford & Company or GAB. Most independent adjusters now days only do limited field tasks such as photograph and estimate damages. Gone are the days when they settled claims. If he does not cut the claim enough to at least cover his fees, and then some, he will feel guilty (and probably not get future business from the insurer).

Indemnification – This is an old and hallowed legal and insurance principal which says that the purpose of insurance is to “indemnify”, or, put one back to where they were before a loss, no more and no less, without “profiting” from a loss. This hallowed principal became obsolete for property insurance claims in the 1950s when insurers began to write RCV, Replacement Cost Value insurance. Anytime a policy holder gets “new for old”, a new roof for an old roof, a new house for an old house, a new television for an old television, that is a profit.

Yet you will hear adjusters lecturing policy holders, “it’s against the law to profit from your loss”. This phony line is used most commonly by adjusters who don’t want to pay a policy holder “profit and overhead” if they do their own repairs or rebuild a complete house themselves, without a building contractor. For advice on how to deal with this situation, see the product section of Uclaim.com.

Independent Agent – One who sells insurance and who can choose from a variety of insurance companies, unlike a Captive Agent. He differs from an “Insurance Broker” in that he is paid by the insurer, not the policy holder. He is a better choice than a Captive Agent, in this respect, because he cannot be completely put out of business if one company gets upset with him.

 

Insurance Agent – See Agent.

Insurance Broker – One who sells insurance and who can choose from a variety of insurance companies. He differs from an “Insurance Agent” in that he is paid by the policyholder, not the insurer. He has a separate license from an insurance agent and his license type can be verified online with your states insurance department website. Theoretically a broker should be loyal to the policy holder, however occasionally you will read about Brokers taking kickbacks from insurers to steer business their way. You will find one Insurance Broker for every 100 Insurance agents in the phone book. They are rare. Some Insurance agents will tell you they are a broker, when in fact they are not. Do not confuse Brokers with “Independent Agents”, who may select from several insurers to place you with, but are still paid by the insurer, not you.

Insured – (See also Named Insured) “The Insured” normally refers to the policy holder, a person, you and your immediate relatives living with you. It usually includes children under 24 years old while away at school. (Compare also to Risk, Named Insured and Certificate Holder).

Insurance Company – The issuer of your policy. Of more importance to you is the basic administrative structure. They all have a CEO (or equivalent) and they all have three departments: Sales (Marketing), Underwriting (Policy creation and policy application approval and cancellation) and Claims. Most companies have these departments in separate geographic locations for the purpose of impeding communication between the departments. The departments are indoctrinated with different philosophies. Agents in the Sales department are taught to “promise the world” and are customer service oriented, which helps get sales. Adjusters in the Claims department are taught to save the company’s money and “adjust” (usually downward) the enemy’s claim (you are the enemy). Most Insurers are Stock Companies (Corporations owned by stock share holders). Some are Mutuals (owned by the policy holders). And some are Reciprocal Inter Insurance Exchanges (like Farmers Insurance Group and AAA).

Insurer – See Insurance Company

Insurance Group – A group of insurance companies, usually as a Reciprocal Inter Insurance Exchange, usually created and owned by one company. Farmers Insurance Group is a good example. In practicality, the companies are nothing more than departments. For example, “Fire Exchange” handles homeowner claims and “Truck Exchange” handles commercial claims for Farmers Insurance. The main benefit to the insurer is to attempt to limit punitive damage awards to a company with a smaller value rather than to the entire group. Insurance Groups should not be confused with “Merged Insurers”.

Insuring Agreement – (See also Dice) One of the four basic original parts of an insurance policy contract. The Insuring Agreement is usually a short paragraph. However it is usually accompanied by several other parts which are, right or wrong, part of the Insuring Agreement: Definitions, Property Coverages, Loss of Use, Additional Coverages and Perils Insured Against. And in business policies, add: Limitations, Extensions of Coverage, Business Income and Extra Expense Coverages.

Kelley Blue Book – (See also NADA and Red Book) AKA “Blue Book”. Tends be higher than NADA Book for cars and pickups. Auto insurers in some states prefer NADA Book for this reason. However it tends to be lower than NADA Book on watercraft. Kelley book is based out of and is also more popular in California. Valuations are free, but limited, online. Complete valuations are possible using the paper back guide books, which are usually available at local public libraries and law libraries.

Last Clear Chance – Common concept in States or jurisdictions governed by Contributory Negligence laws where the person with the last chance to avoid an accident, having failed to take that chance, may have to conceivably pay half the damages even though the last clear chance may have been a very small percentage of the overall fault.

Law – (See also Statutory, Case and Persuasive Law for more details) Most US States courts (except Louisiana) and Federal courts make decisions based on a combination of all three types of laws. Statutes enacted by legislatures are the most powerful laws and take precedence over Case Law and Persuasive Law. Statutes are easier for the common man to understand and read. Louisiana state and various countries worldwide use the statutory law system which was originated by the Roman Empire (Louisiana was founded by the French and France was once a Roman territory). The case law system was originated in Medieval England and passed on to the US and many countries that were part of the British Empire.

One US state’s case law is not binding on another US state’s court, however the second state may consider another state’s case law in making its own decision. If the second state court’s decision is at the lower level, trial court , it is only binding for that case and does not become binding law for that second state. If the second state court’s decision is at the appellate level, it becomes binding law for that second state.

 

Most litigation involving insurance claims will be in state courts since insurance companies in the US are regulated by the individual 50 states. A case may go to a federal court if the parties are in different states or if there are multiple plaintiffs or defendants in more than one state.

Special commentary – Our US insurance laws should be uniform for all states and they should be statutory. The case law system is subject to abuse by the powerful (insurers and their attorneys) who, in our experience, misrepresent case law 99% of the time. The US legal system is “adversarial” as opposed to the English “advocate” legal system. In the US system, attorneys can legally misrepresent cases and make knowingly false allegations because they have a right to free speech under the US Constitution. Attorneys are only bound to tell the truth in a Declaration (which is under penalty of perjury) or if they are on a witness stand. Attorneys and plaintiffs should be barred from making allegations they know to be false. This would help simplify lawsuits by plaintiffs (policyholders) attorneys and reduce abuse of civil procedure by powerful defendants (insurers) attorneys. Confidentiality agreements should also be outlawed. If the media could publish the outcomes of litigation, the adverse publicity would help the consumer to make more informed choices in whom not to buy insurance from. This would in turn help to clean up the insurance claims industry (and reduce litigation!).

Liability – Responsibility for an act.

Legal Liability – (See also “Non Legal Liability”) Acts which are defined by laws or a court judgment for which one is liable for. Negligence resulting in bodily injury and property damage is an example of liability for which insurance provides coverage.

Liability Coverage – Insurance coverage for bodily injury and property damage caused by an insured unintentionally. Dollar limits are usually per person and per occurrence. The dollar amounts are shown on the Declarations page.

Limits – See Policy Limits.

Loss Payee – The person to whom claim proceeds are payable, or whose name should be included on a check if there are multiple payees. The insured is usually a payee, unless there was some fraud or reason to exclude him/her from payment. A mortgagee, the lender on your house or auto loan, is a loss payee. A claim assignee can also be a loss payee.

Loss of Consortium – Loss of ability to have a sexual relationship as a result of an accident or loss.

Loss of Income – One of the major parts of business insurance. It is usually the net profit for a specified period of time after a loss. It can be “actual loss” or have a dollar and time limit. There are significant pitfalls with this coverage. Insurance claim advice on how to avoid the pitfalls and maximize this coverage is in the products section of Uclaim.com.

Malicious Prosecution – If an insurer uses litigation and the judicial system with the intent to batter an insured with paper and legal expense into giving up their claim rather than for a legitimate dispute and if the insurer knew all along that their position was unreasonable and the insurer lost its case, then the insurer can be legally liable for malicious prosecution and subject to fines and other punishment. Improper use of Declaratory Relief litigation by insurers is a prime example. An insurer must first lose their case before an action for malicious prosecution can be brought.

Material – (as in relevant) If a claim is denied based on a policy provision or insurance application information, it must be “material”, or relevant to the cause of the loss. For example, a water damage claim cannot be denied if you failed to disclose that you were a smoker on your application.

Market Value – see Fair market Value.

Med Pay – Abbreviation for Medical Payments Coverage

Medical Payments Coverage – This term is most often seen in automobile and homeowners policies. It will pay small dollar medical bills (typically 5, 10, 15 or 20K) for policy holders and their passengers regardless of fault in auto accidents. $1,000 is a typical limit per person in homeowners insurance.

Merged Insurers – Companies that buy each other out but continue to use the same names. For example, as of this writing, Nationwide owns Allied; Zurich owns Maryland Casualty.

Modified No-Fault Insurance – See No-Fault Insurance

Mortgagee – The lender, bank or mortgage company on the insured’s house or commercial building. The mortgagee should be shown on the Declarations page. They will usually be named on a claim check along with the insured’s name. Do not allow a mortgagee to apply repair proceeds to the principal balance if you intend to repair or rebuild your house. For advice on how to deal with your mortgagee, see the products section of Uclaim.com.

NADA Book – (See also Kelley and Red Book) AKA “The Gold Book”. National Auto Dealers Association guide book to new and used car values. Tends be lower than Kelley Blue Book for cars and pickups. Auto insurers in some states prefer it to Kelley Book for this reason. However it tends to be higher than Kelley Blue Book on watercraft. NADA book is also more popular outside of California. Free, but limited, valuations online. Usually available at local public and law libraries.

Named Insured – (See also Insured) The insured persons whose names appear on the Declarations page and your premium billing.

Named Perils Policy – See All Risk Policy

Negligence – (See also Contributory Negligence, Comparative Negligence and No-Fault) Damages caused unintentionally and accidentally. Damages that could have been avoided had the person casing the damage been more attentive and caring. Blacks Law Dictionary says the legal elements of negligence are duty, foreseeability, causation and damages. Negligence can lead to legal liability, which is what liability insurance is for. In insurance, intentional acts to harm or damage someone or their property are “excluded” or not covered.

No-Fault Insurance – (As opposed to Contributory and Comparative Negligence insurance states) Auto insurance in a few states in which each driver and his insurance pay for their own damages, even if the other driver is at fault. It is based on the individual state’s law which disallows lawsuits to one degree or another for damages caused in auto accidents. In a theoretical “Pure No-Fault” state, no lawsuits would be allowed for any amount of damage. However in reality, the No-Fault states are what is called “Modified No-Fault” states. They have “Thresholds” of two kinds: dollar amount of damage and type of damage. For example, a state may say no lawsuits for property damage under $5,000.00 and bodily damage under $10,000.00. There may be a further condition saying no lawsuits for pain and suffering for soft tissue injury, but only loss of a limb.

Note, while most claims are settled without any litigation or lawsuits ever being filed, the motivation for insurers to settle liability claims is to save the extra expense that litigation would cost and the predictability of the outcome of most accident related litigation. Technically and legally, a negligent party and/or their insurer do not have to pay one penny until and unless a judgment is entered by a judge or jury.

Non Legal Liability – Damages caused by one, but not for which one would be “legally” liable (for example, if an insured’s 5 year old child knocked over a lamp at someone else’s house and broke it). Most homeowners insurance provides limited coverage for this, up to $1,000.00 for example.

Notice of Cancellation – See Cancellation Notice

Notice of Non Renewal – See Non Renewal Notice

Notice of Loss – Most policies require that the insured give notice of a loss to their agent as soon as reasonably possible. If this is not done, you have breached the contract and an insurer does not have to cover your claim.

Notice of Lawsuit – Most policies require that the insured notify the insurer as soon as reasonably possible if the insured is served with a notice of a lawsuit. If this is not done, you have breached the contract and an insurer does not have to defend you or cover your claim.

Non-Admitted Insurer – (Compare to Off Shore Insurer) An insurer not licensed to do business in your state.

Non Renewa l (of the policy) – See Cancellation above for discussion and comparisons.

Non Renewal Notice – See Cancellation Notice above for discussion.

Obvious Total Loss – Where an item is so badly damaged that it is not necessary to obtain a repair estimate to prove that the item is not worth repairing. See also Total Loss.

Occurrence – In fire and casualty insurance, an occurrence is usually an accidental loss that occurs at a specified time. In liability insurance, it can include repeated exposure over a period of time resulting in bodily injury or property damage.

Off Shore Insurer – (Compare to Non Admitted Insurer) An insurer who may do business in your state, but is not backed up or reinsured by your state.

Package Policy – A policy in a bound booklet that includes various categories of insurance common to major groups and types of people or businesses. The idea started in the 1950’s when the first homeowners package policy was sold which included fire insurance and liability insurance all in one booklet. Common package policies are the automobile, boatowners, homeowners, landlord and businessowners package policy.

Payee – see “Loss Payee”.

PD – See Property Damage coverage.

Persuasive Law – (See also Law) Not binding law, but used in written arguments to courts in support of a party’s position. Various sources consist of respected, learned, legal opinions, treatises and case law from other US states or jurisdictions. The most useful source of persuasive law is case law from other US states or jurisdictions.

The second most useful source of persuasive law in property insurance are two fairly comparable treatises called “Couch on Insurance” and “Applemans on Insurance”, one of which is usually available at your local county law library. Each is like a 50+ volume set of encyclopedias of recurring property insurance claim issues in the US over the last 100+ years. They are a good starting place and will often lead you to cases and statutes pertaining to your particular claim issue.

Plaintiff’s Attorney – In insurance claims, usually the attorney who is hired by a policy holder or “third party claimant” to go against an insurance company or one of its policy holders. They usually work on a “contingency fee”, a percentage of the settlement paid by the insurer. Their fees run from 25% to 50% (if tried in court) and the client pays additional “costs” which are usually advanced in the beginning by the plaintiff’s attorney. Advice on how to find an attorney for litigation is included in eBooks for sale in the Uclaim.com product section.

Policy – (See also Basic, Broad and Special Form, Named Perils Policy, All Risk Policy, Contract of Adhesion) – A written contract of insurance.

Policyholder – See Insured.

Policy Limits – The maximum dollar amounts that a policy will pay for various kinds of losses. The major policy limits per category are listed on the Declarations page. The smaller sub limits, for example $500.00 on jewelry theft, are listed within the policy booklet itself. Most policy limits are payable “up to” the shown amount, not an automatic full payment for a total loss.

Power of Attorney – A legal principal and writing whereby one person speaks for another in regard to certain matters as outlined on a piece of paper and signed by the one to be spoken for. The paper must contain the title and words “Power of Attorney”. In an insurance claim, one might give another the right to speak for them only in regard to that claim. An insurer must deal with the designated “attorney”, however a power of attorney does not necessarily relieve the named insured of all his duties under the policy. For example, an insurer may require an EUO from the named insured himself and not a representative. A power of attorney is most often used by people too old or ill to handle their own financial matters. The “attorney” does not have to be a licensed attorney.
The “attorney” can be anyone, a relative or a friend.

Premium – The cost or dollar amount paid for an insurance policy.

Proof of Loss – A list of requirements to be performed by the insured (in the conditions section of the policy under “Your Duties After Loss”) and referred to in small letters as “proof of loss” and due within a certain time period. This would imply that the substance and not the format of the poof is what is important. However, insurers usually require policyholders to submit a preprinted form which they supply called a “Proof of Loss” form. For advice on how to avoid the pitfalls associated with this form, see the products section of Uclaim.com.

P&O – Abbreviation for Profit & Overhead

Profit & Overhead – In property insurance, these terms most commonly refer to the profit and overhead charged by a building contractor. It is usually 10% and 10%, or 20%. It is usually listed at the end of the estimate. Many insurers will try to withhold this if you choose to do your own repairs, or if you choose to take a cash settlement in lieu of repairs or replacement. For insurance claim advice and a detailed discussion of this topic, see the products section of Uclaim.com.

Profit & Loss Statement – In property insurance claims, a profit and loss statement can be used in a business claim for loss of earnings. Insurers will try to get you to submit tax returns in calculating your business earnings and loss. Don’t do it. For advice on how to avoid the pitfalls in presenting your loss of business income and loss claim, see the products section of Uclaim.com.

Property Damage and “Property Damage Coverage” – Terms used in liability insurance to describe insurance coverage for and damage to property of others caused by the policyholder, or an insured, as opposed to damage to your own property covered by your own insurance (unless it is a UMPD claim submitted to your own insurer).

Proximate Cause of Loss – (See Cause of Loss) Also used interchangeably with efficient cause and efficient proximate cause. The common sense and standard dictionary definition is the cause closet to the damaged item. Proximate means “close to”, right? However there are many confusing and even conflicting legal definitions of Proximate Cause. A common definition in insurance textbooks and legal publications says that the proximate cause can be at the beginning or in the middle in a chain of events leading to damage. The term is also used interchangeably with “efficient cause” and “direct cause” in some texts. Blacks Law Dictionary (6th edition) defines proximate cause as “that which stands next in causation to the effect, not necessarily in time and space, but in casual relation.” For example, in a flame that melts a candle, you could say that fire was the proximate cause and heat was the efficient proximate cause.

Public Adjuster – (See also Adjuster). A public adjuster is paid by the policy holder. His job is to maximize, get the insurer to pay the most money on a claim, the opposite of the other adjusters. Public adjusters only handle property claims. They are excluded from injury claims by plaintiff attorney lobbies that fear a loss of business.

Public adjusters were in less than half of the states in the US in the year 2000. They have been kept out of some states by insurance lobbies and plaintiffs attorneys who fear infringement on possible business. The irony is that most plaintiff attorneys don’t take property claims on contingency unless the claim exceeds 100,000.00 dollars and they would charge a 30% fee as opposed to a 10% fee by a public adjuster. The few attorneys who take property claims usually know little or nothing about property insurance and construction anyway. The only time to seek an attorney is if the claim needs to be litigated.

In states where public adjusters are prevalent, their profession requires a separate license from an “independent adjuster” . Beware of independent adjusters who advertise that they are also public adjusters. If you see their name in the yellow pages under “adjusters” and “adjusters public” headings, beware. Some states will allow independent adjusters to “represent the insured” and be paid by the insured. These states have little experience with public adjusters. In 2004 for example, there was such advertising in the Dayton, Ohio phone book by GAB and other independent adjusters. Use your common sense. Insurers hate public adjusters. If an independent adjuster really did what public adjusters do, fight with insurers, they would lose their insurance clients overnight.

Warning about public adjusters – choose them carefully. Unfortunately there are plenty of bad apples and fly by nights thanks to loop holes in licensing laws. If you have a choice of public adjusters, check their resume and work history. If a “PA” says he worked for insurers for fifteen years, make sure it was as an adjuster and not for a carpet cleaning company doing insurance water damage cleanup. If you want to be really safe, hire them on a percentage of the amount over and above what the insurer already offered. If a state limits a public adjusters fee to 10%, then add a clause to the contract that the public adjusters fee apply to the entire amount of the claim, but will only be paid from money received over and above what the insurer already offered. For more information on public adjusters, see the free section of Uclaim.com.

Punitive Damages – (See also Damages for other kinds of damages) – A dollar amount awarded in court or agreed upon in an out of court settlement intended to punish the party who caused damage to another party. The award is usually given to the damaged party (Although in California in 2006 and several years prior, 75% of punitive awards went to the state). The general rule of thumb is 1% of a party’s annual income. So if you make $50,000.00 per year, a $500.00 speeding ticket would probably make you think twice about doing it again. These damages usually coincide with exemplary damages and are not “in addition to” exemplary damages. About six US states do not allow punitive damages.

Special commentary – Oddly enough, the soviet socialist state of California enacted legislation from 2003 to 2006 to allow the state to seize 75% of punitive damage awards from plaintiffs for the purpose of bolstering “a sagging state budget” (and California already was among the top five income taxing states in the US). Our understanding is that the state collected nearly nothing and the end result was that it forced plaintiffs to accept lower out of court settlements. It also discouraged most plaintiff’s attorneys from taking any bad faith cases at all. Insurers did whatever they pleased. 2005, the year Hurricane Katrina destroyed New Orleans, was also the most profitable year in history for the US insurance industry (as it was also for oil companies).

Pure No-Fault – See No-Fault Insurance

RCV – See Replacement Cost Value

Recorded Statement – (Compare to EUO) A less formal question and answer session where the insured is asked questions about a claim by the insurance adjuster, usually tape recorded, but sometimes written. It is not required in most insurance policies, but insurers do it anyway, calling it a duty to cooperate. A refusal by the insured to give a tape recorded statement can lead to a demand for an EUO, a more formal interview, and which is required by the policy if the insurer insists on it. For advice on how to deal with recorded statements and avoid common pitfalls, see the products section of Uclaim.com.

“Red Book” – (See also Kelley and NADA Book) AKA “The McClean Hunter Market Reports”, a guide book to new and used truck values. Includes big rig truck values.

Release – A legal form in which a claimant or insured agree to give up any possible future or further claim against an insurer in exchange for an agreed dollar settlement. It is not mentioned or required in any policy, but used in most liability insurance claims with third party claimants by insurers and in some first party claims by insurers on policy holders. If you are an insured with a claim against your own insurer, don’t sign a release without considering insurance claim advice in an eBook at the products section of Uclaim.com

Reinsurance – Insurance coverage for insurance companies themselves. Most commonly used in a natural catastrophe such as a hurricane where for example all losses paid over 100 million dollars by your own insurer, Allstate for example would be paid by the Reinsurer, Lloyds of London for example.

Replacement Cost Value – Insurance coverage feature in homeowners and businessowners policies which pays the cost for new property to replace old property. It is included in most policies for building structures, but not contents (unless there is an endorsement for RCV on contents). The major condition is that you don’t get RCV if you cash out without doing the repairs or replacement. To avoid major pitfalls when making an RCV claim, see the product section of Uclaim.com.

Reporting Form – A feature in some business policies where the business must keep the insurance company advised of its constantly changing inventory and income levels throughout the year. The premiums may also be adjusted throughout the year.

Restorator – Insurance jargon for a restoration company.

Restoration Company – A company that works to restore or minimize loss to a building structure and/or contents, furnishings and inventory. Most restoration companies are carpet cleaning companies that started doing insurance work cleaning carpets after toilet overflows. They would replace the carpet pad and use portable blowers to dry things out. Look in the telephone directory under “Fire and Water Damage” to find them. The biggest restorator in the US is Servicemaster. Many restorators also have general contractor licenses and have branched into complete building structure replacement if needed.

The biggest mistake that restorators make is not using dehumidifiers enough. This is primarily because the insurers don’t want to pay the extra cost. The resulting damage, mold, is usually hidden inside walls and under floors. Restorators will usually favor the interests of the insurer over the policy holder. To protect yourself from the many pitfalls with restorators, see the products section of Uclaim.com.

Retroactive Date – In some commercial policies such as professional liability, the retroactive date is the date upon which the first policy (before the current year policy) became effective with no lapses in coverage. This date will be printed on the Declarations page of the policy.

Rider – Another word for endorsement. See Endorsement

Risk – When you see the words “the risk”, this usually refers to an insured person or the policy holder (you). It can also be the thing insured, such as your car or your house. In a broader sense, the risk can be the uncertainty of loss.

Salvage – Whatever remains of property after a loss. Once an insurer pays for a loss, the salvage becomes the property of the insurer. While not legally bound to do so, most insurers will give the insured the first chance to bid or buy back the salvage. For automobile salvage, you must act quickly because many insurers will haul your vehicle to another city, sometimes before the claim is even settled. For advice on how to retain your salvage and to avoid a “salvage certificate” on the title, see the products section of Uclaim.com.

Salvage Value – (See also Salvage) The salvage value is the most dollars that a buyer will pay for a damaged item. Most salvage cars are sold at an auction. The average salvage value for vehicles 20 to 25% of the pre loss value. Insurers will often use this figure in deciding whether to repair or “total out” a damaged vehicle. For advice on retaining salvage, and for the best price, see the products section of Uclaim.com.

Scheduled Coverage – (versus “Blanket Coverage”) Description for an endorsement which has an agreed dollar limit of coverage for individually listed of items. For example, $15,000 for “1989 Ford 300D tractor Id# 334563”, $10,000 for “2002 Kubota Loader Id#56934”, $1,600 for “Dell Inspiron 600M Laptop computer”.

Second Party – (See also First Party) In insurance, the insurance company itself is the “Second Party” to the insurance contract, the policy. However, you are more likely to see this term in non insurance related matters since insurers usually refer to themselves as “the insurance company” and not the “second party”.

Settlement – An overly broad legal term that is best to avoid. It is better to negotiate and communicate in terms of the ingredients of a settlement, for example, contents, structure, additional living expense, towing, repair cost, medicals, lost income, extra expense etc. While most policies have sections entitled “Settlement Provisions”, you won’t find a definition for the word “Settlement” in most policies.

Short Rate Refund – This is the refund of premium that is due to you if your policy was terminated before the end of the policy term and it was cancelled at the request of the insured, not the insurer. You will get less of refund if it was you who requested the termination or who switched insurers. Don’t cancel or allow your insurance to lapse unless you have a replacement policy in force. It’s harder to get coverage when you don’t already have a policy in force.

Special Damages – (See also Damages for other kinds of damages) This term is used mostly in third party liability claims and will often accompany general damages such as pain and suffering or a reduction in ones quality of life. Special Damages are the most basic and easiest to calculate of damages, without which there can be no other ensuing types of damages. Also referred to as Actual Damages. Damages that have a dollar cost attached such as property value or cost to repair or replace personal, business or real property, medical bills, towing costs, lost wages, additional living expense, extra business expense.

“Special Form” – One of the three property policy types: Basic Form, Broad Form and Special Form. Special Form began to be offered after Broad Form, probably in the 1950s along with package policies (eg. homeowner’s property and liability). It is the most common form today. Special Form covers all perils on structure with named exclusions, and 16 named perils with named exclusions on contents. It includes RCV (Replacement Cost Value) on structure and ACV (depreciated value) on contents. Of course endorsements can be added for even better coverage. The number “3” in the policy form number often designates Broad Form, eg. DP3, DF3, HO3.

Staff Adjuster – See Company Adjuster. Also sometimes called “In House Adjuster”.

Statutory Law – (See also Law) Laws enacted by legislatures (groups of elected representatives). They are the most powerful of laws and the easiest for the common man to understand. They include codes, regulations and ordinances. The most common statutory laws you will refer to will be unfair claims practices laws and regulations. They will specify for example, how many days an insurer has to respond to your communications. They can run anywhere from a couple of pages up to 50 pages depending on the US state or your own jurisdiction.

Subcontractor – A contractor who is only licensed to perform one trade, such as framing or drywall. They will not be contacted by an insurer for an estimate unless it is for one trade only, such as water extraction and carpet cleaning or a plumbing repair. Beware, because even subcontractors can be cozy with insurers. Insurer’s favorite plumbers or roofers can be used by insurers to deny your claim with unfavorable cause of loss reports.

Subrogation – A legal and insurance principal, also based on a policy provision, that gives the insurer the right to seek recovery of the dollar amount paid to you from the party responsible for your damages. If you paid a deductible and your insurer collects back from a party who caused damage to you, you should get back all or a percentage of your deductible. It could take months or years.

Supplement – As used in claims involving body shops and building contractors, this is a supplemental billing where the contractor or body shop discovers additional damage after the repairs have begun. Some insurance company “preferred” contractors and body shops have a habit of low balling estimates so they can get the job, knowing that they will turn in a supplement after they get the job. If you want insurance claim advice on how to get a contractor or body shop of your choice without getting screwed, see the product section of Uclaim.com.

Tape Recorded Statement – See Recorded Statement.

Third Party – (See First Party)

Third Party Claimant – (See “Claimant, Third Party”)

Total Loss – (See also Obvious Total Loss and Constructive Total Loss) A complete loss to an entire item, even though there may be some salvage value to the damaged item. The rule of thumb is that if the repair cost meets or exceeds market value of the item minus salvage value, then the item is a total loss. All three numbers can be argued one way or another. Whether you want your vehicle or building repaired or totaled out and how to maximize your settlement, for advice, see the product section of Uclaim.com.

Towing Coverage – Towing cost to get your vehicle from the accident scene to a body shop is usually included with collision coverage. It is also included to return a recovered stolen vehicle in comprehensive coverage. However an endorsement must be purchased for towing if it involves towing due to a mechanical breakdown. Pay close attention to the distance the towing covers. Fifty miles is not much.

Threshold – See no-Fault Insurance

UM Coverage – See Uninsured Motorist Coverage.

UMPD – see “Uninsured/Underinsured Motorist Property Damage”.

Underwriting – Insurance jargon for the Underwriting Department. This is a separate department from sales. Salesmen submit insurance applications to underwriting. (See also Insurance Company for further discussion).

Uninsured Motorist Coverage – Your own insurer pays for both bodily injury and collision damage to your vehicle if the other vehicle driver was at fault and had no insurance. Although it is required in many states, it is recommend even if not required, especially if there are many uninsured motorists in your state. In California there were 4 million uninsured motorists in 1996, even though the law required liability insurance. Note – you must have proof that the other driver was uninsured, so don’t let that other driver get away after an accident without at least getting the license plate number.

Uninsured/Underinsured Motorist Property Damage – Pays for collision damage to your vehicle by your own insurer if the other vehicle driver was at fault and had no insurance. This is a great coverage to add for your older vehicle that is not worth having collision and comprehensive coverage on, but require liability coverage by law. The premiums are very cheap considering the odds of the other party being at fault, and in California there were 4 million uninsured motorists in 1996, even though the law required liability insurance. In most states, you can purchase this coverage for your vehicle without being required to purchase collision and comprehensive insurance (although you must have a minimum of liability coverage). Dollar limits are usually limited to $3,000 to $5,000. Note – you must have proof that the other driver was uninsured, so don’t let that other driver get away after an accident without at least getting the license plate number.

Valued Policy – Essentially a policy that pays the policy limit in the event of a total loss without having to worry that an insurer will pay you a lower amount because they think your building is worth less than what you had it insured for. Probably 99% of the policies on building structures are not Valued policies and it is usually a great disappointment to policy holders who think they are entitled to get the policy limit because they paid premiums based on that limit.

Valued policies are most common on special personal property like jewelry, artwork, antique cars. Insurance sales agents know this and promote this kind of coverage. However you can also get it on building structures in some states. In California it is optional and you must ask for it. It is rarely advertised or promoted by insurance sales agents. If your agent denies that it is offered in your state or by his company, check with other agents or an insurance “broker” (see “Broker” definition above).

You must usually supply an independent professional appraisal of the property at the time you apply for the insurance. A few states, Oregon for example, require insurers to sell only valued policies on building structures. This simplifies the claim process.

To view sample valued policy law for California, see the eBook entitled “Claims Practices Laws With UCLAIM Commentary” in the miscellaneous product section at Uclaim.COM.

17 Responses to “Insurance Claim Terms – Jargon and Definitions”

  1. April 5th, 2010 at 9:33 am #Ali

    I will look into the book, but I am not going to get a public adjuster or attorney as I have been the one dealing with insurance company the last three times and I have gotten us a fair settlement from the original low-ball offer. I just wanted some guidance on how to proceed at this step.

  2. May 7th, 2010 at 7:22 am #John Merchant

    I have my own acronym: DICEEMP

    Declarations, Insuring Agreement, Conditions, Endorsements, Exclusions, Miscellaneous Provisions. Additionally there are actually different types of Exclusions. I do not at this moment know their “official titles” as likely defined by lawyers; but they fall into the categories of Exclusions and Conditional Exclusions which I call (maybe excluded or maybe covered). I consider things listed under section 1 exclusions as absolutely excluded and section 2 exclusions as maybe excluded or covered. This would be in the case of when proximate cause can overrule concurrent causation language. Example an absolute exclusion such as flooding occurs at the same time wind damage occurs. With concurrent causation language you would have no coverage at all because flood requires an NFIP policy. Whereas if you have a burst water pipe where the pipes run through the walls it is covered. But if an exclusion for water coming up through the home foundation occurs how can that exclusion apply? Well if the water going through the foundation is rising water then it would ave to be covered either by sump pump and sewer backup coverage or flood insurance. But what IF the rising water coming thru the foundation is caused by a burst pipe? What is the difference between a pipe that bursts in the wall or ceiling versus a pvc pipe that runs thru the bottom of the foundation? It is still a burst pipe. So it should be covered. Well then why does Allstate and State Farm deny coverage based on the rising water exclusion? In order to save money!

  3. June 20th, 2011 at 1:08 pm #Mel H

    Great explanation of insurance terms, very helpful and I thank you.

  4. February 18th, 2012 at 6:46 pm #Christopher Davis

    What is meant by adjustments for base service charges on and insurance estimate or quote. How does the insurance company come up with the figures.

  5. February 24th, 2013 at 7:32 pm #Elaine

    Just to clarify, I filed a claim in August, 2011 for a flood that occurred from an overflowing toilet in the condo above me. The claim was paid and the restoration company supposedly remediated properly. Now I have a strong musty odor and air samples confirm I have elevated mold spores and black mold growing in one of the bedrooms. Since your article mentions 3 years as the window to sue my insurer and four years for breach of contract, I want to make sure I am interpreting correctly.

  6. March 25th, 2013 at 8:32 pm #Rick Chevalier

    I was traveling north. An individual pulled out of his driveway and plowed into the side of my truck, causing damage from the front bumper all the way to my back bumper. The appraiser from my insurance company did not do their job properly. Meaning, she only wrote the damages for the door. She stated that my truck is black on her paperwork. My truck is far from black, it is green. She stated that my interior is gray it is far from gray it is tan. The only thing she got right is the VIN and now they are telling me that they can’t reappraise it. Is this true? If I were to lie like this you people would be all over me. I am located in Florida.

  7. April 12th, 2013 at 3:37 pm #John Merchant

    Rick – hire a public adjuster to get the money that you are owed.

  8. July 31st, 2013 at 5:29 pm #Evelyn Pitre

    The ceiling in my sister’s home in Aurora, Illinois recently fell in, she made a claim with her insurance company and they are denying the claim stating that the nails holding it together were improper. She is the original owner of this home and has lived in this home since 1979. Her denial letter states that the insurance does not cover wear, tear, and deterioration and the problem rest with the original contractor providing faulty workmanship.

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