Posted in Insurance Law
Most people buy an insurance policy and file it away until something goes wrong. At that point the wording matters a great deal. A single definition, exclusion or condition can decide whether a claim is paid, and the language is not always as clear as the insurer later claims.
Policy Language Decides More Claims Than Most People Expect
An insurance policy is a contract, and a denial almost always points to a sentence in it. Insurers cite exclusions, limits and conditions, and policyholders are often seeing that wording for the first time while dealing with a loss. The gap between what a customer thought was covered and what the insurer says is covered is where many disputes begin, and San Francisco insurance litigation often starts at that gap. Reading the policy closely, and reading it before a loss, puts a policyholder in a stronger position.
A San Francisco insurance policy lawyer can compare the policy with the denial and point out wording that was overlooked.
Unclear Wording Is Read Against the Drafter
California has a long-standing rule for contracts in general. Under Civil Code section 1654, language that remains uncertain after the other rules of interpretation have been applied is interpreted most strongly against the party who caused the uncertainty.
Insurers write their own policies, so that principle carries weight in coverage disputes. California courts read unclear policy language in a way that protects the insured’s objectively reasonable expectations, and they generally expect an exclusion to be stated in clear and plain terms.
Exclusions and Definitions Deserve a Slow Read
A policyholder trying to understand a denial should look at more than the first page. Several parts of the document tend to matter most:
- The definitions section, where common words may carry a narrow meaning
- Exclusions, which remove coverage for specific events or causes
- Conditions, which set deadlines and duties after a loss
- Limits, sublimits and deductibles that cap what the insurer pays
- Endorsements, which can add or change coverage
People searching for a San Francisco insurance policy lawyer often start with a denial letter and a policy they have never fully read, and a careful comparison of the two is usually the first step.
Denial Letters Quote the Policy and Leave Things Out
A denial letter usually cites a provision and summarizes the facts the insurer chose to rely on. It may skip other provisions that support coverage, and it may describe the medical or factual record in a way that favors the insurer. Insurers also send reservation of rights letters that let them keep investigating a claim while preserving the right to deny it later, which leaves the policyholder in limbo.
Delays and weak explanations can raise other issues, because bad faith claims handling can include unreasonable delay, a failure to investigate and denials without a real explanation.
A denial is not final, and fighting a denied claim often begins with a written appeal that points to the policy language and the supporting records.
Coverage Disputes Take Several Forms
Policy disputes arise in many settings in San Francisco, including property loss, health coverage, life insurance and disability benefits. The facts differ, but the same questions about wording, notice and the insurer’s explanation come up each time.
A disagreement over what a policy covers is the core of San Francisco insurance disputes, and each side usually has its own reading of the same words.
Income protection policies bring their own questions, and San Francisco disability benefits claims often turn on how the policy defines disability when benefits are denied or stopped. Each type of policy has its own vocabulary, and a term that sounds routine in one policy may carry a very specific meaning in another.
Experience on the Policyholder’s Side
The Law Office of Bennett M. Cohen represents policyholders and has done so for more than 30 years. Attorney Bennett M. Cohen studied at Oberlin College and the University of San Francisco School of Law, and he has represented plaintiffs against some of the largest insurers in the country.
A denial letter is rarely the last word, and anyone who wants help reading a policy against the reasons given can speak with the firm about whether the denial holds up under the wording and under California law.
