If so, did the adjuster offer to pay those bills under Medical Payments?

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PostPosted: Mon Jun 30, 2008 12:06 pm   Post subject:   

Thank you Lori


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PostPosted: Mon Jun 30, 2008 8:58 pm   Post subject:   

When I said that a code violation is an indication of negligence, I meant that once the violation has been documented then it's been confirmed that a defect was not just something small and that it's been documented that it exists. But yes, if a defect is against code then this is something to consider as well. Building codes cover the obvious things so if something that is against code causing an injury, then it's easy to show that it should not have been allowed to have exist.



I can't say why the claim was denied (did your GF actually receive a written denial? It's not a denial until it's in writing) it could be that the adjuster made a bad call or that the adjuster was correct and there is some information that I/we don't know about. I can say that once an adjuster has made a determination it can be difficult to get them to reconsider.



Question... did your GF have any medical expenses? If so, did the adjuster offer to pay those bills under Medical Payments? If the policy has this coverage (most do) and the adjuster failed to offer it, I'd say there is a good chance that the adjuster dropped the ball on this claim.

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PostPosted: Tue Jul 01, 2008 12:04 am   Post subject:   

T-I did not go back and read the thread, but I think the OP mentioned that part of the denial was GF's inability to PROVE that it even happened on the property and that she could not prove the date that it happened...



RE: Medpay, (been a long time now since I handled these and could be a 'Missouri' thing)...but I seem to remember medpay excluding 'residents or tenants' no?



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PostPosted: Tue Jul 01, 2008 1:49 am   Post subject:   

I think that's an exclusion under a personal policy but not a commercial GL policy. GL policy still has the same type of exclusion but it's as an "insured". That is, neither policy provides coverage to an insured under the policy.

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PostPosted: Tue Jul 01, 2008 2:01 am   Post subject:   

Got it, and an insured (clearly) isn't defined as a tenant, or resident of the insured premises....right?



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PostPosted: Tue Jul 01, 2008 3:57 am   Post subject:   

I hope not... always the policy would cover them for liability and such. Smile

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PostPosted: Tue Jul 01, 2008 5:10 am   Post subject:   

That's what I took from it Lori. The OP's girlfriend waited a couple of days to go to the doctor and then didn't report it to the landlord forÂ….x period of time. I've seen these denied all of the time, when there are no witnesses and late reporting of an accident. Who is to say it happened on the property or down the road. I don't see this going anywhere without an attorney, unless I am missing something.

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PostPosted: Tue Jul 01, 2008 6:44 am   Post subject:   

What about proximate cause? And yes it was in writing. He stated that the hazard was not reported to the insured and regular tenants didnt note the hazard and no proof the fall took place there. But deterioration doesnt happen over night. Also how could a lawyer prove these things?


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PostPosted: Tue Jul 01, 2008 10:07 am   Post subject:   

Dasfuk, I agree if those are the facts, I'd have denied it too more than likely.



William I agree with you on

Quote:
deterioration doesnt happen over night.
What about her ability to prove when and where it happened? Don't think that I saying it didn't happen EXACTLY as you say...I'm sure it did, the problem (apparently) is that she needs to prove this...(you always must prove your loss)....


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PostPosted: Tue Jul 01, 2008 11:38 am   Post subject:   

But how must she prove it? I dont think the apartment complex have cameras and she was by herself. So how must she prove it? It is pretty foreseeable. Its not like she is claiming the fall cause her to get into a car accident. Now that isnt foreseeable and have no connection.


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PostPosted: Tue Jul 01, 2008 11:52 am   Post subject:   

Quote:
Its not like she is claiming the fall cause her to get into a car accident. Now that isnt foreseeable and have no connection.
William I don't understand this comment at all or your point...
Quote:
I dont think the apartment complex have cameras and she was by herself
You don't 'think' so? Man, that's the first thing you need to check on!
Quote:
It is pretty foreseeable.
Again, (maybe I haven't had enough coffee yet) I don't get what you mean, what is pretty foreseeable?


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PostPosted: Tue Jul 01, 2008 2:41 pm   Post subject:   

Quote:
He stated that the hazard was not reported to the insured and regular tenants didnt note the hazard and no proof the fall took place there.
I touched on constructive notice before.

Quote:
Also how could a lawyer prove these things?
Lacking a time machine with a seat for two, he could not. But absolute proof is not needed. In court he would only need to be able to convince a jury that it happened as stated. He's put your GF on the stand and she's swear, under oath, that it happened as she stated. It's obvious that something happened to cause her injury. It's reasonable to say that she fell in some way, somewhere. The attorney would then show huge blown up photos of the defect in the railing and how it would be hard for anyone not to notice it. Its then a roll of the dice if the jury believes it. But here is the kicker... if they do, how much are they going to say the property owner owes? Perhaps a _whole lot_ more then the attorney was asking for from the insurance company. That is why insurance companies like to settle many claims without going to court. But on the other hand, perhaps the jury decides that there really was not enough information to show the accident happened as your GF decides so they award nothing. Now your GF's attorney just spend days and days and is not going to see a dime. This is why many attorneys never file suit or go to court.



So you ask how an attorney can prove that the accident happened as stated? Well, it's not always about absolute proof. It's about what each party thinks a jury will decided.
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PostPosted: Tue Jul 01, 2008 3:21 pm   Post subject:   

Tscope what you stated i know they(insurance) know of constructive notice. You stated there is a defect and injury and where people are required to be. They know this so why deny the claim all together? Maybe the adjuster dont like my gf? Also what do you mean by adjuster drop the ball? You stated its not about absolute proof so what do the insurance want from her? Also lori im very sorry for getting you confused im confused too. I dont know how adjusters look at claims all day. adjuster are good i wouldnt be able to take it i would lose my mind.Very HappySmile


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PostPosted: Tue Jul 01, 2008 3:37 pm   Post subject:   

Also could she get the adjuster to reevaluate the claim? Because alot of the pictures that showed deterioration and the rails leaning the adjuster dont have she didnt think the adjuster needed them. very hard for a owner taking care not notice it. Along with the photos could she point out to the adjuster the points you made on here tscope? Also is there any other things to point out? And the photos with the leaning rails and deterioration what can those prove to adjuster?


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PostPosted: Tue Jul 01, 2008 5:10 pm   Post subject:   

There are two different perspectives on most losses. But there is only one perspective that matters... what a jury things. Do you know what a jury will decide? Does the adjuster? Nope, to both questions. The adjuster needs to consider how much information there is that shows their insured is liable. It appears the adjuster thinks there is not enough. Your GF should be thinking there is enough information (otherwise she'd not be pursuing the claim).

Quote:
You stated there is a defect and injury and where people are required to be. They know this so why deny the claim all together?
I only need to address the information in your post. You told me it happen so I'm accepting that. Of course, the adjuster does not need to simply accept this as fact. As you've stated yourself, how can your GF prove it happened as she stated.

[/quote]Also could she get the adjuster to reevaluate the claim? Because alot of the pictures that showed deterioration and the rails leaning the adjuster dont have she didnt think the adjuster needed them. very hard for a owner taking care not notice it. Along with the photos could she point out to the adjuster the points you made on here tscope? Also is there any other things to point out? And the photos with the leaning rails and deterioration what can those prove to adjuster?[/quote]Yes, the adjuster can change her mind. Granted, it's human nature to avoid changing ones mind once a decision is made but people do it. Also, if the adjuster changes her mind then she needs to deal with the claim all over. I'm not saying she won't do it... just that it's a little more difficult to do.



Yes, supply all the photos. Your GF needs to prove her side to the adjuster. Photos are a _great_ way of doing this. It leaves little room for guessing. I'd also mention all the other items that you posted. They were good points. It's also good to let the adjuster know your willing to work with them if they are willing to discuss the matter further. Attorneys and adjusters are always at odds... but it's seldom that they don't treat each other with respect. Attorneys may know they are right but they also know the adjuster has the money and the process of getting the money can be made hard or easy. It's much easier to get money being nice to someone rather then making their life difficult.



I also think this thought all the time... "crap in, crap out". If someone gives me nothing to work with, they are probably not going to get much from me. If they lay out everything on a silver platter, they are probably going to get better results. To be honest, if your GF were to make up some nice documents with the photos laid out on them and write a nice clear letter... I'd imagine that it would go a long way.
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