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How Do We Investigate Insurance Coverage?

Brandon Evans   |  August 4, 2017   |  

What is Insurance?

Insurance is something you buy to protect against uncertain financial loss or harm. Your insurance covers unforeseen occurrences by helping you pay for bills.  It can also protect you when are injured by someone else’s negligence.  It that case, the at-fault party’s insurance company pays you a settlement to make you whole.  The types of insurance that Riddle & Brantley handle include Auto, Vehicle, Home, Umbrella, and various types of health insurance including Medicaid and Medicare. If you want to know what types of coverage your policy provides and the limits of your protection then simply review the declarations page that you receive from your insurance company.

Important Insurance Terms to Understand

  • Liability
  • Medical Payments
  • No Fault
  • Health Insurance
  • Medicare
  • Medicaid
  • Workers Comp

Liability Insurance

This is any type of insurance policy that protects individuals or businesses from claims caused by negligence in driving vehicles, maintaining safe premises, and other claims such as malpractice.  Having insurance protects people and businesses when they are held liable for causing injury or they get sued.

Auto Liability Insurance

This coverage pays for property damage and bodily injury claims when a negligent driver causes a vehicular wreck.  If the driver that caused the wreck is uninsured then your own uninsured motorist policy will cover damages. Another type of Auto Insurance coverage found in most liability policies is underinsured motorist coverage. This type of insurance provides coverage that will cover your bodily injury claim in the event that the negligent driver is inadequately insured (does not have enough insurance coverage to pay all of your damages).  In most cases, there is no increase in premiums for using your underinsured or uninsured coverage.  We all know that insurance rates can go up if you are at fault for an accident.

What if you hit a cow in the road?  Is this uninsured coverage?  No! You have to pursue the owner or keeper of the cow.  These can be difficult cases but we have successfully handled several cases like this in the past by making claims against the homeowner’s coverage or farm policy of the owner or keeper of the cow.

Medical Payments Coverage

This is a wonderful source of insurance if you have it.  We call it Med Pay.  It will pay medical bills to any occupant of the vehicle or any guests injured on property regardless of fault.  However, the amount of coverage is usually capped at much lower limits than liability coverage and there are usually time limits for submitting bills for payment under these policies.  We handle of a lot of med pay claims for our clients by submitting bills to the medical providers.  Many times, the insurance company pays the medical providers directly under these claims.

Under home owner policies Med Pay is insurance that generally provides medical coverage to injured individuals that are not members of the family. Additionally, medical payments under home coverage will cover bills regardless of the negligence involved.  The only catch is that the insurance company only pays those bills deemed reasonable and necessary.  The attorneys at Riddle and Brantley have handled a large number of med pay claims in all types of premises liability claims.

Business Coverage

This type of insurance protects businesses and commercial properties when owners or employees injure others.  The types of coverage under these policies can vary depending upon the policies.  We usually call these policies Commercial General Liability policies or CGL.  In most cases, these policies have higher limits of coverage than personal policies.

What is No Fault?

In some states, insurance companies will utilize No Fault Insurance. With this type of policy the automobile insurance will cover part or all of your medical expenses and lost earnings caused by a car accident even if the accident was your fault. Florida and Kentucky are a couple states that have this type of insurance.  The rules of coverage and amounts of coverage vary from state to state.  North Carolina is not a “no fault” state.

Umbrella Insurance

Umbrella Coverage is additional liability insurance that provides coverage above limits of other basic policies.  For example, an umbrella policy may provide over $1,000,000 in coverage compared to most personal auto policies that are capped at lower amounts ($300,000 for example).  In essence it provides coverage that exceeds your limits of coverage listed for homeowners, auto and boaters insurance.  In North Carolina most umbrella carriers will not provide this extended protection unless your home and auto carry liability limits of at least $500,000.  We don’t see very many cases that involve umbrella coverages because most people don’t have this type of insurance but we have handled several umbrella claims in the past.

Health Insurance

Health insurance covers medical expenses that are defined in the policies.  Usually premiums are paid by the insured or the insured’s employer and payments are made to the providers based on terms contained in the policy that determine co-pays, deductibles, and in or out of network providers.  Medicare is a type of health insurance.  It is a government funded entitlement program to provide health insurance to people receiving social security or social security disability.  Medicaid is another type of health insurance provided by the government (funded by individual states) to provide medical benefits to people and children of lower income families.  At Riddle and Brantley we tell our clients to keep all Explanation of Benefits records provided by the health insurance company because these documents help us keep track of related medical providers and bills.

Workers Compensation is also a type of insurance that pays for medical bills of injured workers while on the job.

Subrogation

In many cases we handle, we find that these health insurance companies seek reimbursement (called subrogation) for payments made on medical bills arising from an accident if the negligent party’s insurance company pays the claims.  At Riddle and Brantley, we deal with these subrogation claims on a daily basis and our goal is to reduce these claims as much as possible to put as much money as possible and fair in our injured client’s pocket.  The health insurance carriers for North Carolina state employees and for federal employees, including the armed services (US Air Force, Army, Navy and Coast Guard) make claims for reimbursements of medical bills they pay and we handle these claims for our clients.

Auto/Motorcycle/Pedestrian/Vehicular Wrecks

What types of coverage do we investigate and pursue for most vehicular accidents?  We look for the following types of insurance coverages.

  • Coverage on the vehicle involved in the collision (usually called the owner’s coverage).
  • All coverages for the driver which can include more than one policy and even other family members’ household policies.
  • Stacking of liability policies is allowed in North Carolina so we are very careful to obtain all policies of both driver and owner of the at fault parties.
  • Any potential Umbrella policies of driver and owner.
  • Injured party’s own policies which may have underinsured coverages.
  • Injured party’s household family member’s policies which may have underinsured coverages.
  • In North Carolina we can stack underinsured policies so we always obtain all policy information from our client and household family members.
  • Medical Payments coverage which also provides insurance funds to pay for medical expenses and this can come from at least two sources, the vehicle itself or the injured party’s own policy.
  • Uninsured coverage on our own policies in the event that the other driver/owner had no insurance or the accident is a hit and run.
  • We represented an injured party in a serious auto collision that occurred in Goldsboro, North Carolina. Our client was severely injured, but had no health insurance coverage.  In order to assist her with obtaining the medical care she needed, we assisted her in applying for Medicaid and helped coordinate her care with the necessary medical providers while that claim was pending on a lien basis, with an offer to pay them out of any eventual recovery.  In the meantime, we learned that the at-fault driver was operating a vehicle owned and insured through his employer.  The employer’s insurance policy had limits of $1,000,000.  We made contact with the employer’s insurance company and demanded that it extend its coverage for the claim. Because of the extent of the injuries, it was apparent that our client would be treating for months or even years after the accident, and she would have no source of income in the meantime.  We informed the carrier that if they were in a position to discuss settlement immediately, we could do so, but if they were not, we would have to file suit because our client was not in a position to await the conclusion of her treatment.  We were therefore able to persuade the insurance company to tender its coverage of $1,000,000, even as our client and the other injured party were still treating.  We then began working on the amount we could put in our client’s pocket and secured reduction agreements with our client’s medical providers, including a 75% reduction for a very large emergency room bill.  We also secured an agreement on a future Medicare Set Aside fund in order to protect our client’s eligibility for Medicaid and Medicare coverage, if her applications were to prove to be successful.  This allowed us to finalize this significant settlement of a very complex claim in about 8 months.

Case handled by Gene Riddle and Adam Smith and included only to serve as a general example.

Truck or Tractor Trailer Wrecks

We usually begin investigating these wrecks within 24 hours or less after being hired so that we can preserve evidence and attempt to locate all sources of insurance coverage on the at-fault truck.  We investigate the insurance by hunting for coverage in this order.

  • Liability insurance on the truck. This is usually a commercial policy or fleet policy with much larger limits than an individual driver of personal cars.  Most of the insurance companies in our truck cases in the past have had a minimum of $1,000,000 in coverage.
  • Liability insurance on the driver.
  • Umbrella coverage for the company that owns the tractor.
  • All coverages on the trailer.
  • All underinsured coverages for our client but we usually don’t need these in truck cases.
  • Medical payments coverage from our client’s vehicle and personal policies.

Premises Liability/Slip Falls

When someone falls at a grocery store, a business or home and suffers injury as a result of an unsafe condition, we refer to this case as a premises liability. These cases are different from auto accidents because you generally have limited resources for payment of your damages.  These types of claims include any accident that occurs on property, even dog bites. Our sources for insurance coverage usually include:

  • The liability coverage for property owner.
  • The medical payments coverage which is usually limited to a small amount but will pay regardless of fault.
  • Self-insured coverage which comes from the businesses own funds but handled like insurance (Wal-Mart has this type of plan).
  • Other parties/vendors that may have serviced the business or property and created and failed to remedy an unsafe condition (for example, a cleaning company that mopped or waxed a floor).
  • For dog bites we look for insurance on the dog owner and the keeper of the dog which can be different.

Other Accidents

We also handle boat accidents.  We investigate coverage on the owner or driver and hunt for boat, trailer and homeowner coverages.  In some cases, the boat owner has a rider to include boat coverage along with homeowner’s policy.

  • We recently represented a police officer who was riding as a passenger in a Pro Sports recreational watercraft when the boat collided with a bridge. We worked with the North Carolina Wildlife Resources Commission to obtain a report of their investigation, which found the collision to be the result of pilot/captain error.  We sent a demand letter to the pilot asking him to have his insurance carrier contact us.  The pilot’s homeowner’s insurance carrier soon contacted us and advised that the boat was not covered by any watercraft insurance, and that the claim was not covered under the homeowner’s policy.  We argued to the carrier that the boat was housed at a dock that was covered under the homeowner’s policy, and that the boat therefore must be covered by extension.  We also sent a letter to the owner of the boat informing him that he should consult with his insurance agent because if his homeowner’s policy did not acknowledge coverage, we would have no choice but to consider suing him individually.  The owner/pilot then hired an individual attorney to represent his interests and encouraged his homeowner’s policy to cover the loss.  Our attempts were successful and we were able to settle the claim with the homeowner’s insurance carrier for $302,000.

Case handled by Gene Riddle and Adam Smith and included only to serve as a general example.

We have also handled golf cart accidents where we investigate auto coverage, homeowner’s coverage, and medical payments coverage. Let our thirty plus years of experience assist you in finding all coverages available for your injury case. Riddle and Brantley is experienced in hunting for all possible insurance coverages that can provide sources of recovery for our clients.   Give us a call at 800-525-7111 or contact us now for a free consultation about your case.