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Disabled Claimants Must Seek Treatment and Give Regular Updates

Fri Apr 20th, 2018 on     Disability Insurance,    

In Florida, as is the case in other states, recipients of disability benefits — whether through private disability insurance or through a public program like SSDI — must reasonably follow the treatment plans required by their physicians, and must regularly update their insurer as to their condition.  Failure to do so could result in a loss of benefits (through premature termination of benefits), or a reassessment of disability benefits that reduces the amount you receive on a monthly basis. Reasonable Efforts to Mitigate Generally speaking, insured policyholders in Florida (including disability insurance policyholders) have a duty to mitigate — in other words, they must make reasonable efforts to minimize their losses.  In the disability context, this means that disability claimants must attempt (to the degree possible) to “fix” their disabling condition, or at the very least, to minimize the impact of the condition on their life. Once your physicians recommend a treatment plan, it is important that you follow said treatment plan.  Failure to do so will likely constitute a violation of your duty to mitigate your losses — if you do not follow your physician’s recommended plan, your insurer may terminate benefits prematurely and will likely argue that your disability would have resolved had you followed the plan. If you failed to follow a given treatment plan, you may still be able to receive benefits, but you’ll have to introduce evidence that demonstrates that your disabling condition would not have improved or resolved even if you had followed the […]

Policyholders: Be Careful Not to Misrepresent Yourself on Your Insurance Application

Fri Apr 13th, 2018 on     Insurance Claims,    

In some cases, your insurer may deny your claim due to a specific misrepresentation in your insurance application — even if the misrepresentation at issue was not intentional and was merely a mistake borne of a simple misunderstanding. Material Misrepresentation as a Defense Insurers can use a material misrepresentation defense to avoid having to pay out for your legitimate insurance claims.  Oftentimes, an insurer will discover some mistake in your application and will anchor their arguments on it.  For example, if you fill out a disability insurance application and write down your family history of disability (and other health conditions) incorrectly due to a lack of information, the insurer may argue that this mistake constitutes a material misrepresentation. If you’ve had your claim denied or delayed (or otherwise handled in an unfavorable manner) due to a purported “material misrepresentation,” then you may feel as though you don’t have many options.  In reality, however, policyholders can utilize a number of different arguments to overcome this defense. Not all Misrepresentations Preclude Insurance Coverage The mere fact that you made a mistake — or even intentionally misrepresented something on your insurance application — is not enough to preclude insurance coverage.  According to Florida Statutes section 627,409(1), a misrepresentation, omission, or mistake will only prevent the insurance claimant from recovering damages if the insurer would not have issued the policy in the first place (given the misrepresentation at-issue). Further, your insurer cannot preclude coverage unless the particular misrepresentation is causally linked to the loss […]

Can You Sue Your Insurance Agent for Their Mistakes?

Fri Apr 6th, 2018 on     Bad Faith Insurance,    

In Florida, insurance litigation disputes — often involving over-broad and unexpected policy exclusions — may lead one to question the liability of their insurance agent.  After all, if the insurance agent obtained the policy on your behalf, it’s possible that they have not satisfied their obligations and have somehow misled you into entering into an insurance agreement that did not adequately meet your needs. In the event that your insurance agent failed to adhere to their duties, you may be entitled to sue them for negligence (and thereby recover damages for the losses over which your insurer has refused to extend coverage).  There are, of course, limits to consider — the law does not grant you an absolute right of action against your insurance agent.  Arguably, every dispute over a denied insurance claim is (to some degree) unexpected, or else you would not have agreed to it in the first place. Duties Owed by the Insurance Agent Insurance agents in Florida owe a number of duties to the insured (their client).  Pursuant to currently-applicable case law, they must: Exercise reasonable care in securing insurance coverage that the client has specifically requested, and notify the client as to any issues regarding its availability; Properly consider the explicitly-defined needs of the client when obtaining insurance coverage; and Inform and explain the coverage that has been secured at the client’s direction. This can be difficult to take in all at once!  Consider the following example for clarity. Suppose that you engage with an […]

How the Health Insurance Appeals Process Works in Florida

Fri Mar 30th, 2018 on     Health Insurance,    

In Florida, and elsewhere, health insurance policyholders are entitled to appeal adverse determinations by their insurer — such as a denial of coverage — and thereby request that the insurer conduct a full review of their original decision. The appeals process is the first of several steps in challenging the determination made by your health insurer.  After you have exhausted the internal appeals process, you can move forward with an external, third-party review of the insurer’s decision, submit a complaint with a Florida state agency (such as the Florida Agency for Health Care Administration), or bring an action against your insurer (thus precipitating litigation). Even if you’re not sure whether you’d like to file a lawsuit against the insurer and pursue litigation in the Florida courts, it’s worth consulting with an experienced Miami health insurance lawyer to help guide you through the appeals process.  Depending on the circumstances surrounding the denial of your health insurance claim, you may be able to persuade the insurer to accept your claim. The Appeals Process in Florida So, how does the appeals process work? When you file a claim, you’re essentially requesting that your health insurer cover (and therefore reimburse) the costs of treatment.  If your insurer denies your claim, however, then that qualifies as an adverse determination, which you are entitled to challenge pursuant to the appeals process. Every insurer tends to have somewhat different grievance and appeals procedures (though they all must comply with state and federal regulation).  For example, some Florida […]

Bad Faith Lawsuits: Making Sure Your Claim is a Strong One

Fri Mar 23rd, 2018 on     Bad Faith Insurance,    

In Florida, insurers have a duty of good faith that they must adhere to.  Simply put, insurers must act fairly, honestly, and with due regard towards the interests of their policyholders.  If they fail to do so — for example, by wrongfully denying a claim, unreasonably delaying the handling of a claim, or otherwise interfering with the policyholder’s ability to recover the damages to which they are entitled — then they may be held liable pursuant to Florida bad faith insurance law. Bad faith disputes can be multi-layered and complicated.  In order to prove that the defendant-insurer has committed bad faith, you’ll have to show that they acted unfairly or dishonestly, or that they acted without due regard to your interests.  This is a “holistic” determination that depends on the total circumstances surrounding your claim.  You’ll have to prove that — given the circumstances — the insurer violated their duty of good faith.  Doing so is not always easy, but our Miami bad faith insurance lawyers are here to help. The insurer will almost certainly fight tooth-and-nail to avoid bad faith liability.  When you bring a bad faith claim, in Florida or elsewhere, the insurer will expose the weak points in your arguments.  For example, an insurer might argue that the circumstances justified a delay to give them time to investigate the insurance claim further, given that there was not sufficient evidence in the original submission for them to determine whether to payout. Potential Weaknesses to Avoid When Bringing Your […]

Florida Property Insurers Must Cover Damage to Personal Property Too

Fri Mar 16th, 2018 on     Property Insurance,    

Usually, property loss does not involve exclusive damage to the dwelling unit itself — there may also be damage to other, non-dwelling structures (such as a fence around the property), or more commonly, to items of personal property that also reside within the dwelling.  In some cases, the personal property of the policyholder may be of significant value, and as such, their loss may expose the policyholder to unexpected financial vulnerability. For example, suppose that you own a number of antiques of significant value.  You intend to sell them to help pay for your child’s college tuition fees.  One day, however, a fire destroys much of your home, and the antiques are damaged beyond repair.  Their value is lost in an instant.  If the insurer does not provide adequate coverage that accounts for the losses you sustained due to the damage to your personal property, then you could be left in a very challenging financial position. If you have valuable personal property, it’s therefore critical that you consult with an experienced Miami property insurance lawyer for guidance. Duty to Cover Losses Sustained Personal Property In Florida, insurance companies providing homeowner’s insurance must grant policyholders coverage for their personal property, though limits on such recovery are frequently written into the policy to minimize the insurer’s eventual liabilities. It’s worth noting that Florida law requires insurers to give a policyholder the option to exclude their personal property from coverage (so long as the policyholder gives a formal, written statement of intent).  Excluding […]

Your Insurer’s Delay Can Give Rise to a Bad Faith Claim

Fri Mar 9th, 2018 on     Bad Faith Insurance,    

As a general rule, insurers will act to avoid or otherwise minimize their liabilities under their insurance contract with a policyholder.  Sometimes, however, the actions taken by an insurer clearly violate their duty of good faith, and thus give the policyholder an opportunity to sue and recover damages pursuant to a bad faith claim.  Actions giving rise to bad faith claims include those that involve unreasonable delays in handling, resolving, and processing an insurance claim submitted by the policyholder. Bad faith claims can be somewhat confusing for those who are unfamiliar with the push-and-pull typical of many insurance disputes — as such, you’ll likely want professional guidance to help you navigate the challenges and complexities of bad faith litigation.  Get in touch with a qualified Miami bad faith insurance lawyer for assistance. Insurers Have a General Duty to Act in Good Faith In Florida, insurance companies owe a general duty of good faith towards their policyholders.  Essentially, the duty of good faith requires that the insurer act fairly and honestly towards one of their policyholders, with due regard of the interests of the policyholder.  In determining whether the insurer acted in bad faith, Florida courts must consider the totality of the circumstances surrounding the unreasonable delay at-issue. Suppose, for example, that you have submitted a claim, but the insurer continues to delay their decision on whether they will pay.  After investigating further, your attorney discovers that the insurer did not properly investigate and evaluate your insurance claim, and further, that […]

A Look at Commercial General Liability Insurance and Bad Faith Issues

Wed Feb 28th, 2018 on     Bad Faith Insurance,    

As a business owner, CGL insurance coverage is fundamental to effectively running your business in a highly-litigious society.  When a improperly mopped floor can result in hundreds of thousands of dollars, or even millions, in potential liability to injured third-parties, the value of CGL insurance skyrockets — CGL insurance provides the “peace of mind” necessary for a business to successfully operate. This reliance on CGL insurance can lead to challenging situations when the insurer wrongfully denies a legitimate insurance claim, or otherwise fails to step in and adhere to their duties under the contract.  Businesses facing millions in potential liability are put in an exceedingly vulnerable position, and insurers often take advantage of this power dynamic to undervalue claims and deny coverage.  Fortunately, Florida law entitles CGL policyholders to sue and recover damages on the basis of bad faith. Consider the following. Wrongful Denial In Florida, bad faith requires that insurers conduct a reasonable investigation of the facts surrounding the insurance claim at-issue, that the insurer not misrepresent the extent and nature of coverage, and that the insurer not wrongfully deny a legitimate insurance claim (i.e., without reasonable justification for such denial).  If your CGL insurance claim has been wrongfully denied, and you can prove that the defendant-insurer did not have reasonable justification for the denial, you could potentially recover damages for bad faith. Failure to Defend CGL insurance requires that the insurer step in and defend you in the event that an injured third-party makes a claim against you […]

Short-Term Disability Insurance in Florida — The Basics

Wed Feb 21st, 2018 on     Disability Insurance,    

Short term disability insurance benefits serve as a form of temporary wage replacement for those who are suffering from a serious disability (though it’s worth noting that not all plans require employment, or a history of employment, to qualify for disability benefits).  If you have been seriously injured in a car accident, for example, to such and extent that you can no longer work for a period of time following the accident, then your short term disability insurance will kick in and you will be entitled to receive benefits. Many people unfamiliar with disability insurance do not understand what short term disability insurance is, and whether they can actually receive benefits pursuant to their policy.  There is a real and unfortunate “knowledge gap” when it comes to short term disability, particularly in scenarios where the policyholder may be automatically covered under an employer-based group plan. In reality, short term disability insurance is fairly straightforward to understand.  Consider the basics. Short Term Disability Benefits Short term disability benefits payout when you have been injured, or are suffering from an illness or condition that is severe enough to disable you — in other words, enough to prevent you from fully and adequately handling your job/career duties for a specified time period (up to one year, usually).  Benefits vary depending on the insurance plan, and sometimes, on the nature of the work that you are involved in.  Some plans pay a percentage of your wages, while other plans pay a set amount of […]

Property Insurance Provisions Must Be Construed in Favor of Coverage

Wed Feb 14th, 2018 on     Property Insurance,    

If you are challenging the wrongful denial of your property insurance claim, the insurer is likely to assert that the language in the insurance contract is rather ambiguous, and that it should be interpreted in a manner that favors them. For example, suppose that your property insurance contract includes various provisions that exclude lightning damage from coverage.  A tree near your house is hit by lightning, which results in a fire.  The fire then spreads to your house, causing it to burn down.  Would you be entitled to make a property insurance claim, given the exclusionary provision at-issue?  The insurer is likely to argue no.  On the other hand, the provision is rather ambiguous with regard to the chain of causation.  It could be argued that the damage was not directly caused by the lightning, but instead by fire, which is covered. Ambiguity has often been used by insurers to entice policyholders into signing, only later to be construed in a manner that retracts coverage, thus minimizing the potential liabilities for the insurer.  Fortunately, Florida case law favors policyholders in the interpretation of ambiguous policy language.  Let’s take a quick look. Ambiguous Property Insurance Provisions Must Be Construed in Favor of Coverage In Florida, ambiguous provisions — where true ambiguity exists — of an insurance policy must be liberally construed in favor of the policyholder (coverage), and strictly construed against the insurer.  As the policyholder, this is highly protective and is likely to benefit you when it comes to litigation […]

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