Wisconsin contractor fined for crossing insurance claim lines

Insurance Restoration contractors need to read this decision from Wisconsin discussing the line between a restoration contractor and adjuster in an insurance dispute.

As a leading insurance claim appraisal company within the state of Texas, My Claim Appraisal has provided our recommendations to the Texas Department of Insurance regarding the recent legislative changes involving the insurance claim appraisal process. Specifically, 28 TAC 5.9800, .9801, .9802, .9803, .9804, .9805. At My Claim Appraisal, our core perspective is that claim appraisal, when structured efficiently and correctly, serves as the most effective tool for Texas consumers, particularly the working class, to achieve the proper identification of their damage and the cost to repair those damages after they have submitted an insurance claim. By utilizing impartial parties, it is intended to be a faster and less expensive alternative dispute resolution mechanism than hiring a Public Adjuster or Attorney. The focus should be on ensuring this mechanism is functional, fast, and affordable, as intended by the Texas legislature. Attached is our recommendation to the Texas Department of Insurance surrounding the Residential Property Appraisal Process, sent by one of our Founders who is also a Texas resident and insurance policyholder. As with every recommendation we make as a company, our focus will always be on the policyholder, and what is best for the policyholder. Although some critics may disagree with our timeline recommendation, based on our company’s results, we know these timelines are achievable when the proper practices and processes are in place by companies and individuals that choose to be involved with the claim appraisal process. Our recommended timeline will directly benefit the policyholder by bringing a quick conclusion to a disruptive and stressful time of their lives. 

🛑 “But my house is insured…” Yes, but did you disclose all the material facts? When it comes to insurance, it’s not just about having a policy — it’s about what you told your insurer when you got it. ✅ A material fact is any information that could affect an insurer’s decision to accept your application, calculate your premium, or process a future claim. 🏠 In domestic insurance, examples include: ✅Previous claims made on the property ✅Whether the house is vacant for long periods ✅Use of the property for business ✅Type of roofing or building materials ✅Any renovations or structural changes ✅Lack of proper security systems 👌Why Material Facts Matter in a Claim When a claim is filed, the insurer will investigate whether all relevant facts were disclosed when the policy was taken out. If it’s discovered that a material fact was concealed or misrepresented — whether intentionally or accidentally — the insurer may: 🚫Reject the claim entirely, 🚫Reduce the payout, or 🚫Cancel the policy from inception (as if it never existed). Example: A homeowner insures their property but fails to disclose that the house is under renovation and unoccupied. If a fire occurs, the insurer might argue that this material fact increases the risk of damage and would not have issued the policy under the same terms — leading to a denied claim. “But My House is Insured” — The Common Misconception Many policyholders mistakenly believe that once a policy is issued, all is secure. However, an insurance contract is only valid if full disclosure was made. Simply having an active policy doesn't guarantee a claim will be honored if material facts were not properly disclosed. This is where people often feel let down, not realizing that non-disclosure voids the integrity of the policy. 📌 The Importance of Disclosing Material Facts 1. Avoiding Claim Rejection Disclosing all relevant information ensures that there are no surprises at the time of a claim. Insurers can only make fair decisions when they have complete and accurate information. 2. Maintaining Trust and Legal Standing Insurance contracts are legal agreements. Failing to disclose material facts can be considered fraud or misrepresentation, potentially leading to legal consequences and loss of coverage 3. Better Tailored Coverage Honest disclosure enables insurers to offer products that better match the actual risk, ensuring you get the right protection for your needs. 4. Peace of Mind Knowing you’ve disclosed everything important removes any doubt or stress during the claims process. It builds trust and long-term value between you and your insurer. 🔐 Insurance is built on trust (utmost good faith) . Disclosure is not optional — it’s essential. Let’s educate, inform, and protect ourselves from unnecessary risks. # Materialfacts # Disclosure # TheShieldInvestment

Truthfully, not everyone can ________? Multiple conversations over the last several weeks with several people in insurance industry have led up to this comment. The Adjuster diaries was created to assist, aspiring or up incoming talented insurance adjusters. In today’s society where we often experience celebrations in mediocrity. Not everyone can do everything they want regardless of the dedication. Insurance adjusting is no different. About every 7 to 10 years we see a trend of a flood of brand new adjusters coming into the marketplace being promised they will make a fortune within their first year of adjusting. Due to this incorrect information there are people with zero construction, acumen or business acumen coming into the Adjuster market, freshly licensed. It’s unfortunate that in most situations the carrier or the independent adjusting firm is unaware of the skill set the new Adjuster has. The words fake it until you make it simply do not apply here. Additionally, the new adjusters coming into the marketplace affect the dollar amount the independent Adjuster makes per file, and the quality of the work is directly seen in the marketplace. If you want to be a successful insurance adjuster, there are certain things you need to have before you begin. A basic understanding of construction is critical either in commercial or residential, if you want to go into property. If you want to go into automotive, then a basic understanding of automotive is needed. Never mind the specialty lines or complexities of specialty insurance. That’s a whole other topic. Although there are multiple licensing entities across the United States that sometimes promise, huge incomes after becoming licensed this simply isn’t accurate. The truth of the matter is without a firm foundation you will most certainly fail. The unfortunate thing about this is the insured, and the insurance carrier will pay the price for your shortcomings. This industry can be a great place to establish yourself and make a great living, but you have to be honest when entering into it. Not everyone is cut out for this business, it is a difficult space but rewarding for the right person.

Truthfully, not everyone can ________? Multiple conversations over the last several weeks with several people in insurance industry have led up to this comment. The Adjuster diaries was created to assist, aspiring or up incoming talented insurance adjusters. In today’s society where we often experience celebrations in mediocrity. Not everyone can do everything they want regardless of the dedication. Insurance adjusting is no different. About every 7 to 10 years we see a trend of a flood of brand new adjusters coming into the marketplace being promised they will make a fortune within their first year of adjusting. Due to this incorrect information there are people with zero construction, acumen or business acumen coming into the Adjuster market, freshly licensed. It’s unfortunate that in most situations the carrier or the independent adjusting firm is unaware of the skill set the new Adjuster has. The words fake it until you make it simply do not apply here. Additionally, the new adjusters coming into the marketplace affect the dollar amount the independent Adjuster makes per file, and the quality of the work is directly seen in the marketplace. If you want to be a successful insurance adjuster, there are certain things you need to have before you begin. A basic understanding of construction is critical either in commercial or residential, if you want to go into property. If you want to go into automotive, then a basic understanding of automotive is needed. Never mind the specialty lines or complexities of specialty insurance. That’s a whole other topic. Although there are multiple licensing entities across the United States that sometimes promise, huge incomes after becoming licensed this simply isn’t accurate. The truth of the matter is without a firm foundation you will most certainly fail. The unfortunate thing about this is the insured, and the insurance carrier will pay the price for your shortcomings. This industry can be a great place to establish yourself and make a great living, but you have to be honest when entering into it. Not everyone is cut out for this business, it is a difficult space but rewarding for the right person.

If I had 10 minutes with someone who doubts the necessity of title insurance, I would tell them one thing. Ok, I couldn’t do it in 10. But if I had to try: What we call "title insurance" is actually title insurance AND closing services, and those two components go hand in hand. Settlement services are essential, but they are clunky and annoying. Somebody has to make sure that when you get to the moment of closing, a lot of details have been accounted for accurately and fairly. Every party involved needs to understand exactly what they are committing to before they sign. When people only think about title insurance as a policy they pay for and file away, they miss everything else the industry provides from the moment you sign a contract on a property. But even when people understand that settlement services are part of what they are paying for, the insurance component itself is still widely misunderstood. The difference between title insurance and other insurance products is that people buy so few houses in their lifetime that they think about title insurance infrequently and talk about it infrequently. You pay for title insurance once upfront, and it lasts for the entire time you own the home, so consumers only look at it a few times in their entire life. Protecting that asset costs significantly less than one percent of the total cost of buying and financing the home. So if someone doubts whether title insurance is necessary, I would explain what it actually is - not just insurance, but the closing and settlement work that makes buying property possible and protects you when issues arise. That usually takes about ten minutes…or a few hours.

Last month, a team member watched me review an insurance policy starting from the last page. "That's... different," she said. Let me explain why we do this; and what it catches. Years ago, I noticed a pattern. The most restrictive definitions, the narrowest interpretations, the clever exclusions - they lived in the back half of policies. Page 200 had the teeth. Page 1 had the smile. So we flipped our process. We now read every policy three times. First pass: backwards, definitions first. Second pass: forwards, coverage grants next. Third pass: diagonal - following every cross-reference, every "subject to," every "as defined in Section." It sounds excessive. Until you see what it finds. Last week, page 3 promised broad professional services coverage. Page 187 defined professional services to exclude "administrative acts." Page 94 defined administrative acts to include "processing applications." For an MGA that processes applications all day, that's no coverage at all. The traditional front-to-back reading would see the promise before the restriction. Our backwards approach sees the restriction first, then questions the promise. The insurance market has evolved. Policies have become three-dimensional documents; meaning changes based on which angle you approach from. Reading backwards isn't about being contrarian. It's about seeing what's actually there, not what you expect to find. Our team member now reads backwards too. She found a seven-figure gap in her first review. The client had been told their coverage was "comprehensive" by the prior broker. It was. If you only read forwards. Perspective changes everything. In insurance, the ending often rewrites the beginning. By the way… Every week we share curated insights that cut through insurance chaos and help you make the best policy decisions: Join here: https://lnkd.in/garzxSxG

Morrison Mahoney Partner Cara Joyce recently argued successfully at the Connecticut Supreme Court, prevailing on behalf of her insurance agency client. Cara had previously obtained summary judgment at the trial court stage and prevailed before the Appellate Court in relation to this matter as well. Plaintiffs’ homeowner’s insurance claim was denied by the insurer after a house fire because their policy had non-renewed days prior when they failed to replace a portion of missing siding on the house that was identified in an inspection. The insurance company had notified the agency of the inspection results and asked the agency to pass the information about the needed repairs on to the plaintiffs. The agency sent the plaintiffs a certified letter informing them of this, per Connecticut’s statutory requirements. Plaintiffs never claimed the letter, the policy non-renewed, and ~10 days later, their house burned down in an accidental fire. The insurance company declined to cover the claim, as the policy had non-renewed. Plaintiffs claimed they were never informed of the inspection results by the agency. They sued the insurance company and the insurance agency, claiming that the insurance agency had a duty to inform them of the impending non-renewal. All defendants obtained summary judgment, which was affirmed on appeal. The Appellate Court concluded that most of the plaintiffs’ claims were unpreserved and affirmed the trial court that the insurance agency had no duty to inform them of the non-renewal. The Supreme Court granted certification to the insurance agency only, and in a 4-2 decision with two judges dissenting, the Supreme Court affirmed the lower courts’ rulings in favor of the insurance agency defendant. The Supreme Court agreed that the plaintiffs’ claims of a long-standing relationship with the insurance agency did not provide an exception to the general principle that an insurance agency’s duty ends when they have procured the policy they were requested to procure. This win limits our client’s duty and confirms that they have no ongoing duty unless special circumstances exist. Great work, Cara! Read more here: https://lnkd.in/eP8fBtTj

RIV (Reinstatement Value) insureds need protection   It is well known that RIV policies indemnify insureds more completely than market value policies. However, court cases indicate that insurers act unilaterally in such cases and prejudice their customers severely. One such recent case is United India v M/s Valley Iron & Steel (2025), decided by the Delhi High Court. In this case the insured sustained near total loss owing to a cloud burst in their area and the entire plant was submerged in mud and debris with damage all round. They had a RIV policy and as per the request of the surveyor, submitted a plethora of documents for assessing the loss on RIV basis. The insured started reinstatement but owing to various reasons the same could not be completed in 12 months and the insurer compelled a settlement of Rs. 10 crores on market value basis even though the claim was for Rs. 58 crores. The insured claimed that they were coerced into signing the discharge voucher. The insured made repeated pleas for on account payments, but they were not considered and as a result the reinstatement stopped and finally the claim had to be settled by Arbitrators for Rs. 33 crores on market value basis. In this regard the HC cited a similar case in the Madras High Court: Hefc Ergo General Insurance Co Ltd vs M/S Rohini Movie Park Rukmini (2019), where the HC stated in para 50: “In the given case, contention of the insurance company is in fact contrary to the public policy. The petitioner case is contrary to the written insurance policy. Taking advantage of the distress situation of its client, forcing the insured to receive compensation, is unreasonable and contrary to the own assessment of loss. Quoting depreciation and under-insurance, which is not applicable for Reinstatement Value policy is against law and public policy.” The HC also cited Renasa Insurance Company Ltd. v. Watson [2016] ZASCA 13 where it was held that “an insurer cannot take advantage of its own breach by withholding payment and thereafter insisting that the insured failed to reinstate within the stipulated period. The Court emphasised that insurers are expected, at the very least, to release the indemnity value to enable reinstatement, and failure to do so frustrates the very mechanism envisaged by reinstatement clauses.” Another case cited was Great Lakes Reinsurance (UK) SE v. Western Trading Ltd. [2016] EWCA, in which “the Court recognised that an insured cannot be said to have failed to act with “reasonable despatch” in reinstating property where liability is either denied or unreasonably delayed by the insurer.” (para. 98). It is clear that the IRDAI needs to encourage RIV policies but safeguard insured’s interests by a special Protection of Policyholder section for these policies highlighting the need for interim payments at least upto market value level and ensuring that the 12 month period in the clause is not used for arm-twisting the insured into a market value settlement etc.  

Encouraging to see Florida's leadership making bold moves that both protect consumers and support a healthier insurance market. Lower auto insurance rates paired with improved carrier profitability is a rare win-win. Smart regulatory reform can drive real results, and Florida is setting an example worth watching. California should pay attention!