General Activities
The Boxwood Group works closely with a major wholesale insurance broker's specific issues, assisting them with claim issues relating to polices they placed. The work involves a review of coverage as well as claim advocacy that often involves the brokered policy and any other applicable coverages.
Boxwood recently worked with a major medical provider network by doing a census audit of their medical providers to improve the quality of their data base. Boxwood sorted the data to be audited and provided the audit tool for this project.
The Boxwood Group is engaged in ongoing work for a global insurer, performing workers’ compensation, auto, general liability, and property claim audits of third party administrators that service the insurer’s primary book of business.
Boxwood acts as an advisor/consultant to a global Fortune 500 corporation risk management (“RM”) department on complex liability and property claims, coverage questions, and claim process issues. In addition, Boxwood has helped the RM group create internal presentations, claim process procedures, as well as managing a TPA RFP marketing effort. As part of the RM group Boxwood is presently managing 12 runoff programs and overseeing the monthly invoice payment requests and validity of adjustments, as well as evaluating the necessity of LOC’s.
Client Comments
Dear Tom,
Thanks very much for your help on the Lin matter. There is great potential for your service. If I were a corporate general counsel you would be first on my list to call. Having seen large resources expended on litigation through unimaginative and emotional decisions, I perceive that your resolution method, in many respects is better than mediation or arbitration, should be an initial recourse.
Best wishes,
Reece Williams Esq.
Callison ,Tighe & Robinson LLC
Columbia, South Carolina
Tom,
I appreciated meeting you and the great job you did on the audit. In all the years I've been around, yours was absolutely the best I have seen. Your comments and suggestions were right on and I'm sure will help us improve and fine tune our program and procedures.
Thank you!
Darlene Niebuhr
Director Workers Compensation Claims
C.R. England,
Lessons Learned
Component Part
Insurer denies coverage for damage to cab of truck when insured's component part (refuse body) damaged claimant’s truck and frame.
Insured manufactures a refuse body which they installed on claimant’s truck and frame. The claimant purchased the truck and frame separately from a truck manufacturer and sent it to the insured to attach a refuse body to the frame. The insurer contends the whole truck is the insured’s product as the insured's product was incorporated into the truck and rely on exclusion K. Despite appeal, that pointed out that the truck and refuse body are two independent and distinct products and that the insured did not manufacture, sell, handle, distribute or dispose the truck, the insurer relied on outside counsel coverage opinion and maintained their denial. A negotiated settlement was reached between the insured and the insurer.
Late Notice (Claims Made)
Employment Practices Liability – pays for claims first made against the insured within the policy period and reported within the policy period.
(SC)– Agent said he reported the claim prior to renewal to wholesale broker. Wholesale broker has no record of FNOL and reported claim under renewal policy. Coverage for claim declined for late notice. Due to a late ROR, vague policy wording, a deal was struck to share the loss between agent, insurer, and broker.
(CA)- Agent reported wrongful discrimination claim to wholesale broker. The loss was not reported to insurer within the policy period. EPLI policy had a $7,500 retention per claim and the claim was a 132a petition for wrongful termination. With the help of the agent’s claims person the claim was defended by the WC defense attorney and settled for a nominal amount all within what would have been the EPLI retention.
Claim Handling Gone Astray
Insurer agreed to defend the insured owner and project developer for a very unusual claim for an alleged odor in a newly completed condo unit. The insurer properly reserved their rights as to coverage.
One year later the insured received his first communication concerning the claim and was asked to attend a settlement conference. At the conference the defense counsel offered up a large amount of money to settle the claim and without any prior notice then asked the insured to contribute if he wanted the claim to settle. The insured declined and complained to the insurer.
As it turns out the insurer was not aware of the conference, the defense attorney had no authority to settle the claim, the insured was the only defendant left, all the contractors had been dismissed and trial was scheduled in less than 2 months. The plaintiff had several experts and the insured had none.
The insurer stepped up to the plate to handle the claim and after some negotiating was able to work out a deal with the insured that was satisfactory to all parties.
Misrepresentation on Policy Application Provided Grounds to Rescind Policy
Insured responded to underwriter's questions on application that they did not work in NY. Subcontractor employee fatally injured on insured's job in NY City. Policy Declarations restate the insured’s representations under “Business Description” that includes, “no work in NY.”
Policy condition clearly provides that insured agrees that statements in the declarations are accurate. Claim declined based on material misrepresentation and policy rescinded.
Under NJ Law rescission is appropriate where the applicant withholds or misrepresents information requested in an application. See Ledley vs. Williams Penn Life Ins. Co., 138N.J., 627,651 A.2d 92 (1995).
Pigtails Anyone ?
Insurer declined coverage in large apartment fire loss due to alleged inaccurate information obtained in the underwriting process concerning aluminum wiring. Although the underwriter had no standards concerning the issue and there was no “aluminum warranty” on the policy, the loss was declined for a material misrepresentation.
Retail broker had information concerning the presence of aluminum wire which was not passed on to the wholesaler who conveyed to the underwriter a lack of aluminum wiring in the buildings.
“Pigtails” is a term used to describe connecting copper wire to receptacles and switches, and then to the existing aluminum wire using a crimping process. The term pigtails, when used to describe a building’s wiring, are a giveaway that aluminum wire is present.
There was a weak paper trail concerning the issue between all parties.
There was a real question as to whether the issue was material to underwriting the property since the underwriter insured properties with aluminum wiring. Matter eventually settled with all parties contributing.
NY Late Notice, New Dawn
An employee of the insured (a subcontractor) hurt his toe on a pallet jack on 12/3/2009 and filed a WC claim. On 1/5/2010 the general contractor’s insurer then tendered the potential claim to the insured based on a contractual agreement. The insured sent notice to its insurer on 1/27/10. The insurer declined coverage for late notice.
The matter was appealed based on the fact that the policy was written and the loss occurred after 1/17/2009, the effective date of NY’s new amendment to its insurance law concerning notice to insurers, and the insurer had not been prejudiced by the timing of the first report. Coverage accepted.
When is a Demand a Demand?
Executive Risk Policy – period 3/28/11 – 3/28/12. On 1/14/2011 the plaintiff wrote a letter requesting that certain stock options be exercised. The insured advised the plaintiff and former employee that she was too late. On 12/13/2011 her attorney made a demand for the options citing the delay in exercising the options was clearly the fault of the former employer. Insurer declined coverage citing:
- The 1/14/2011 letter was a demand that occurred prior to the inception date of the claims made policy.
- The claim was reported 60 days after the expiration of the prior policy (3/28/10 – 3/28/11) and is late.
- The claim made under the current policy is for “Related Claims” because they are based on the facts, circumstances, etc. of declining to exercise the options under the prior policy (which has been deemed late reported).
- And that the policy does not respond to loss which constitutes benefits due or to become due under any plan.
This claim is being appealed to the insurer’s senior management.
No Business Interruption Coverage When Insured Discontinued Operation
Insurer paid for total loss (scheduled value) of property when insured's service vessel sank. Insured did not continue business as replacement cost of service vessel was economically not feasible. However, excess insurer will not pay business interruption claim as they contend service vessel was at the end of useful life (despite expert’s report to the contrary prior to the loss ) and there were no work orders for the new year.
Excess insurer adjuster has not met with the insured and has been relying on accounting firm and outside counsel in declining claim. Excess insurer would not listen to appeals from retail broker and wholesale broker. Claim is being litigated.