My roommate is involved in a claim and I am a former claims adjuster, albeit I have not ever handled California injury claims. I'm hoping to get some opinions on this …
- California venue, California policy
- Single car accident w/ injured claimant passenger
- FOL dispute
- Insured says claimant "threw themselves" out of moving vehicle due to verbal argument
- Claimant states insured pulled over to stop & let claimant out of the vehicle, accidentally hit the gas pedal while claimant was in process of exiting which caused claimant to sustain road-rash type injury as they were dragged a few feet when the vehicle lurched forward
- Adjuster has stated that they have contractual obligation to "side with" insured when FOL are disputed and there is an absence of any other evidence to support either party's version
- Adjuster has denied liability, stating an exclusion in the policy for intentional acts (ie: they are saying that since they have to go w/ their insured's version of the FOL, which are that claimant threw themselves out of the vehicle while it was moving, that would be considered an intentional act and thus the loss would be excluded from liability coverage)
Does this sound right? As far as I know, no recorded statement has been taken from the claimant, only the insured (claimant is my roommate). Claimant also states that all communications have been via email and they (claimant) have not received any formal, written correspondence from the adjuster (ie: no denial letter specifically stating the reason for the denial).
There are a lot of issues that come up for me, when I put myself in the shoes of the adjuster. I understand that they have a contractual obligation to go with what their insured says when FOL are being disputed, however, what I don't understand is how the adjuster can use the exclusion for intentional acts, when it comes to an allegedly-intentional act on the behalf of the claimant.
First of all … the exclusion for intentional acts would be part of the insurance contract, which the 3rd party claimant is not a party to. And secondly, not only does it not make sense for a normal, sane adult to "throw themself" out of a moving vehicle just because of a verbal argument, but even if the claimant had in fact done that for whatever reason, how could the insured possibly know that? Assuming claimant did not ever outrightly state that out loud to the insured, it doesn't seem like something that would hold up in court.
What do you all think? Please feel free to disagree w/ me, all I ask is that you provide the logic behind your reasoning. 🙂
Insurer denying liability based on exclusion for intentional acts – does/can that exclusion extend to claimants?
byu/blondesellery inInsurance
Posted by blondesellery
3 Comments
This is probably a coverage disclaimer under MedPay. If the passenger is seeking coverage for medical bills under the policy, they are subject to the policy contract.
Some carriers do share their policy language when there’s a denial, they may be required to based on the situation.
I think it’s a bold choice to make but 🤷🏻♀️ there’s three sides to every story right?
Whose car was it? They would exclude if the claimant is actually considered insured.
I am not licensed in CA (anymore)…had to read this a few times… but it’s interesting…
did the insured turn the claim in? did the claimant file suit against the insured? IMO the only way this COULD be covered would be per the scenario the claimant is stating, that is the insured intended to stop and let the claimant out and ACCIDENTALLY accelerated and caused the injury. that seem moot given the insured’s statement. much like the insured would have no way of knowing if the claimant “threw themselves” out of the vehicle, the claimant would have no way of knowing if the acceleration was accidental or intentional.
i agree that the intentional acts exclusion seems incorrectly applied as that would seemingly only apply if the insured intentionally accelerated as the claimant was exiting the vehicle (which if true, could play to the benefit of the claimant in court), not if the claimant intentionally jumped out of the vehicle.
i always like to say that coverage does not dictate liability. seems that the claimant may have a reasonable claim against the insured, it just wouldn’t be covered by the policy. get an attorney if the damages are serious enough. doesn’t seem that a quick payday is in the cards.