From California Insurance Commissioner: All Business Interruption Insurance Claims Caused by the COVID-19 Pandemic Must be Accepted, Forwarded, Acknowledged, and Investigated Fairly

On April 14, 2020, California Insurance Commissioner Ricardo Lara and the California Department of Insurance (“CDI”) directed all agents, brokers, insurance companies, and other Department licensees to accept, forward, acknowledge, and fairly investigate all business interruption claims caused by the COVID-19 pandemic.

The agency said that, “despite the Department’s on-going guidance to businesses statewide during the COVID-19 pandemic, it has received numerous complaints from businesses, public officials, and other stakeholders asserting that certain insurers, agents, brokers, and insurance company representatives are attempting to dissuade policyholders from filing a notice of claim under its Business Interruption insurance coverage, or refusing to open and investigate these claims upon receipt of a notice of claim.”

The Regulations require all agents, brokers, insurance company representatives, and other Department licensees to accept any communication from the policyholder or its representative indicating that the policyholder desires to make a claim against a policy that reasonably suggests that a response is expected as a notice of claim. Upon receipt of a notice of claim, every Department licensee is required to transmit such notice of claim to the insurer immediately.

The Notice also provides:

  • Upon receipt of a notice of claim, subject to certain exceptions, every insurer is required to acknowledge the notice of claim immediately, but in no event more than 15 calendar days after receipt of the notice of claim.
  • If the acknowledgment of a claim is not in writing, a written acknowledgment of the receipt and date of the notice of claim must be made in the claim file of the insurer.
  • Failure of an insurance agent or claims agent to transmit a notice of claim to the insurer promptly will be imputed to the insurer, except where the subject policy was issued pursuant to the California Automobile Assigned Risk Program.
  • Upon receipt of a notice of claim, the insurer is required to provide the policyholder with the necessary forms, instructions, and reasonable assistance, including but not limited to, specifying the information the policyholder must provide in connection with the proof of claim and begin any necessary investigation of the claim.
  • Thereafter, every insurer is required to conduct and diligently pursue a thorough, fair, and objective investigation of the reported claim, and is prohibited from seeking information not reasonably required for or material to the resolution of a claim dispute before determining whether the claim will be accepted or denied, in whole or in part.
  • After conducting a thorough, fair, and objective investigation of the claim, the insurer must accept or deny the claim, in whole or in part, immediately, but in no event more than 40 days after receipt of the proof of claim. The amount of the claim accepted or denied by the insurer must be clearly documented in the claim file unless the claim has been denied in its entirety.
  • If the claim is denied in whole or in part, the insurer is required to communicate the denial in writing to the policyholder listing all the legal and factual bases for such denial.
  • Where the denial of a first party claim is based on a specific statute, applicable law or policy provision, condition, or exclusion, the written denial must include reference to and provide an explanation of the application of the statute, applicable law, or policy provision, condition, or exclusion to the claim. Lastly, every insurer that denies or rejects a third party claim, in whole or in part, or disputes liability or damages must do so in writing.

Click here to read the full text of The Notice.

If you or someone you know are being denied business interruption benefits by your insurance company, please call Kantor & Kantor for a free consultation at 800-446-7529 or use our online contact form. We understand, and we can help.

 

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