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Who is involved in an insurance claim?

Posted on: December 5, 2022

LEGALLY REVIEWED BY:
Chi Hung Nguyen
December 5, 2022

Many parties to an insurance case means you need the right lawyer to handle each

It can be hard to get the insurance company’s attention. Usually, a claimant is injured in a car accident or truck accident. He or she files a claim with the insurance company. The claimant is ignored, or feels like the insurance company is taking advantage of him or her and wonders “Insurance company won’t call me back”? The claimant feels like the insurance company is failing the most important duties owed: to work towards resolving a claim quickly, fairly and the right way. But this does not always happen.

What do you do when an insurance company is not calling you back? Contact an experienced personal injury lawyer as soon as possible. A part of the problem may be that you are not speaking with the right person. Understanding who play each role in an insurance claim can help you get to the right point of contact.

What is a claimant and a plaintiff?

A “claimant” is the person who was hurt, and is not represented by a lawyer. To get a response and stop being mistreated by the insurance company, the claimant hires a lawyer and eventually becomes known as the “plaintiff,” or person who brings the lawsuit.

The term “insured” means the person who is covered by the insurance policy. An insurance policy is a contract, and the people or entities named and make up that definition are covered. Insureds can be added to an existing policy through additional insured endorsements. Additional insured endorsements are issued by the insurance broker, and typically a page long. For example, one contractor can add another to the policy, or a tenant can add their landlord. In car accidents, the auto policy usually makes everyone who is in the household an insured person covered by the insurance policy.

On the other side are those that help bring about the insurance policy deal:  the insurance agent and the insurance broker.

It is important to know the difference between the insurance agent and the insurance broker

One may accidentally call themselves with the other’s job title. But both have different legal duties and which person made certain promises to the insured or claimant can make or break your case. The difference between them is not always clear.

A court may not see or care about the difference between these job titles. An insurance broker may act as the insurance company’s agent, and the agent may owe certain duties and have to do certain things for the insured because of an obligation under the law.

In one New York lawsuit, the court said that an insurance broker who acts like an insurance agent can owe the legal duties of both the broker and the insurance agent, and then become responsible for failing to carry out those duties. In this case, the broker got insurance for the policyholder while also collecting insurance premium payments for the insurance provider. By mixing the funds and carrying out both jobs, he chose to accept responsibility for all of those duties. When he failed to fulfill those duties, he exposed himself to liability.

Usually, insurance agent works for the insurance company. The insurance broker works for the insured, or person who is trying to get insurance. But both are basically middlemen between the two sides. Both usually are the first to communicate or receive communication about a claim, can both can become liable for misrepresentations they make under the law.

What is an insurance broker?

Specifically, an insurance broker is an independent contractor with a license to work. The broker looks for and gets insurance that covers everything that the insured person wants covered under the market conditions. They do not usually have technical or specialized legal knowledge, they just facilitate the deal. They do not actually make the terms or wording of the insurance policy. They also do not actually make a decision on whether insurance is going to cover a particular claim or not. If they find out a claim, the broker’s duty is to tell the insured to go to the insurance company’s claims department.

If the person is paid on commission and hired by the policyholder or insured, then he or she is probably an insurance broker. Brokers also have their own insurance to cover for any mistakes they make in their job or course of business.

What is an insurance agent?

Not all insurance companies use brokers. Some just use insurance agents. Insurance agents are like the salesmen of the insurance company’s policies. They have a contract or agreement with the insurance company, have certain legal duties or obligations, and may have the ability to issue insurance policies and bind the insurance company to their contract agreements. Put simply, this means that the insurance agent works for the insurance company directly, given certain power and authority, and because of this, they can enter into an agreement on behalf of the insurance company. The insurance company has to honor agreements made by their authorized agents.

If the person is paid by the insurance company directly, then he or she is probably an insurance agent.

The details about what the insurance agent and the insurance broker can and cannot do depends on the wording of the agency agreement between the person or company that hired him or her. This contractual agreement spells out what is expected, including job duties and other legal obligations and responsibilities they must carry out. It also describes how much authority the person has when carrying out his or her duties under the contract.

This can seem fairly straightforward for the insurance agent and the insurance broker. Do what the contract says you can do, and nothing more. But in reality, putting this into practice can be a challenge.

For example, let’s say that an insurance agent is given the power to add another person that will be covered under the insurance policy, or a new covered loss location. The claimant gives the insurance agent new information to add a new insured or new covered loss location. The agent confirms this change, and notifies the insurance company to make those changes. The insurance company does not add the new insured because the update got lost in the shuffle, and does not follow all of the steps so that the coverage clearly tells you which loss locations are covered and which are not. The next year, the insurance company changes its contract with the agent so now the agent does not have the authority or ability to add a new insured. If the new claim is made, then the insurance company may not only be liable to the agent under the agent agreement, but the insurance company can also face a lawsuit for not doing everything it was supposed to do in order to ensure that they determined the level of coverage for loss locations. The insurance company can be liable for the actions of their insurance agents.

Injured claimants need to understand who they are working with for many reasons. One important reason is notice. The claimant must provide notice of their claim to the insurance company in order to seek monetary relief for the injuries and property damage they suffered. If the claimant is confused and mistakenly believes that the broker works for the insurance company directly instead of the insurance agent, then the notice may be ineffective. Waiting too late to provide notice and file a claim can lead to no recovery at all.

What is an insurance adjuster?

An insurance adjuster is the person who evaluates and makes decisions about an insurance claim. There are many levels of insurance adjusters with different levels of authority to enter into settlements. The goal of most insurance adjusters are pay and close out claims. They may want to enter into a settlement quickly. But that may not be enough. Whether it is because a particular insurance adjuster was not trained, misinformed or simply does not care, the adjuster’s actions can expose an insurance company to bad faith claims if they do not do their job well. It is the job of your car accident lawyer to help you build a claims case and persuade the insurance company that your claim needs to paid and minimize any possible delays.

People buy insurance – which is essentially a promise to help provide coverage in the future if something bad or unexpected happens. The insured wants peace of mind. The insured wants to feel protected, and receive that protection on time, with the least amount of stress possible. Unfortunately, neither the insurance broker or the insurance agent always completely and perfectly describe everything you need to know about full coverage and service under a specific insurance policy. The complex structure and many moving parts of the insurance company does not make the recovery process any easier.

 

Contact an experienced personal injury lawyer

Navigating complex personal injury cases and handling insurance companies can make the recovery process even more difficult. Experienced attorneys strategically weigh the cost and benefits of each case to minimize the time and expense involved while maximizing their clients’ compensation.

Are you trying to secure your financial recovery with the help of experienced attorneys? If so, we can help.

The Pusch & Nguyen Law Firm has helped countless Texans handle their insurance disputes. Our experienced trial lawyers have gone up against some of the biggest names in the insurance industry while successfully bringing home payouts for clients. Our successful reputation speaks for itself, and with offices in both Houston and San Antonio, we are well equipped to assist Texans who are in dire need of our services. Register online for a free case evaluation or call us today at 713-366-4624 (Houston) or 210-702-3000 to schedule an appointment with a member of our team.

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