Carlsbad's Insurance Law Attorney

What does an Insurance Lawyer do?

Insurance is complicated. In any injury, there could be factors like Group Health, Workers Compensation, Medicare, Medi-Cal, your own private medical insurance, just to name some. The function of an insurance lawyer, like Mark Caruana, is to coordinate all those benefits to maximize your recovery.

On one side is the consumer paying premiums and anticipating payment when devastating accidents occur. On the other side are the companies taking huge risks to offer insurance in the hopes of making profits. As an Insurance Lawyer, Mark Caruana works with one side or the other to aid in understanding laws, completing paperwork and surviving the process of going to trial.

Major U.S. Insurance Laws & Decisions

Even though most insurance regulation in the United States happens at a state level, there are some significant pieces of U.S. insurance legislation. There are also notable court decisions. From initially ruling that insurance contracts are not commercial products subject to insurance regulation, the U.S. Supreme Court upheld federal insurance regulations in the 1944 United States v. Southeastern Underwriters Association case.

Affordable Care Act

The Affordable Care Act is actually two laws: the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. The laws expand Medicaid and other government health insurance programs. They create subsidies for private health insurance policies based on income and also create requirements for certain mandated coverage in private insurance policies.

Medicare, Medi-Cal, Military Liens

Each of these will require a right to reimbursement and there are issues than can be raised with each of them.

Good Faith

One of the key principles in insurance is the concept of good faith. Insurance as a contract and as a financial product only works when both parties are honest with each other and work to fulfill the terms of the contract based on the true facts of the situation. Failing to apply for an insurance contract in good faith is a form of cheating. Refusing to pay a fair claim is another form of cheating. The opposite of good faith is bad faith.

For example, a person applies for life insurance. They answer on the form that they don’t have any pre-existing medical conditions and that they have never been hospitalized. In fact, that isn’t true. The person was hospitalized last year with a serious illness. Five years later, the insured dies of the same illness.

The life insurance beneficiaries try to make a claim on the insurance policy. The insurance company refuses the claim and refunds the premium. The contract is null and void because the insured didn’t enter into the insurance policy in good faith.

An insurance company can also act in bad faith. They can refuse to pay good claims. When an insurance company doesn’t have a good argument for denying a claim, they can face administrative penalties as well as a lawsuit for failing to handle the claim good faith. The penalties they face are in addition to legal actions to force them to pay the claim according to the terms of the contract.

Frequently Asked Questions

  • What does the term “bad faith” insurance mean?

    “Bad faith” refers to unreasonable or unfair conduct by an insurance company. An insurance policy is considered a contract between you (the Insured) and your insurance carrier (the Insurer). Bad faith insurance is any matter regarding an insurance claim by an Insured that is wrongfully denied by the Insurer. This contract requires that your Insurer acts in “good faith” toward you. When an Insurer unreasonably withholds the benefits of the policy from its Insured, it is considered to be in “bad faith.”

  • Why do insurance companies (insurers) commit “bad faith?”

    Insurance companies have a self interest to not pay claims; it saves them money. Companies receive thousands of claims daily and wrongfully deny many of them. Very few people actually dispute their claim, which keeps millions of dollars with the company. If an insurance company refuses to pay your claim, denies payment or offers an insufficient amount, it would be wise to hire a lawyer to enforce the insurance company’s obligations. You should never have to represent yourself alone against an insurance company or accept an unfair settlement offer.

  • What are some examples of “bad faith” conduct?

    Some examples are:

    • Failing to promptly and thoroughly investigate a claim
    • Unreasonable interpretations in translating policy language
    • Refusing to settle the case or reimburse you for the entirety of your loss, etc.
    • Unreasonable denial of benefits to a claim or termination of an insurance claim that should have been paid
    • Unreasonable delay in making payments to the policyholder
    • Unreasonable failure to defend a policyholder who has been sued under a policy containing a liability provision
    • Unreasonable attempts to under-settle or lowball the payment of a claim
  • How do I know I have a “bad faith” insurance claim?

    When you purchase an insurance policy, whether for life insurance, disability insurance, homeowners insurance or any other type of policy, you are entitled to the full benefits of the policy if you have a covered claim. If the insurance company refuses to pay or if it delays your payment, you may have a bad faith insurance claim.

  • Can an insurance company deny my claim?

    Yes. Insurers have the right to deny your claim if you have reneged on your end of the contract, or if the claim is fraudulent or not covered by the policy. Bad faith occurs when the insurance company’s conduct is egregious.

  • What if my insurance company still continues to deny my claim and commits bad faith?

    Insurance policies are very confusing and filled with many loopholes which can keep you from getting all the benefits you are due. If you are having a problem collecting benefits you feel you are entitled to, bring your policy and documentation to Holland & Lamoureux for a free consultation. After a quick review of the policy, we will be able to determine whether or not coverage applies for your loss, and whether or not the Insurer has committed bad faith.

  • What can I recover if I sue my Insurer for bad faith?

    If the Court finds the Insurer wrongfully denied your claim, you would be eligible to recover the benefits of the policy for the claim, and possibly consequential losses and damages suffered for emotional distress, lost income and attorney fees. In some cases where the Insurer has exhibited flagrant, intentional and/or gross misconduct, punitive damages are awarded.

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