[INSURANCE COMPANY] APPROVED REPAIRS THEN STOP PAYMENT

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I am writing this regarding the recent activity on my Insurance claim.  In September 2011 my basement sustained a large amount of water damage.  [An adjuster] came out to my home to survey the damage.  On this date I received the written claim which states that I am to be given $11,669.04 in order to repair my basement to its condition prior to the storms.  The event was classified as water damage.  I specifically advised [the adjuster] that water entered the basement through the french doors & the 90degree elbow disconnect from the pvc pipe which recycled water through the sump pump (See claim documents provide by [adjuster] attached in fax).

In the days that followed I pursued quotes for repair with 3 different contractors & selected the one that came closest to the claim amount I was awarded.  The contractor pointed out the following concerns:

-The entire basement area will need 2 coats of paint to be repaired as it is 10 years old.  The estimator only quoted 1 coat.

-The ceiling tiles had warped from the humidity & moisture.  These would have to be replaced.  The estimator did not address the ceiling.

-I have 15 recessed lights placed in my ceiling.  An electrician would have to come in to properly reset once replacement ceiling was put in.

As none of this was included on the original claim, I contacted [the company] to send [the adjuster] back out for further review & possible increase in funds on my claim.  At that time I was told that [the adjuster] is no longer working in my area & once they could send me a new adjustor they would contact me.  Two weeks later [another adjuster] came out to our home to address our concerns.   [He] took a quick look at our basement & proceeded to go out to his vehicle for the next half hour.  He came back into our home & advised that we were not covered under our policy & if it was him conducting the initial assesment we never would have been awarded the $11,000.  We got our agent on the phone & proceeded to debate what our policy included and did not.  It became quickly apparent that [they] were not on the same page as to what we were paid for, what was available to us here in Virginia and what monetary amount [the company] would provide.

Since this I have been on the phone several times & each employee has become ruder than the next:

[The adjuster]  (adjustor#2) advised that we were not going to receive any further funds than we already had received ($6800) & that we should consider it a gift.

Our agent-advised we were fully covered by VA standards and that the water backup coverage [the adjuster] refers to is not available in Virginia.

When I attempted to add this coverage (for future) via the website (and as [the adjuster] was standing next to me) it allowed me to do so. 

-The next day customer service emailed that I did already have the needed water backup coverage policy in question.  

-This evening another employee called me from customer service  to discss & the end result was the employee advising they did not care if I escalated the matter.

At this point, it is obvious that there are several inconsistencies in what we are being told & the issue is becoming more confusing by the day.  Bottom line I was told almost 2 months ago that I had full coverage & now suddenly I am told I should not have received a cent.  The error is theirs not mine.  Please confirm whether you are able to intervene.

Andrew P.:

Bottom line I was told almost 2 months ago that I had full coverage & now suddenly I am told I should not have received a cent.  The error is theirs not mine.

Actually, the error IS yours. There is no such thing as "full" coverage any more than there is a "perfect" anything.

Had you actually read your policy, you would have understood that EVERY insurance policy has exclusions and limitations.

The two exclusions that affect your claim are:

1 - Flood. That's a standard exclusion in homeowners policies. Which is why there is a National Flood Insurance Program for people to buy separate flood policies. The water that entered through your french doors was excluded.

"Flood, surface water, waves, tidal water, overflow of a body of water, or spray from any of these, whether or not driven by wind"

2 - Sewer and sump backup. That you were able to buy the coverage as an option after your loss means you didn't have it when you had the loss. The water that backed up through your sump was excluded.

"Water or water-borne material which backs up through sewers or drains or which overflows or is discharged from a sump, sump pump or related equipment"

Andrew P.:

(adjustor#2) advised that we were not going to receive any further funds than we already had received ($6800) & that we should consider it a gift.

He's right. It's a gift. You shouldn't have been paid anything at all.

That the first adjuster made a mistake is acknowledged by the company letting you keep the $6800.

You aren't entitled to any more.

Andrew P.:

In the days that followed I pursued quotes for repair with 3 different contractors & selected the one that came closest to the claim amount I was awarded.  The contractor pointed out the following concerns:

-The entire basement area will need 2 coats of paint to be repaired as it is 10 years old.  The estimator only quoted 1 coat.

-The ceiling tiles had warped from the humidity & moisture.  These would have to be replaced.  The estimator did not address the ceiling.

-I have 15 recessed lights placed in my ceiling.  An electrician would have to come in to properly reset once replacement ceiling was put in.

You'd have to fix all that anyway. You've got $6800 to apply to the repairs. Use it wisely. You can probably make it stretch further by buying your own materials and avoiding the contractor markup and hiring individual trades to do the labor. Contractor's and insurance estimates always have a lot of fat in them that can easily be trimmed if you get a little creative.

You can even do some of the work yourself. Like painting. And if you have a suspended ceiling with removable tiles, you can buy the tiles and replace them yourself.

PS: Read your car insurance policy, too, in case you think you have "full" coverage. There's no such thing as "full" coverage there either.

Andrew P.:

Please confirm whether you are able to intervene.

This not a lawyer referral service and lawyers do not surf this site looking for clients. 

2 people from [the insurance company] have confirmed that I have water back on my policy via email.I checked my policy and it states that I have sewer back up.

Adjuster jack, Here is in detail what I have on my policy.Can you please advise if anything helps during my current status,or what I can add to help me in the future.

Deluxe Plus Homeowners Policy form

VA Water Damage Endorsement form

Amendment of Policy Provisions form

Bldg. Struct. Repl. Cost Ext. Lmt. End. form

Thanks

Andrew P.:

Deluxe Plus Homeowners Policy form

That's probably the equivalent of the Homeowners Special Form HO-3. It's probably 20 pages or better so you'll have to read it.

Andrew P.:

VA Water Damage Endorsement form

That one might eliminate the sewer/sump backup exclusion but you'd have to post the wording of the form so I can read it.

The policy would still have the flood exclusion.

Andrew P.:

Amendment of Policy Provisions form

That could be anything. You'll have to read it or post some details.

Andrew P.:

Bldg. Struct. Repl. Cost Ext. Lmt. End. form

Replacement Cost Coverage provides that covered repairs to the structure are paid without depreciation. Typically, though, you get paid the depreciated amount up front and the balance when the repairs are completed.

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Adjuster Jack..Here is a letter from the adjuster I am still waiting for the VA Water Damage Endorsement form

We have carefully reviewed the information about your loss that was reported to us, as well as the policy provisions that
apply to this claim. Based on this review, we were unable to provide coverage for your claim. Our investigation revealed the
damage to your basement and any personal property in the basement resulted from ground/surface/flood water and or
sewer/drain back-up which is not afforded coverage under your policy. Please refer to Section I Your Property, paragraph
Losses We Do Not Cover Under Coverages A and B of the Allstate Insurance Company Deluxe Plus Homeowners AP 142
policy which states:
Losses We Cover Under Coverages A and B:
We will cover direct physical loss to property
described in Coverage A Dwelling Protection
and Coverage B Other Structures Protection
except as limited or excluded in this policy.
Losses We Do Not Cover Under Coverages A and B:
We do not cover loss to the property described in
Coverage A Dwelling Protection or Coverage
B Other Structures Protection caused directly
or Indirect Iy by any of the tottowttrgrregardless of --:--
any other cause or event contributing
concurrently or in any sequence to the loss.
A. 1. Rood, including, but not limited to
surface water, waves, tidal water or
overflow of any body of water, or spray
from any of these, whether or not driven
by wind.
2. Water that backs up through sewers or
drains.
3. Water that overflows from a sump
pump, sump pump well or other system
designed for the removal of subsurface
water which is drained from a
foundation area of a structure.

4. Water below the surface of the ground,

regardless of its source. This includes

water which exerts pressure on, or

flows, seeps or leaks through any part

of the residence premises.

We do cover direct physical loss caused

by fire, explosion or theft resulting from

items 1 through 4 listed above.

c.l. Weather Conditions that contribute in any

way with a cause of loss excluded

Thanks for your help !!!

Your policy has the same exclusions I referred to earlier.

Andrew P.:

I am still waiting for the VA Water Damage Endorsement form

Still waiting?

I'm confused.

Did you have the coverage on your policy before the loss or not?

If you did have it, it would be listed on the declaration page of the policy and the form would be attached to your policy.

Unfortunately, I did a little more looking on the internet and I am a bit concerned that even the VA Water Damage Endorsement might not help you get any more money from the insurance company.

Earlier, you wrote:

Andrew P.:

I specifically advised [the adjuster] that water entered the basement through the french doors & the 90degree elbow disconnect from the pvc pipe which recycled water through the sump pump

It's not clear exactly what you are saying about the sump pump.

Read the following court decision regarding a similar situation and you see what I mean:

http://constructionlawva.com/wp-content/uploads/2011/06/Dent-v.-Allstate-Indemnity-Co..pdf

If all the water came through the french doors and the sump pump failed to remove it, that would not be a back up and therefore not coverage by the endorsement since it would all be flood damage.

Adjuster Jack,

I have sewer back up on my policy

Here is their defination on the policy...Protect your property against water damage. . .
Insurance protection is available for water damage caused by backed up sewers and drains. The annual cost of adding this important coverage to your Homeowners policy is $25. This option includes a $250 deductible and is subject to the terms of your Homeowners policy. If you wish to add this coverage to your present policy But I am still for VA Water Damage Endorsement form.

The coverage blurb doesn't help.

Post the wording of the endorsement when you find it or get a copy.

Meantime, did you read the case decision?

And could you explain the emphasized part about the elbow disconnect:

Andrew P.:

I specifically advised [the adjuster] that water entered the basement through the french doors & the 90 degree elbow disconnect from the pvc pipe which recycled water through the sump pump

LossesWe Do Not Cover Under Coverages A and B:
We do not cover loss to the property described in
Coverage A —Dwelling Protection or Coverage
B —Other Structures Protection caused directly
or indirectly by any of the following, regardless of
any other cause or event contributing
concurrently or in any sequence to the loss.
A. 1. Flood, including, but not limited to
surface water, waves, tidal water or
overflow of any body of water, or spray
from any of these, whether or not driven
by wind.
2. Water that backs up through sewers or
drains.
3. Water that overflows from a sump
pump, sump pump well or other system
designed for the removal of subsurface
water which is drained from a
foundation area of a structure.
4. Water below the surface of the ground,
regardless of its source. This includes
water which exerts pressure on, or
flows, seeps or leaks through any part
of the residence premises .
We do cover direct physical loss caused
by fire, explosion or theft resulting from
items 1 through 4 listed above.
5. Earth movement of any type, including,
but not limited to earthquake, volcanic
eruption, lava flow, landslide,
subsidence, mudflow, pressure,
sinkhole, erosion, or the sinking, rising,
shifting, creeping, expanding, bulging,
cracking, settling or contracting of the
earth. This exclusion applies whether or
not the earth movement is combined
with water.
We do cover direct physical loss caused
by fire, explosion, theft or breakage of
glass or safety glazing materials
resulting from earth movement.
6. Enforcement of any building codes,
ordinances or laws regulating the
construction, reconstruction,
maintenance, repair, placement or
demolition of any building structure,
other structure or land at the residence
premises . This provision does not apply
to the replacement of damaged glass
which constitutes a part of the covered
dwelling with safety glazing material
where required by ordinance or law.
We do cover direct physical loss caused
by actions of civil authority to prevent
the spread of fire.
7. The failure by any insured person to
take all reasonable steps to preserve
property when the property is
endangered by a cause of loss we cover.
8. Intentional or criminal acts of, or at the
direction of, an insured person , if the
loss that occurs:

----------------------...

Virginia Water Damage Endorsement
Coverage SB — Sewer or Drain Back up — AP152

For an additional premium, and when Coverage SB —SEWER OR DRAIN BACK UP appears on your Policy
Declarations in the section entitled "POLICY COVERAGES AND LIMITS OF LIABILITY ":
1. We will cover direct physical loss to covered property under Coverage A —Dwelling Protection ,
Coverage B —Other Structures Protection and Coverage C —Personal Property Protection caused
by water or any other substances which backs up through sewers or drains.
A deductible will apply to each covered sewer or drain water back up loss. The

Andrew P.:

For an additional premium, and when Coverage SB —SEWER OR DRAIN BACK UP appears on your Policy
Declarations in the section entitled "POLICY COVERAGES AND LIMITS OF LIABILITY ":
1. We will cover direct physical loss to covered property under Coverage A —Dwelling Protection ,
Coverage B —Other Structures Protection and Coverage C —Personal Property Protection caused
by water or any other substances which backs up through sewers or drains.

The important words are in bold.

There are 4 exclusions related to water:

Andrew P.:

1. Flood, including, but not limited to surface water, waves, tidal water or overflow of any body of water, or spray from any of these, whether or not driven by wind.
2. Water that backs up through sewers or drains.
3. Water that overflows from a sump pump, sump pump well or other system designed for the removal of subsurface water which is drained from a foundation area of a structure.
4. Water below the surface of the ground, regardless of its source. This includes water which exerts pressure on, or flows, seeps or leaks through any part of the residence premises .

The endorsement eliminates ONLY exclusion 2. Water that backs up through sewers or drains.

Since your basement was flooded by water coming in through the french doors the entire loss would not be covered.

All I can say at this point, is that you should be thankful for the money you already got.

Adjuster Jack,

First I would like to say Thanks for all your advise.

My (walk up) basement was flooded by the sump pump failure then the water was coming in from the sump pump well from the drain outside and through the door.

Andrew P.:

water was coming in from the sump pump well from the drain outside and through the door.

I don't see that as making a difference.

In that case decision I posted earlier, the court ruled:

• Moreover, if surface water only partially contributed to the damage, the entire loss still would not be covered under the Homeowners Policy. (See Statement of Undisputed Facts, Ex. A) (excluding loss "caused directly or indirectly by any ofthe folloWing, regardless of any other cause or event contributing concurrently or in any sequence to the loss"); see also Casey v. General Acci. Ins. Co., 178 A.D.2d 1001, 1002 (N.Y. App. Div. 4th Dep't 1991) ("[w]hile the clogged drain certainly contributed to the loss, the actual cause ofthe loss was the presence of surface water. Since the policy expressly excluded any loss 'caused directly or indirectly' by surface water 'regardless of any other cause or event contributing concurrently or in any sequence to the loss', we grant judgment declaring that the exclusion is applicable as a matter of . law"); Front Row Theatre v. AmerIcan Mfr. IS Mut. Ins. Cos., 18 F.3d 1343', 1347 (6th Cir. Ohio 1994) ("[w]hen damage to an insured's property is caused by both a covered and an excluded event, coverage may be expressly precluded by language in the policy.")

Had the french doors been sealed at the bottom so that no water could come through it's possible that water coming from outside back through the sump would have been covered.

It appears that [this company] is the only company that doesnt offer sump pump coverage in Virginia