Rules for Responding to Coverage Questions - Property & Liability Resource Bureau (2024)

Rules for Responding to Coverage Questions (04/20/2023)

In General

never tell insurers to pay a claim or deny coverage, etc. instead, suggest if there is a stronger argument for or against coverage (if there is a stronger one);
apply facts from the question to the research you provide, rather than just citing the law;
answer questions in the order in which it is received, but always within 5 business days (let your supervisor know if you are getting bogged down and need help);
be sure to review all questions on the day they come in to avoid looking at the cq on day #4 or 5 and only then realizing it is out of the scope of our services or belongs to another PLRB department;
if you know an adjuster has already denied a claim, and your opinion is that the better view is clearly that the claim is covered, reach out to the adjuster by phone first and discuss your opinion briefly, and then ask if they want your opinion in writing. Don’t be muscled into providing a coverage opinion you don’t agree with, but also avoid creating a written documentation, i.e., your coverage opinion, in the adjuster’s claim file that you know the adjuster disagrees with and has denied coverage already;
try to end all coverage opinions with language that encourage the adjuster to use our services again, such as the following:

Your company’s membership is based on a flat fee, and is not based on your actual usage of our services. So, feel free to reach out to us whenever you like, as it does not cost your company any additional amount. We enjoy receiving coverage questions and look forward to hearing from you again. Have a great day.

Rush requests

as noted above, try to answer all cqs in the order they come in. That said, from time to time an adjuster might be in a bind and needs a rush reply from you. On the one hand, we don’t want an adjuster to think they can jump to the front of the line every time someone asks for a rush. On the other hand, if the person does not normally call with a rush request, consider bumping them to the front of the line, but if you do, include as the bottom of your reply, the following:

As a courtesy to you, I am happy to assist you with your “rush” question. For future questions though, please notethat typically, in fairness to all of our members, we answer the questions we receive in the order in which they are submitted.

Our goal is to reply to all questions within 2 to 5 business days from when they are received, assuming we are provided with theinformation needed to provide an analysis, i.e., policy language, sufficient facts, state of loss, etc. The amount of time it takes to reply to a question will vary based upon the complexity of the question as well as the volume of other coverage questions received. If 5 business days have passed, and you have not heard back from us, please feel free to contact us and inquire about the status of your question, if for no other reason, to make sure there has not been a communication glitch.

Thanks for submitting your question. We are happy to assist you.

Too Many Forms

If it appears the adjuster has dumped their entire claim file on you and sent a bunch of irrelevant forms that will take you hours to review, consider sending the following reply:

Thank you for submitting your coverage question. I see that you have attached many forms with your question. We try to respond to each inquiry as quickly as possible. However, when an attachmentincludes numerous forms, of which many are not applicable, it delays the process. Since youare most familiar with your company forms, would you kindly please identify which form(s) you would like me to review for coverage. I will then analyze the policy language in those forms and get back to you as quickly as possible.

Double Dipping

Every once in a while an adjuster sends the same question in several times. This may be because they had an error message the first time they sent it and didn’t realize we received it, or perhaps they didn’t like the first coverage opinion they received from PLRB. When you catch a duplicate, consider responding as follows:

Our logging system indicates that you submitted the same coverage question twice. We are always happy to assist you, but in order to keep our response time for all coverage inquires as short as possible, we request that you only submit the samequestion once. If you ever disagree with the coverage reply from PLRB, you are more than welcome to contact the attorney who initially responded to you and discuss the matter, or feel free to let me know and I can inform my supervisor.

If you ever submit the question twice by mistake, and you get an automatic reply from PLRB informing you who the question was assigned to, we would greatly appreciate it if you would notify us so we can prevent two of our attorneys duplicating the same work.

If you had no idea that the same question was submitted twice, I am sorry to bother you. We take great effort to reply to member coverage inquiries as quickly as possible. Thank you for submitting your question.

Liability question sent to property department by mistake by a member whose membership includes liability (or from a Property only member but it’s an HO Section II question)

Please send all questions sent to the wrong department to Beth. If Beth is out for more than a day, please send it to the person with the fewest questions for the day by looking at the coverage rotation chart (push staff questions on the top of the coverage logging page).

Liability Question and a. Not from a company whose membership includes liability AND 2. It is NOT a Section II HO question

Property only members may still ask LIRB Section II coverage questions. However, they may not ask any other liability questions, i.e., not CGL, Businessowners Liability etc. Nor may they as any auto questions, even if they are first part auto questions. If you get a liability (other than HO Section II), or an auto question, please forward their question directly to me. I will then respond back to them explaining why we cannot help. But this will allow me to send marketing materials to them or their supervisor to encourage them to add liability to their property membership.

Outside the Scope of What We Do

From time to time, you may get a question that may be based on a property claim, but the topic raised is simply outside the scope of our services / expertise. On the one hand, I hate to leave a member empty handed. On the other hand, we don’t want to send them something we have no expertise handling Sometimes you can tell them it is outside the scope of what we do, but you might send them a link from an outside source on the matter, and always encourage them to check with local counsel.

California Question

All property questions involving California law should be given to Ransella (since she has a CA law license). Be sure to ask her to send you one of her non-CA questions back to you so the work load remains even. Ransella need not wait for you to ask her to send you one of hers. If Ransella is on vacation for more than a few days, consider responding old school:

PLRB is not permitted to render opinions on the application of California statutes and court decisions to specific claims involving California law, however we can provide materials on the California matter you raised. California defense counsel should be consulted on the application of California statutes and court decisions to specific claims scenarios.

CA Liability question. When you get a CA question, please contact Ransella to be sure she will be available to review it. If so and she co-signs it, you can send it. If Ransella is not available, please provide the same caveat with your more general response:

Member conflict

From time to time you may get a cq that involves two companies, both of whom are PLRB members. Often you have an idea there is another carrier involved before you know its name. When this occurs, stop the adjuster in their tracks, if it’s not too late. Then explain there may be a potential member conflict, and you don’t want to know the other carrier’s name. You may then provide them with legal materials on the topic they raised, but you should make it clear you cannot give an actual opinion on the matter. If you do find out the other carriers name, and they are not a PLRB member, you can provide a coverage opinion. If it turns out the other carrier is a member, again, you may provide legal materials on the topic but you cannot provide a coverage opinion without first getting written permission from both companies stating they give PLRB permission to provide a non-binding coverage opinion. Consider using language for other insurance or primary / excess issue, such as:

Thank you for submitting your coverage question involving “other insurance.” Unfortunately, the issue you have raised involves a potential member conflict between your company and another PLRB member insurance company. As a result, I am able to provide you with some general information on the subject matter, but not a coverage opinion. (See the discussion below.)

If you would like an actual coverage opinion on this matter, I would need written permission from both you and the other member company stating that you both acknowledge that two PLRB member companies are involved in this claim and that you both give permission for PLRB to provide a non-binding coverage opinion on the matter raised.

Specific CQ Rules for Individual Member Companies

For all of the companies listed below, if you get a coverage question from someone who is not authorized, please don’t just turn them away. Instead, 1. explain to them who, if anyone, at their company, i.e., their legal department, does have access to the PLRB coverage attorneys and tell them they may forward their question on to that person/department, and 2. Please offer to talk to them over the phone and provide them with instructions on how to navigate our website to find materials that may be on point with their coverage needs. (For example, you can’t tell them if the wear and tear exclusion applies, but you can show them how to locate the wear and tear discussion in our policy annotations and how to pull up cqs and law reviews on point.) Having this one-on-one tutorial over the phone is really important because this will increase the likelihood that the person who reached out to you will continueusing our services.

When responding by email, it will be helpful to use the following language:

Per the request of senior management at your company, PLRB is not permitted to provide your company with coverage opinions. You do, however, have full access to our extensive online coverage database for purposes of finding information on any coverage issues you may have.

However, I am able to instruct you on navigating our website so that you can locate materials relevant to whatever coverage issues you may be interested in. If you have any questions about this, please feel free to call me.

State Farm (no cqs)
– nobody is permitted to ask coverage questions
– they do have access to our database, and you may assist in telling them, over the phone only, how to navigate our website

– but you may not provide them with any direct research

You may send the following language:

Per the request of State Farm’s home office, we have been instructed that State Farm employees are not permitted to send coverage questions to PLRB. You do, however, have full access to our coverage database for purposes of finding information on any coverage inquiries you may have.

I am sorry I am not able to directly assist you.Please note, however, I am more than happy to instruct you on navigating our website if you want tips on locating materials relevant to whatever coverage issues you may be interested in. If you have any questions about this, please feel free to call me.

Travelers / St Paul

– only Tim Penn or Brian Budris of Traveler’s may submit cqs to PLRB, but do not give their names out to Travelers employees as they don’t want to be contacted for every cq.

-instead, use the following language if you receive a Travelers coverage question:

Unfortunately, Travelers does not allow coverage questions to be submitted to the PLRB. Instead, such questions should be referred to your Claim Center’s PCQM liaison.

I am sorry I am not able to directly assist you.Please note, however, you do have theability to search PLRB’s website to review coverage materials that may be of use to you.If you have any questions about navigating PLRB’s coverage database, please do not hesitate to contact me.

Erie (provide arguments for both sides)
– likes wiggle room in our replies.

– you can tell them what may be the stronger view re: coverage, but they want wiggle room in case they chose to take the opposite view. Thus, when replying, try to present arguments for and against coverage. If you lean towards coverage, be sure to also provide any legitimate arguments against. However, do not create silly arguments against coverage, only provide reasonable arguments.

Progressive Insurance

If a Progressive employee reaches out to PLRB for a Legal Opinion, you should send an email alert to:

1. Traci Toth, traci_m_toth@progressive.com

And copy

1. Devin Clippinger, Devin_Clippinger@progressive.com

Furthermore, PLRB should not complete the Legal Opinion unless specifically instructed by one of the two primary contacts.

Farmers Mutual of Nebraska

Coverage questions may only be submitted by their legal department. I was actually given four names of those who can ask coverage questions. They are:

Mark Gokie, Vice President and Assistant General Counsel
Kerrie Snowden, VP & Assistant General Counsel
Ann Par, EVP, Secretary and General Counsel
Jennifer Martinez,Associate General Counsel

However, you only need remember that coveragequestions are limited to anybody fromFarmersMutualof Nebraska with some version of “general counsel” in their title,(as the 4 people listed above are the only ones in the legal department).

Please note, that they want thesame restriction for building code inquiries. Anyone atFarmersMutualmay request a copy of a building code, but only their legal department can ask PLRB for its interpretation of a building code.

USAA

It appears that USAA is now permitting liability questions (this was in question a originally).

IAT

At this time, IAT does not permit any staff to answer any coverage question. Use the language at the beginning of this provision.