Ordinance and law denied per condition

Simple enough. Spaced 1x’s have been an easy supplement for as long as I can remember. A friendly field adjuster acknowledges my concern on this roof being decked with 1x’s and tells me yes the policy holder has local OL and instructs me to supplement for the deck saying it won’t be a problem. Pretty much what I hear anytime I run into this, and it goes just as easy as it sounds. But since SF lets any CAT desk adjuster who answers the phone make decisions and revisions on any given claim notes get lost or not recorded at all, so this has finally caused me a problem. Just when I think I’ve heard it all, along comes that “one desk adjuster” to proud to back peddle. Just a few hours ago I was denied a code upgrade request on a spaced roof deck stating “the condition of the material is old and brittle and broken so we’ll be denying coverage for the costs incurred”. Naturally I ask them if they would kindly instruct me to the page in the policy where it states that code upgrade coverage is determined by current material conditions I’d be happy to explain further to the policy holder. Of coarse she refused the direction request. I proceeded to tell her that as an insurer their contractual liability for a loss in this policy includes the cost of replacing this deck as it is no longer a suitable substrate for the application of new shingles per local code description and that attempting to even discuss its aged condition is a moot point. At this point I think it became more about pride because she shut dialog completely down and said she’ll notify the PO that the cost falls on them. So from here I spoke with the PO and made sure she fully understood her own coverage on this as well as the stance being taking by her insurer. She’s on board to stand her ground and do what’s needed but I honestly don’t know exactly what’s needed. I figured I would tell her let’s give her a agent a call and ask why she been paying a premium which includes OL yet she’s being denied a cost she’s incurred after an upgrade. I also told her we can call back in to the CAT department and if a reasonable adjuster picks up the phone it’s possible we could get some dif results depending on how the denying adjuster noted the claim. It’s almost like no adjuster will even discuss anything that’s already been noted as denied no matter how retarded the reason for denial was. Anyways, I guess what I’m asking is what is the “right” next move here, or order of moves. I would think that this should be as simple as just getting the facts in front of any other eyes besides hers to get a change made. This was a simple approval that was made complicated in very weird way. So yea any advice on a couple options my PO may have here I’d be greatly appreciative. Thanks

State Farm has recently startled fighting decking. I would get the home owner involved like you did. Then I would just demand desk appraisal.

These situations blow. Be sure you are always receiving any thing they approve verbally in writing from that adjuster. A new revised estimate including those line items. Even is crossed out and noted as PWI only. Or at least an email recapping it. It’s the prudent thing to do.

Tape a call pro. Best five dollars I’ve ever spent on an app for my phone. I’m in Virginia and I believe the laws vary from state to state but I do not even have to let anyone know that I am recording the conversation. Whenever I catch them slipping, I bring up the tape play it for the customer and have them write an email regarding the refusal to pay for what was incurred. Also in the email they demand that it be paid as they are now operating in bad faith and violating the state laws regarding the act of unfairly settling claims. Since you have no tangible proof that this is happening at the moment you can download the app record them violating the law and send an email or you can demand Appraisal, those are your two options at this moment as far as I can see.

First, paragraph breaks are your friend. Second, the Homeowner is the one with a vested interest. Given it is SF, have the Homeowner/Policy Holder call their Agent and demand they are provided with the coverage they are paying for. Most SF Agents can be very helpful. If they have the bad luck of having a weak Agent, the Homeowner should call the Adjuster’s Manager and demand to be treated fairly. You should be there to join them on the call to provide technical construction answers.

We mostly quit arguing with Adjusters over fair and legitimate charges. We submit our supplement and if the Adjuster wants to argue about it, we let the Homeowner take over. If they would prefer to pay for it, doesn’t matter to us. Most will pursue their IC with great enthusiasm when they find out their IC is refusing to pay.