Subject: Clarification Needed on Insurance Claim Denial for Tunneling
I’m navigating my first homeowners insurance claim and I have questions about the language used in my policy regarding a recent water damage incident.
In short, I experienced a pipe break beneath my house, which resulted in significant water overflow through the washing machine’s walls and pipes. The damage was sudden and accidental, and while the insurance is covering the water damage, they’re denying coverage for the plumbing repairs. I acknowledge that the policy excludes coverage for the pipes themselves and for trenching, but the plumbers I hired indicated that tunneling could potentially be covered, which is the most costly part of the repair, totaling about $20,000 out of my pocket.
My home is built on a slab foundation, and the installation of a sleeper system was noted by my adjuster as unusual in my area. Given that there were no accessible points within the house, the plumbing company had to tunnel under it to access the broken pipe. On their invoice, tunneling, trenching, and backfilling were all distinctly identified. However, I received a denial regarding this aspect of the claim last night. The adjuster referenced “a clogged pipe” and stated that trenching and backfilling were not covered, which seem to be misinterpretations of my situation. I am specifically seeking to have the tunneling costs covered.
I have included his response below along with the relevant insurance policy excerpt he cited for denying coverage. I find the wording to be vague. The policy does not mention anything about excluding access to broken pipes, only addressing the pipes themselves and “structures and water damage or losses” from beneath or outside the home. This ambiguity, combined with the adjuster’s mischaracterization of my claim, raises questions about the decision to deny coverage.
Coverage Position:
“You are covered for the interior water damage caused by the drain clog. There is no coverage for any wear and tear to the plumbing or any plumbing within the foundation, and therefore no trenching and backfilling is covered per the policy provisions.”
SPECIAL PROVISIONS
SECTION I – PERILS INSURED AGAINST
Coverage A – Dwelling And Coverage B – Other Structures
The Exception to A.2.c.(6) is deleted and replaced by the following: Unless otherwise excluded, we cover damage to A – Dwelling and B – Other Structures from a Sudden and Accidental Discharge or overflow of Water or Steam from within a plumbing or drain system, heating system, air conditioning system, or household appliance, subject to the following:
a. We do not cover loss caused directly or indirectly by or resulting from seepage, meaning a gradual, continuous, or repeated seepage or leakage of water, steam or fuel over a period of fourteen days or more, resulting in damage to the structure, whether hidden or not:
(1) From a plumbing, heating, air conditioning or automatic fire protection system or from within a domestic appliance; or
(2) From within or around any plumbing fixtures, including, but not limited to, shower stalls, shower pans, shower baths, tub installations, sinks or other fixtures, including ceilings, walls, or floors.
b. We do not cover any loss or damage to foundations or foundation slabs resulting from any seepage, leakage or other discharge or overflow of water or steam.
c. We do not cover loss to the system or appliance from which the water or steam escaped. We will cover the cost of tearing out and replacing any part of the building necessary to repair or replace the heating system, air conditioning system, plumbing supply or drain system, or household appliance. However, such tear out and replacement coverage only applies if the water or steam causes actual damage to a building on the “residence premises.” There is no coverage for any testing of the foundation or plumbing within the foundation, tear out, repair or replacement of the foundation or foundation slab.
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It sounds like you’re dealing with a frustrating situation, particularly with the language used by your adjuster and the interpretation of your policy. Here are a few points to consider as you navigate this claim:
Clarify Terms: It seems there’s a significant difference between “tunneling” and “trenching.” If your plumbers have indicated that tunneling is indeed a necessary process for accessing and repairing the broken pipe, emphasize this distinction when communicating with your adjuster. Tunneling might fall under the necessary repair work to address a sudden water loss, separate from typical exclusions for wear and tear or maintenance issues.
Policy Interpretation: The language of your policy may appear vague, which can indeed work in your favor. Since it’s ambiguous regarding access to broken pipes, particularly in cases where no internal access points exist, you could argue that the cost of tunneling should not be excluded simply because it was necessary to access the plumbing system. Highlight that the policy specifically provides coverage for water damage caused by sudden and accidental discharges, which was the case for your incident.
Adjuster’s Miscommunication: Your adjuster referenced a “clogged pipe” when denying the claim, which you noted seems incorrect based on the circumstances of your situation. Document this miscommunication, as it could support your case that the denial was not based on the actual incident but on a misunderstanding of the specifics of your situation.
Gather Documentation: Compile all the relevant documentation, including invoices, plumber reports, and photographs of the damage and repairs. Ensure your argument is clear and supported by evidence. This will help you present a more compelling case when discussing the coverage with your adjuster.
Ask for a Re-Evaluation: Request a formal re-evaluation of your claim that focuses specifically on the tunneling aspect. It may also be beneficial to ask for a supervisor or a more experienced claims adjuster to review your case if the initial adjuster remains unyielding.
Consider Professional Advice: If negotiations with the insurance company continue to be unproductive, it may be worthwhile to consult with a public adjuster or an attorney who specializes in insurance claims. They can provide insights into your rights and the clarity of your coverage under the terms of the policy.
Navigating an insurance claim can be intricate, especially with miscommunications involved. Keep pushing for clarity, and don’t hesitate to assert your case for coverage based on the specific circumstances of your claim. Good luck!