Subject: Vague Language in Policy and Incorrect Terminology Used in Claim Denial
I’m currently navigating my first homeowners insurance claim and have a few questions about the specific language being used, particularly regarding a recent denial from my adjuster concerning water damage and tunneling.
After a pipe broke beneath my house and caused water to overflow through the walls and into the washing machine, I filed a claim. While the water damage is being covered, I’m facing issues with the plumbing repairs due to the adjuster’s decision. Although my policy excludes coverage for the pipes themselves and other related expenses like trenching and backfilling, the plumbers I consulted indicated that tunneling— the method used to access the broken pipes—might be coverable. This tunneling incurred significant costs, totaling around $20,000, which I’ve had to pay out of pocket.
Since I have a slab foundation with a sleeper system installed (which my adjuster noted is unusual for my area), there were no access points in our home. The plumbing company had to tunnel under the house to reach the damaged pipe. On the invoice from the plumbers, tunneling, trenching, and backfilling were clearly defined as separate services. Last night, I received the denial for the tunneling claim, but my adjuster referenced “a clogged pipe” and incorrectly stated that “trenching and backfilling” were the only things excluded, which does not align with the details of my situation. I am specifically seeking coverage for the tunneling cost.
In reviewing my policy and the adjuster’s denial response, I find the language to be vague. The policy states exclusions for the pipes themselves and for structural damage caused by water, but there is no mention of excluding “access” to broken pipes, which is a crucial distinction in my case.
Here’s the adjuster’s response regarding our 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 this: 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 (gradual, continuous, or repeated leakage over 14 days or more).
b. We do not cover any loss or damage to foundations resulting from seepage or other discharges.
c. We do cover costs for tearing out and replacing parts of the building to repair systems, but only if the water or steam causes actual damage to the building.
d. We do not cover water that enters the home from outside plumbing systems.
Is it just me, or does this policy language seem ambiguous? I’m hoping to clarify my position and present an argument for covering the tunneling costs. Any advice on how to approach this with my adjuster? Thank you!
It sounds like you’re facing a complex situation with your homeowners insurance claim, and it’s understandable to feel frustrated, especially given the nuances of insurance language. Here are a few points you might consider when making your case to your adjuster regarding the tunnelling costs:
Clarification of Terms: Since your adjuster used terms like “clogged pipe,” which may not accurately reflect your situation, it’s essential to clarify what the plumbing company did and how it relates to your policy. It sounds like your plumbing issue required tunnelling due to a lack of access, which should be distinguished from trenching or backfilling.
Policy Language Interpretation: The language in your policy does focus on the plumbing system and excludes damage to the pipes, but it seems you are highlighting a gap regarding access to repairs. If “access” isn’t explicitly mentioned as an exclusion, you might argue that the cost to gain access—specifically through tunnelling—should be covered since it was necessary to fix the issue.
Document Everything: Make sure you have all your documentation—photos, invoices, reports from the plumbers, and a detailed explanation of the work that was done and why it was necessary. Clear documentation backing up your claim can strengthen your case significantly.
Seeking Further Clarification: When you communicate with your adjuster, ask for a detailed explanation of why the tunnelling costs were included in the denial. Request that they reassess the situation, considering that the plumbing needed to be repaired and that accessing it was essential.
Utilize a Claims Advocate: If things continue to be complicated, consider consulting with a public adjuster or an insurance attorney who can provide expert advice tailored to your specific situation and help negotiate with your insurance company.
Appeal Process: If your adjuster remains firm on the denial, look into the company’s appeals process. You may need to formally appeal their decision and provide additional evidence or documentation to support your claim.
Check for State Regulations: Some states have regulations that can impact how insurance claims are handled, including issues related to vague policy language. It might be helpful to look into this or consult a local expert.
Navigating insurance claims can be challenging, but it sounds like you have a reasonable argument regarding the tunnelling costs based on the specific circumstances. Keep advocating for yourself and be persistent in communicating the specifics of your claim. Good luck!