Tuesday, September 23, 2008

How to read an insurance policy: the known loss doctrine, part 1

The insuring agreement often incorporates the "known loss doctrine," generally with words to the effect that the policy covers "bodily injury or property damage that was not, prior to the policy period, known to have occurred by any insured."

The known loss doctrine is one of the most basic concepts of insurance coverage. Insurance is supposed to be a gamble: You pay $1.00 in premiums now as a gamble against the risk that without the insurance you would have to pay $10.00 in loss (or attorney's fees) in six months. You can play the odds by negotiating premiums against limits. If the premiums become too high vis a vis the chances of the insured event occurring (many people--but not me--say this is the case with disability insurance) or the maximum payout is too low (generally, dental insurance), you choose not to purchase the insurance.

The whole system falls apart if you purchase insurance for a loss you already know has occurred. In law school parlance, the insurance is no longer against a "fortuitous" event.

Litigation around the known loss doctrine predictably concerns what it means to be "known": who knew, what they knew, and when they knew it. The issue frequently comes up in environmental contamination litigation: An insured may argue that although there was some evidence of contamination at the time the policy began, the insured did not know the extent of the contamination. The Supreme Judicial Court of Massachusetts has stated in this context that the only requirement for the loss to be exempt from coverage is that "the insured has evidence of a probable loss when it purchases the policy." SCA Services, Inc. v. Transportation Ins. Co., 419 Mass. 528, 533 (1995).

Another common context for the known loss doctrine is construction defect litigation. Arguments frequently arise about punch lists demonstrating problems such as lack of caulking or other insufficiencies in the building envelope. Insurers argue that those punch lists show that the insured contractor was aware of probable water infiltration into the building, while the insureds argue that the punch list only demonstrated that the contractor had work to do before the job was finished.

In a future post I will discuss how the known loss doctrine applies where the insured knew of the occurrence but did not know that the occurrence could lead to liability.


Anonymous said...

I was confused about the difference between disability insurance and health insurance. I found a page at https://www.disability-insurance-update.com/disability-insurance-options.html that did a pretty good job of explaining what it is and the options. An agent is going to call tomorrow to clear up a few things.

Nina Kallen said...

Disability insurance is similar to unemployment compensation, except that it is strictly voluntary and dependent on the insured paying premiums. If you become disabled and therefore unable to work, disability insurance will give you a monthly stipend based on a percentage of your income at the time you began purchasing the insurance. I have heard it said that disability insurance is generally a bad deal based on the price of premiums versus the likelihood of ever needing the insurance. To me, though, the fear of not being able to support my family if I become disabled makes the high premiums worth it.

Health insurance pays your medical costs after whatever deduction your plan has, regardless of whether or not you are working.