September 27, 2024 - Barbara Thornemin

In the legal realm, especially in the context of insurance, the term “first-party claims” refers to claims made by an individual or business to their own insurance provider for compensation or coverage of losses they have directly suffered. Understanding first-party claims is crucial, as they are a key component of many insurance agreements, ensuring that policyholders receive benefits for damages or injuries covered under their policies. The Munley Law Glossary provides a comprehensive definition of first-party claims, which are foundational in various types of insurance policies such as auto, homeowners, and health insurance.

Defining First-Party Claims

A first-party claim occurs when the insured (the policyholder) files a claim with their own insurance company after experiencing a loss or damage covered by their insurance policy. In essence, the claim is made against the insurance company that provided coverage to the policyholder, rather than against another party. This is distinct from third-party claims, where a claim is made against another individual’s or business’s insurance for damages caused by that third party.

For example, if a person has auto insurance and their vehicle is damaged in an accident, they would file a first-party claim with their insurance company to cover the costs of repairs. If the policy includes coverage for personal injury protection (PIP), the individual can also file a first-party claim for Medical expenses and lost wages due to injuries sustained in the accident.

Types of First-Party Claims

First-party claims can be found in various types of insurance policies, including but not limited to:

Auto Insurance Claims: This includes claims made for property damage to one’s own vehicle, as well as claims for personal injury protection (PIP) and medical payments coverage. For instance, if your car is damaged in a collision, or if you suffer injuries in an accident, you can file a first-party claim with your auto insurance provider for compensation.
Homeowners Insurance Claims: First-party claims under homeowners insurance are typically made for property damage or loss due to event such as fire, theft, or natural disasters. If your home sustains damage from a covered peril, like a storm or fire, you can file a claim with your homeowners insurance company to cover repair or replacement costs.
Health Insurance Claims: First-party claims in health insurance occur when a policyholder seeks reimbursement for medical expenses covered under their health insurance plan. This can include claims for hospital visits, surgeries, or prescription medications.
Disability Insurance Claims: A policyholder with disability insurance can file a first-party claim to receive benefits if they are unable to work due to illness or injury. These claims provide financial compensation to help cover lost wages during the period of disability.

The Process of Filing a First-Party Claim

When a policyholder experiences a loss or injury, they must follow specific steps to file a first-party claim. While the process may vary slightly depending on the type of insurance and the company, the general steps include:

Notifying the Insurance Company: The policyholder should contact their insurance company as soon as possible after the loss or injury occurs. Many policies require timely notification, and delaying too long may result in the denial of a claim.
Providing Documentation: The policyholder must provide documentation to support the claim. This may include receipts, estimates for repairs, medical bills, police reports (in the case of an accident), or photographs of the damage.
Assessment by the Insurance Company: Once the claim is filed, the insurance company will assess it by reviewing the policyholder’s coverage, examining the evidence, and potentially sending an adjuster to inspect the damage. For example, in homeowners insurance claims, an adjuster may visit the property to assess the extent of the damage.
Settlement: If the claim is approved, the insurance company will offer a settlement, which may be a lump sum or periodic payments, depending on the type of claim. The settlement amount will reflect the coverage limits specified in the policy.

Challenges in First-Party Claims

While first-party claims are meant to provide protection and compensation for covered losses, the process isn’t always straightforward. Policyholders may face several challenges, including:

Claim Denials: Insurance companies may deny first-party claims if they believe the damage or injury is not covered under the policy. For instance, if an insurance company determines that the damage to a home was caused by wear and tear rather than a covered peril like a fire or storm, they may deny the claim.
Underpayment: Even if a claim is approved, some insurance companies may offer less compensation than the policyholder believes is justified. In these cases, the policyholder may need to negotiate with the insurance company or seek legal help to receive fair compensation.
Delays in Processing: Insurance companies are required to handle claims in a timely manner, but some may delay the process, leaving policyholders waiting for the funds they need to cover repairs, medical bills, or lost wages.

In the legal world, a bad faith claim arises when an insurance company acts dishonestly or unfairly toward its policyholder, failing to fulfill its contractual obligations. As described in the Munley Law Glossary, bad faith claims play a crucial role in insurance disputes, often involving situations where an insurer unjustly denies a claim, delays payment, or undervalues compensation owed to the policyholder. Understanding bad faith claims is essential for consumers who rely on insurance companies to act in good faith and uphold their end of the agreement.

Defining a Bad Faith Claim

At its core, a bad faith claim refers to a legal cause of action that allows policyholders to seek compensation from an insurance company that has wrongfully denied or mishandled a legitimate insurance claim. Insurance policies are contracts, and under these contracts, insurers are obligated to act in “good faith” and deal fairly with their policyholders. When they fail to do so, it is considered acting in bad faith.

Examples of bad faith behavior by an insurance company may include:

Unjustly denying a valid claim: This happens when the insurer refuses to pay for a covered loss without a reasonable basis.
Delaying the claim process: Some insurers may unnecessarily delay the investigation or payment of a claim, causing financial hardship for the policyholder.
Offering an unfairly low settlement: The insurance company may try to settle a claim for significantly less than its actual value.
Failure to properly investigate the claim: Insurers are required to thoroughly investigate a claim to determine its validity. If they ignore key facts or fail to conduct a reasonable investigation, it can be grounds for a bad faith claim.

Types of Bad Faith

There are two main types of bad faith claims in the insurance context: first-party bad faith and third-party bad faith.

First-Party Bad Faith:
- First-party bad faith occurs when the insurer fails to handle a claim made directly by the policyholder. For example, if someone files a homeowner’s insurance claim after a fire damages their property, and the insurer wrongfully denies coverage, the policyholder may bring a first-party bad faith claim.
Third-Party Bad Faith:
- Third-party bad faith typically involves liability insurance claims, where the insurer has a duty to defend and indemnify the policyholder in lawsuits brought by others. For example, if an insurer fails to settle a lawsuit within policy limits, leaving the policyholder exposed to excess liability, the policyholder may have grounds to bring a third-party bad faith claim.

Common Examples of Bad Faith Actions

Insurance companies engage in bad faith practices in various ways, including:

Refusal to communicate: If an insurance company consistently fails to respond to inquiries or delays communication, it may be acting in bad faith.
Failure to investigate: An insurance company is required to thoroughly and promptly investigate a claim. If it fails to do so, the policyholder could have a case for bad faith.
Unreasonable interpretation of policy language: Sometimes, insurers use overly narrow or unreasonable interpretations of policy terms to deny a claim. This is considered a bad faith practice.
Offering a lowball settlement: When an insurer knowingly offers much less than the policyholder is entitled to, it can be considered bad faith.
Ignoring or misrepresenting facts: Misrepresentation of the facts or ignoring key evidence is another common bad faith tactic used to deny or devalue claims.

Legal Consequences of Bad Faith

When a policyholder believes they have been wronged by their insurance company, they can file a bad faith claim. If successful, the insurance company may be liable for various damages, including:

The original claim amount: The insurer may be required to pay the full amount of the claim that was originally denied or underpaid.
Consequential damages: This could include financial losses that resulted from the insurer’s bad faith, such as costs incurred due to delays in receiving payment.
Emotional distress: In some cases, if the bad faith action caused significant emotional suffering, the policyholder may be compensated for pain and suffering.
Punitive damages: Courts may award punitive damages in egregious cases of bad faith to punish the insurer for particularly harmful or deceptive conduct and to deter similar actions in the future.
attorney’s fees: The policyholder may also recover attorney’s fees and legal costs associated with bringing the bad faith claim.

Proving a Bad Faith Claim

In order to prevail in a bad faith lawsuit, the policyholder must demonstrate that the insurance company acted unreasonably and without a legitimate basis in handling their claim. This typically requires showing that:

The claim was valid: The policyholder must prove that their insurance claim was legitimate and covered under their policy.
The insurer failed to honor its obligations: Evidence must be provided that the insurer did not act in good faith and failed to meet its contractual duties.

How to Protect Yourself Against Bad Faith

There are a few steps policyholders can take to reduce the chances of facing bad faith actions from their insurer:

Keep detailed records: Always document your communications with the insurance company, including emails, letters, and phone conversations. Having a paper trail can be crucial if a bad faith claim arises.
Know your policy: Make sure you understand the terms and conditions of your insurance policy. This knowledge can help you spot unreasonable denials or delays.
Act promptly: File your claim as soon as possible and respond promptly to any requests from the insurer.