Determining Cause of Loss

October 26, 2015

A hole was discovered in a client's pool super structure. They have an all risk policy. The insured believed ice fell off the roof and damaged the pool wall. The insurance company had an engineer review, and they advised that the trajectory was such that ice from the roof could not have damaged the pool. The pool is a saltwater pool, and the damage was not from the freezing of the water within the pool. We advised the adjuster that if it was not the ice, we are not aware of what caused the damage, only that it clearly occurred during the winter months. The adjuster advised that we must advise him of what caused the damage prior to them providing coverage. We feel that we should only have to report that there is a loss on the property and that unless the carrier can exclude it from the exclusions within the policy, they should pay for the damage. Who is correct? Must the insured have knowledge of what caused the damage?

New York Subscriber

You are correct. The homeowner just has to report the loss and cooperate with the carrier. If the carrier's engineer cannot determine the cause of loss, and the carrier cannot identify an exclusion, then the loss should be paid. There is no exclusion for mysterious damage to pool linings. The insured gets the benefit of the doubt, and the loss should be paid.

 

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