Ten Things About Your Insurance That Your Insurance Company May Not Want You to Know

	by Ray Bourhis Bourhis & Wolfson The average American spends thousands of dollars per year of insurance. Homeowners, automobile, medical, life, business, disability, umbrella and other coverages. Because most of us never suffer the large losses that everyone worries about, people have very little experience in dealing with insurance companies on large claims. Those that do are often in for a bit of a shock. Delay, the use of complex policy language to deny claims, and substantial underestimating of losses by carriers are common. Many people don't realize that insurance companies, like banks, earn their profits from investments, stocks, bonds, venture capital and real estate. The profitability of a company depends on how much money they have available to invest. If a company owes X million to all claimants at a given point in time, it can save 8% or more of that per year in investment profits by merely engaging in delay. It can save another 30 to 40% by engaging in lowballing. Another 20 to 30% can be saved by wrongful claim denials on confusing policy language. Whether an uninsured will recover for a legitimate claim at all, and if so, the amount he or she will be paid, depend largely on the policyholder's own knowledge of his or her rights and responsibilities. Policyholders are often at the mercy of their insurance company. The company wrote the policy, the company interprets the policy, the company evaluates the claim and the company holds the money. So the policyholder is really at a substantial disadvantage to the insurer. However, there are ways to begin to level the proverbial playing field. To do so, you must familiarize yourself with important principles of insurance law which judges and legislators have fashioned over the years for your protection. Here are ten such principles: 1. An insurance company must act in utmost good faith in the interpretation of their policies, and in the investigation and payment of claims. It is unlawful for an insurer to engage in unreasonable delay; to put their financial interests ahead of the financial interests of the policyholder; or to lowball (underpay) claims. They cannot use deception or trickery in sales or claims handling. They cannot compel an insured to hire an attorney in order to be paid what they are owed. They must be fair to their policyholders. The violation of any of these standards is a violation of the duty of good faith which the law imposes on insurance companies. It exposes the carrier to potentially significant damages. 2. If an insurance company unreasonably denies a claim or breaches its duty of "Good Faith and Fair Dealing," and you must sure them in order to recover your policy benefits, the insurance company must pay for your legal costs and attorney's fees. If the attorney's fees and other damages were not available, the policyholder could not be made whole and the insurer would be able to under-settle claims merely by arguing that they are offering more to settle that than what the uninsured would net on the actual value of the claims, after payment of their legal fees. If an insurer makes this argument to you in an effort to underpay, thank them in advance for offering to pay your costs and attorney's fees. That is exactly what they doing by engaging in such conduct. 3. If an insurance agent misrepresents the coverage being provided at the time the agent sells you your policy, the insurance company will have to honor the coverage representations made by their agent. Insurance agents are really nice. Otherwise, they wouldn't be able to sell you any policies. The same is true for claims adjusters. Otherwise, they wouldn't be able to settle any claims. It is important to distinguish these nice individuals from the company itself. The purpose of an insurance company is not to be nice, but to make money for its stockholders. If it makes more money than expected, the stock goes up. If it makes less money than expected, the stock goes down. When the stock goes up, executives are given bonuses. When the stock goes down, they are given headaches. The name of the game in the home office begins with the word "profits." Don't ever forget this. When the home office trains agents or claims adjusters they don't tell them to be sinister. There are no conventions at which agents are taught to misrepresent coverage and adjusters are taught low-balling techniques. What does happen, however, is that agents are told very little about the policies they are selling. They may know something about what is covered, but they know very little about what is not. If you were to spend the rest of your life talking to insurance agents about policies they are selling, you would probably not find a single agent who would be able to simply pull out a policy and explain it. The truth is that agents don't understand policies. They just sell them. Most agents won't even show you a copy of the policy they are urging you to buy. If you ever see a policy at all, it will probably be sent to you in the mail directly by the insurance company days, or weeks, after you have purchased the insurance. So at the time of sale, you don't know what you are buying other than what the company or agent promotional or sales pitch conveys to you. 4. If the amount of your insurance coverage is not sufficient to cover your actual loss because the insurance agent recommended that you insure for less than the amount you actually needed, the insurance company may be responsible for paying your entire loss, not just the amount of the policy benefits. For example, when an individual purchases business property or homeowner's insurance, they will often ask the agent what the policy limits should be before the particular property in question. Sometimes, the agent, in attempting to give you the lowest premium bid possible (in order to beat out the competition), will underinsure the property, (e.g. insuring a property for $600,000 that would cost $800,000 to replace) thus lowering the premium quoted. Perhaps the agent rationalizes that the policy contains a "replacement guarantee" anyway. The problem is that replacement coverage is useless unless you actually rebuild the property with "like, kind and quality: of what was destroyed. In the event of catastrophic loss, many policyholders decide to take their insurance payment and buy elsewhere, rather than actually rebuilding. In that case the underinsured policyholder loses a bundle. Moreover, personal property and business property are usually insured under these policies as a percentage of the face value of the policy, not a percentage of the replacement value of the property. Therefore an underinsured policyholder is uninsured for both the building coverage and the personal or business proper coverage. This is another good reason to take notes when you buy your policy in the first place, and to keep these notes in your insurance file. If the limit which your purchased were recommended by the insurance agent and they are insufficient, you are entitled to be paid for all losses on the basis of what your limits should have been. 5. Any ambiguity in your policy must be interpreted in your favor and against the insurance company. Take a look at this paragraph from a State Farm homeowners' policy: "We do not insure under any coverage for loss consisting of one or more of the items below: a. conduct, act, failure to act, or decision of any person, group, organization or governmental body whether intentional, wrongful, negligent or without fault; b. defect, weakness, inadequacy, failure unsoundness in: (1) planning, zoning, development surveying, siting; (2) design, specifications, workmanship, construction, grading, compassion; (3) materials used in construction or repair; or (4) maintenance; of any property (including land, structures, or improvements of any kind) whether on or off the residence premises." Every insurance company has a Mad Hatter Department. This Department is in fierce competition with its counterparts at other insurance companies to see who can write the most incomprehensible and loophole-filled gobbledygook in the industry. I'm convinced that insurance companies have secret awards dinners at which bonuses are given to those who have written the most obtuse, self-canceling phrases of the year. The reason policies are so incomprehensible is not because insurance companies cannot find people who can write in plain English. It is because the companies know that the less clear the policy is, the less clear their obligation to pay will be. So they write policies that they have to obtain "coverage opinions" on from law firms to whom they pay hefty fees to explain what they have written. Believe it or not, even these lawyers are often wrong. You can turn this confusion from a disadvantage to you and into an advantage by simply showing that an applicable provision is ambiguous. If it is, coverage must be provided, and the claim must be paid. 6. The insurance company, not the policyholder, has the obligation of providing the applicability of a "limitation" or "exclusion" in the policy. Insurance policies typically contain a very brief "insuring clause" describing what's covered. Dozens of paragraphs and thousands of words are then spent listing exclusions, exceptions and limitations. When a large claim occurs, insurance companies want to be able to write a letter to their policyholder denying coverage by quoting from one or more of the "exclusions." The bottom line will be that they sure would like to pay your claim, but golly darn, they just can't. Many insureds will either accept what they are being told or will seek advice from someone in the insurance industry or from a lawyer who doesn't specialize in this field. As a result, many legitimate claims go either unpaid or severely underpaid. What you should know is that the insurance company, not you, has the burden of proving that an exclusion or limitation in the policy is (1) clear, (2) conspicuous and (3) applicable. The shifting of this "burden" concerning exclusions - to the insurers - is contrary to the usual rule of the law that the party making the claim is the one who hears this burden. Because most policyholders are unaware of this rule, insurance companies often avoid paying legitimate claims based on exclusions that, if challenged, the exclusions, to the company. 7. In cases involving your insurance company's duty to defend, its duty to defend is broader than its duty to indemnify. The liability portion of every business, homeowner, auto or similar insurance policy is the portion of the policy that protects you from lawsuits by others. It requires the insurance company to pay your legal defense costs and fees if you are sued. Sometimes an insurance company will say that it doesn't have to defend you because you have been sued for something that is not specifically covered in the policy. It must also defend you in any situation which potentially seeks covered damages. For example, if a complain filed against you does not see damages within the scope of your overage but is capable of being amended or modified to include such damages, your insurer must defend. Furthermore, if the insurance company learns of facts from any source which would trigger coverage (not just the complaint itself), it must also defend you. In addition, it must defend where the policyholder has a reasonable expectation that it will do so. If there are multiple causes of action in the complaint against you, let's say that you were sued in a complaint alleging both negligence, breach of contract and intentional misconduct, then if the insurance company must defend any of those causes of action, it must defend all of them. If an insurance company that has a duty to defend in a particular case refuses to do so, then it may well be responsible for all resulting damages, including payment of the amount of any judgment entered against you, or of any settlement (including collusive or fraudulent.) 8. An insurance company that tries to rescind (eliminate) your policy coverage once you have made a claim, on the grounds that you made a misrepresentation on your insurance application, may be violating the law. This point can be complicated. Just remember that some policy application questions are very, very broad. For example, on a health care policy application, you may be asked to "list all of the physicians you have seen during the past five years." Or, "have you ever been treated for diabetes, cancer, heart disease, head injury or pain." Note that such a question is tricky. If an agent asks this question verbally, most people will think in terms of important medical visits or serious conditions. They will not think of every doctor they have seen during the past five ears and may not focus on treatment for tension headaches, which technically fall within the latter question as "head injury or pain." After fifteen or twenty questions all containing numerous sub-parts people tend to glaze over somewhat. So when the agent slides an application across the table one assumes that the answers the agent has written down are accurate. They sign under a declaration citing penalty of perjury. I have seen many insurance companies later try to escape paying a large claim by accusing a policyholder of trying to defraud them by obtaining insurance under false pretenses. They point out solemnly that doing so is illegal. Some people become so frightened that they give up their claim. If you are innocent of any wrongdoing, don't give in to such tactics. There are three important principles to remember on this subject: (1) Read all policy applications yourself and read them skeptically; (2) Don't fall for a bluff when an insurance company tries to rescind. If you have been honest, stand up for yourself and fight it. You will probably win and will wind up proving that the insurance company was engaging in bad faith as well by trying to take away your coverage after the claim occurred; and (3) There are "incontestability periods" in most policies and under the law. That means that beyond a particular date (e.g. two years), the company can no longer rescind the policy for an alleged misstatement on the application. When they try to rescind, don't rollover, examine the situation carefully. 9. Punitive damages are awardable against insurance companies of engaging in oppressive, fraudulent or malicious conduct. Use this fact in negotiations where applicable. Insurance companies love to tell anyone who will listen that punitive damages are a terrible and unwarranted things, a concept cooked up by lawyer parasites to get rich off innocent, misunderstood insurance companies. Don't buy it. Punitive damages are the only thing that prevents insurance companies from engaging in even more outrageous bad faith conduct than they already do. If a given insurance company has, let's say $100 million, in valid claims that have been made, it knows that its investment profits on this money alone will likely exceed $15 million per year. It also knows that if it merely delays, long enough, many insureds (particularly if they are ill or have lost substantial assets or property) will substantially under-settle their claims. If they have died during the delay, the company may never have to pay. In addition, the company knows that if it wrongfully denies the claims, many policyholders will not be willing or able to fight them. Last, even as to those who do fight, insurers know that most people will not be willing or able to fight them. Last, even as to those who do fight, insurers know that most people will probably wind up with a lawyer who knows little about insurance law or who doesn't have the financial capacity to fight a multi-billion dollar industry with an infinite supply of lawyers. Therefore, instead of just paying out the money to policyholders to whom it is owed, an aggressive insurance company can keep much of the money owed, and can earn even more back on investments made during the delay period. So that little, or none of the actual money owed is ever paid. The insurers also know how difficult it is to recover punitive damages in courts these days. Punitive damages are disfavored by judges and juries alike. If you are going to recover punitive damages against an insurance company, you had better have some very persuasive evidence or the judge will not even permit the issue to go to the jury in the first place. If punitive damages do go to the jury and the case is not extremely strong, the jury will toss you out the door. In addition, if punitive damages are awarded, the judge can reduce them. Finally, the insurance company can appeal the verdict. So the insurance company has quite a bit going for it in avoiding ever having got pay a substantial punitive damages award. The rarity of punitive damages awards that actually stick, makes it very important that such an award be appropriate in light of the conduct and wealth of the particular insurance company. For years, insurers have been trying to get state legislatures or Congress to cap punitive damages at say, $300,000 or $400,000. That sounds like alot of money until you look at the figures. If you must deter someone with a bank balance of $500 million from making money illegally, it would certainly not be too much to award one to ten percent - to make it less profitable to engage in the legal practice. Naturally, an insurance company is not going to be deterred by smaller amounts. But if you take the same percentage, 4%, or 5% and apply it to an insurance company with a net surplus (beyond reserves and expenses) of $800 million, then punitive award comes to $40 million. There are very few $40 million or more punitive damage awards upheld against insurance companies. But a $300,000 or $400,000 cap would be laughable to a multi-million dollar insurance giant. They would continue with business as usual, because the illegal profits earned would be far greater than the potential damages threatened. In any event, the prospect of punitive damages can give you as the Insurance consumer, important leverage to encourage an insurance company to treat you fairly in the first place. That is really what punitive damages are for, to make an insurance company think twice before ignoring the law. The companies realize that even those who know the least about insurance law may happen to wind up in the hands of a lawyer who, after subpoenaing the claims file, and fighting through fifty or so depositions, obtains the evidence necessary to ask a jury to set an example. This fact can be helpful for you to know when trying to negotiate a fair claim settlement on your own behalf. 10. You can usually get free legal advice from an insurance law expert so that you know your rights before you talk to your company, rather than after it is too late. Lawyers who take on these insurance bad faith cases have to evaluate them carefully beforehand. These cases are usually taken on a percentage or contingency fee with the lawyer advancing all the costs. The cases had better be good ones or the lawyer will soon be out of business. Therefore, a great deal of time is spent giving free legal analysis to insureds, whether a case is ever filed or not. Use this to your advantage to get free advice regarding your claim. Make certain that the lawyer you are getting the advice from is truly an expert in this field. Seek a referral to a specialist from a lawyer friend, and question the attorney thoroughly before relying on his or her options. Obviously you should make sure that the expert insurance lawyer does not specialize in representing insurance companies. As mentioned earlier you are spending a great deal of money every year on insurance. Be aware that to get what you're paying for, against this industry, you have to know something about your rights. Store this article with your insurance papers. If the insurance underwriters were right in their projections, you will never need to review it because like most people you will never have a large claim. Remember that protecting yourself and your family starts but does not end with this information. When it comes to insurance, Caveat Emptor is always the rule!
	This page was a reproduction for educational and informational purposes only.   Original by: Bourhis & Wolfson Insurance Law and Policyholder Representation 1050 Battery Street, San Francisco, California 94111 info@bourhis-wolfson.com

When Insurance Adjusters Can Be Liable for Errors & Omissions

According to our attorneys, they say ‘Yes’. Insurance adjusters in Texas can be liable for independent acts, errors and omissions (E&O) when they violate insurance codes, breach contracts or negligently handle claims. The primary reason for this is that insurance adjusters, who are trustees, have specific duties and obligations to fulfill when investigating and processing a claim. Failing to honor these duties can open adjusters up to liability and lawsuits.  We are not attorneys.  We are not adjusters.  We are roofing contractors who guide and navigate the chaos and headache for you.

It’s important to note that this liability is not limited to company adjusters (i.e., adjusters who are staff of insurance companies). It can also impact independent and public adjusters.

If you believe an insurance adjuster has made an error or omission that compromised your claim, contact Roofing Professionals of Texas.

We have decades of experience handling thousands of insurance claims on behalf of consumers. Perseverant, enthusiastic, diligent and relentless… we have the skills, knowledge and resources to effectively prevent bad faith insurance practices and help our clients get what is owed to them. We are ready to explain your options during your free consultation.

Has an insurer undercut, compromised or denied your valid hail damage claim?

Adjusters’ errors and omissions can take many forms, some of the most common of which include:

1.    Failing to acknowledge the claim – Adjusters are legally required to promptly respond to new claim submissions and communications regarding the claim. Ignoring claims and failing to communicate with the claimant can constitute an unfair settlement practice for which an adjuster can be liable.

2.    Making misleading or false statements – Written or oral statements an adjuster makes to deceive a contractor or policyholder can open the adjuster up to liability. These statements are typically made in an effort to undercut or deny the claim – or to get a policyholder to withdraw the claim. For example, insurance adjusters may make misleading or deceptive statements like (but not exclusive to):

·         The policy doesn’t cover the damage associated with the claim, despite the fact that the damage IS covered.

·         The policy only covers part of the damage and necessary repairs, despite the fact that all of the repair costs (including O&P) SHOULD BE covered per the policy.

·         You need to accept this settlement offer because it’s the best you’ll get, despite the fact that claim IS worth more and that negotiating IS a viable option.

·         You don’t need to or shouldn’t retain a lawyer because a lawyer can’t help you, despite the fact that an attorney CAN help you protect your rights, interests and claim.

3.    Failing to provide complete, accurate claim information to the provider – When a property damage claim is submitted, the insurance adjuster should collect certain information as part of the claims process. This information should then be promptly and accurately passed onto the insurance provider. Failing to collect all of the necessary information or failing to accurately provide all of the necessary information to the insurance provider can be the basis of an E&O claim against the adjuster.

4.    Failing to meet claim deadlines – Property damage claims (like many other types of insurance claims) are time sensitive. If the adjuster misses a filing deadline for a claim (for any reason), that adjuster can be held accountable for the error.

5.    Breaching the contract – The insurance policy is a contract between the policyholder and the insurance provider. Although the adjuster is not specifically a party to the contract, (s)he can be personally liable for mishandling the claim. For example, when an adjuster fails to reasonably investigate a claim or when (s)he relies on unqualified “experts” to assist in the claims investigation, (s)he can be liable for breach of contract.

It’s important to point out that these are not the only ways in which insurance adjusters may open themselves up to E&O liability.

4 Red Flags You May Have an Errors & Omission Claim against an Insurance Adjuster

Here are a few common warning signs that an adjuster may have been professionally negligent in handling your claim:

1.    The adjuster is unresponsive to your claim submission or fails to promptly respond to any of your inquiries regarding the claim.

2.    The adjuster uses ambiguous, convoluted or conflicting language when explaining your coverage or the claims process.

3.    The adjuster uses high-pressure tactics to try to coerce you into accepting a low settlement offer.

4.    The adjuster denies your claim without providing any (or a valid reason) for the denial in writing.

If you have experienced any of these (or other) questionable incidents when dealing with your insurance adjuster, contact Roofing Professionals of Texas to provide you with a no cost assessment.

Contractor & adjuster scams

It can happen to anyone... Hurricanes, tornados, hail or fires can leave your home and business in ruins. You want to get back on your feet quickly.

But a disaster also lures crooked building contractors and public insurance adjusters. They'll exploit the confusion and emergency conditions to try and fleece you and your insurance policy.

Most contractors and public adjusters are honest. But know the warning signs of a swindle — and how to fight back.

Just as important, don't try to inflate or fake insurance claims yourself. Jail time, fines, humiliation, and separation from your family and friends — it's a big price for trying to scam a few insurance dollars.

Contracting with contractors

Don't pay for bids. Crooked contractors may simply take your money and disappear. Most reputable contractors won't charge you simply for bidding on your repair work.

Local contractors. Use established local contractors, if possible. But... be careful if the contractor arrives in an unmarked vehicle, seeks your repair work door-to-door, or tries to cut costs by using materials "from another job." These contractors may be unlicensed, dishonest and untrained transients from another state.

• Often they'll use low-grade material.

• Their work may be shoddy and even dangerous.

• They may disappear with your money after finishing only part of the job, or not doing any work.

Look professional? Does the contractor have professional-looking business cards and letterhead? If not, you could be dealing with an untrained and incompetent "wildcatter."

Signed contract. Get a signed contract — before work begins. But don't sign any contract with blanks. A dishonest contractor could fill in unfair or fraudulent terms later.

• Also... make sure it's a legitimate, printed document — not something scratched out on a piece of paper. Make sure you have a copy for your files.

• Don't pay extra when a contractor says the cost of materials has "suddenly increased." Pay only what's spelled out in your signed contract.

No cash. Never pay in cash; pay only with check or credit card. A contractor who demands cash may be trying to avoid paying taxes or buying legally required insurance.

Repairs insured? Check with your insurance company to make sure your policy covers the repairs. Also have your insurance adjuster estimate the damage and probable cost to repair. This will give you a reliable basis for negotiating repairs with contractors.

Inspect damage. If practical, have an adjuster from your insurance company inspect your damage before repairs begin. Your insurance company may require an adjuster's inspection before you rebuild.

Your insurance claim could be denied if you make expensive, permanent repairs before the adjuster inspects the damage.

Signing off. Sign the certificate of job completion only when all repairs are finished to your satisfaction, and per your signed contract.

Fight back. Contact your state insurance fraud bureau and local office of consumer affairs right away if you suspect a repair scam.

---

Adjusting to adjusters

Insurance companies employ their own adjusters. They'll evaluate your property damage and help walk you through the claims process, free of charge. In many states, you can also hire public adjusters to help you file claims and negotiate your insurance payment. Public adjusters represent the claimant, and usually charge you 10-15 percent of any insurance settlement.

Schemes. Most public adjusters are honest and competent, but some are crooked. They may come from out of town, and go door to door, trying to bilk disaster victims with insurance schemes. They might:

• Charge you a large fee, and then disappear without handling your claim.

• Refer your repair to a dishonest contractor for a kickback, and you may receive shoddy repairs in return.

• File false and inflated claims against your policy. Sometimes they'll also try to convince you to join the scheme.

• Use their position of trust to access your Social Security number and other personal data for scams involving identity theft.

Licenses. Public adjusters need licenses in most states. Ask Texas Department of Insurance if an adjuster is properly licensed in your state, or has any complaints or disciplinary actions. If the adjuster comes from another state, contact that state's insurance department to make sure the adjuster is licensed.

References. Ask people you trust if they can recommend a reputable adjuster.

Learn more. To learn more about public adjusters, check out websites of organizations such as the National Association of Public Insurance Adjusters.

Fight back. If you suspect a public or insurer's adjuster is being dishonest, contact your state insurance department right away.

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Roofing Professionals of Texas is seeking qualified sales persons who are detail oriented, have strong organizational and have interpersonal skills to build a successful career within our company.

100% commission - Must have a ladder and ability to get on roofs

Must be able to work in a team atmosphere

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Must be out going, and able to make friends easily

Must provide your own transportation

100% commission - Must have a ladder and ability to get on roofs

Have your email address, your vehicle information, and best number to reach you at when you call in.

Required license or certification: driver’s license

What we expect:
* Must have a vehicle
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* Sales and customer service experience
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* Must have computer skills
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* Work with a team
* Capable of cold call door knocking in lead areas

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* Manage your schedule meet with customers and document system with sales

* Build trust and educate customers
* Identify customer needs and wants
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* Submit proposals and contract documents on a timely basis
* Be able to multi-task and think outside the box
* Maintain a professional appearance and demeanor at all times.

Benefits:

What We Offer

This position is 100% pay per performance, however, we offer the most aggressive pay structure IN THE DALLAS / FORT WORTH / METRO-PLEX Guaranteed! 
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469-906-2600
www.roofingprotx.com

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Mark Romano, whistleblower from ALLSTATE tells how some insurance companies rig the system

Former Allstate executive turned whistleblower,  was in charge of a computer program called "Colossus" that calculates money people are paid in claims. He "tuned" the program to increase profits, which he says was unfair to customers.

Mark Romano gripped the steering wheel and tried to keep his car from swerving into another commuter on the busy Illinois tollway.

Stress?  It was December 2007, and Romano was a senior manager at Allstate and its top expert in Colossus, a program that calculates how much a person might be paid for an injury claim. He was in charge of two projects to “tune” and “recalibrate” Colossus, work he knew could affect payments to thousands of people.

Colossus was part of a quiet revolution in the insurance industry.  Before the early 1990s, insurance was a decidedly human endeavor, especially when it came to setting rates and paying claims. To set premiums, insurers relied on computations from their actuaries — mathematical wizards armed with statistics and tables that assess various risks. When it came to paying claims, insurers often sent adjusters into the field, where they met face-to-face with people injured in car wrecks.

Today, insurers have an array of computer programs that guide the flow of trillions of dollars to and from customers around the world. These programs include sophisticated “catastrophe models” that use weather data and other factors to predict an insurance company’s losses in a disaster. “Scoring models” use credit histories and secret algorithms to estimate which customers are more likely to file claims. Colossus and similar programs help companies manage claims. Like a TurboTax program for medical injuries, adjusters plug in information about a person’s loss — from a damaged spine to a fractured finger. Colossus then cranks out a range of payments to cover the costs. Insurance industry critics and even many insiders call these programs “black boxes” because their formulas, data sets and operational policies are cloaked in secrecy.

Few people at Allstate knew more about Colossus than Romano. On organizational charts, he was Allstate’s Colossus “subject matter expert.” And in late 2007, at age 49, he was at the peak of his career, working in one of the nation’s largest insurance companies — and wondering whether he should leave it all behind.

Romano has thick black hair and wears thin glasses. His brown eyes widen when he wants to make a point. He had gone into the business to help people, but he knew that his work on Colossus would do the opposite.

During his hour-long commute to Allstate’s sprawling campus in Northbrook, his mind drifted to his daughter at the College of Charleston, to his son in private school, his wife’s multiple sclerosis, medical bills, his mortgage, the decades he put into his career. The dizzy spells grew worse. Doctors prescribed motion sickness medicine, relaxants and physical therapy. Then the headaches came — migraines as long and powerful as a Midwestern freight train, box cars of pain, one after another after another. Something had to give.

Birth of Colossus
Among computer programmers, the name Colossus has a rich history. In World War II, British code-breakers called their hulking new programmable machine Colossus and used it to decipher German teleprinter messages. In 1970, filmmakers released “Colossus: The Forbin Project,” a science fiction movie about an army supercomputer that tries to take over the world. (At one point, the computer tells its human creator, “You will come to regard me not only with respect and awe but with love.”)

The insurance industry’s version of Colossus was born in Australia. In the 1980s, a government-chartered insurer ran into financial trouble because of claim costs, which were growing at an annual rate of 14 percent. The insurer set its sights on its adjusters.

It’s the adjuster’s job to evaluate people’s losses and come up with ways to settle their claims. This often meant assessing what people did in their careers and how an injury might affect their future income and overall enjoyment of life. Longtime adjusters talk about the challenge of sizing up people when they’re suffering, and the knowledge adjusters need, from medicine to car repairs, to calculate a fair settlement.

The inherent complexity in putting numbers on injuries also meant that adjusters often came up with different amounts for similar types of claims. In Australia, payments varied by more than 80 percent. So to reduce these disparities and lower overall costs, the Australian insurer worked with a software company on a novel idea: embed the experience and knowledge of their best adjusters in a computer program.

The programmers studied how top adjusters made decisions and then created software to mimic their work. This program became known as Colossus and required answers to as many as 700 questions, ranging from the severity of injuries to how people experienced the loss of enjoyment in life. Injuries were broken down into 600 different codes. The program analyzed legal settlements and jury verdicts, combined this information with data entered by the adjusters, and generated what were supposed to be fair settlements.

A few people questioned whether computer programs were up to this complex task. An Australian law professor wrote that the development of Colossus was “just one instance of an important challenge of the information age: how to ensure that computer-based decision making is fair and non-discriminatory.” But Colossus was a huge success. Within a few years, payments for similar claims were more consistent and the costs of those claims had stopped rising.

In the United States, the insurance industry was experiencing its own period of self-analysis. It began in 1989, when Hurricane Hugo flattened parts of South Carolina. The storm caused $4.2 billion in damage to insured property — at the time the most expensive loss in history. The second wake-up call came in 1992 when Hurricane Andrew generated $15.5 billion in claim payments, $10 billion more than actuaries had predicted. Andrew bankrupted 11 insurance companies and prompted dozens of others to flee the Florida market altogether.

Amid this sticker shock, industry leaders asked why they had so badly underestimated their potential losses. They found answers in newly created “catastrophe models,” computer programs that predicted potential damages in a hurricane or other disaster. These models warned that future hurricanes would be even more costly, and with these new predictions in hand, insurers soon justified massive rate increases in home insurance premiums, especially in South Carolina and other coastal states.

While insurance premiums are the insurance industry’s main source of income, payments for claims are its biggest costs, the equivalent of rubber for a tire manufacturer. Claims also are at the heart of why people buy insurance. Insurance is based on the idea of sharing risk, a grand communal exercise that involves collecting $4.6 trillion every year from people across the world and then shifting some of this to a smaller pool who suffered losses. Insurance keeps communities destroyed by disasters on life support until their economies recover; it helps keep people out of bankruptcy after car wrecks and house fires. And it was largely for these noble purposes that Mark Romano decided to make insurance his life’s work.

An adjuster’s story
Romano grew up in Tampa, Fla., and by his account had a relatively uneventful childhood. He loved catching and dissecting animals for biology classes and thought someday he might go into medicine. He played trombone in the high school band. His mother was a school librarian. His father was regional director for the Florida Department of Agriculture and Consumer Services, and Romano remembers his dad coming home angry about how consumers had been bilked in one way or another. After high school, Romano enrolled in Florida State University, where he gravitated toward the school of insurance and risk management. “I was interested in the basic concept of risk, that you could transfer it from one person to an entity or spread it among many people,” he said. “And you were helping people, and I grew up with two parents who in one way or another helped people.”

Romano’s first job was as an adjuster with American States Insurance, and his first day at work came after a drenching Florida rainstorm. His boss told him to grab a map and clipboard and take measurements of damaged homes. “It was overwhelming, but it was cool,” he said. “I absolutely loved being on the road. Everything was face to face, and it would be very common to meet people in their homes, sit in their kitchen and talk about their injuries.”

Romano handled auto insurance claims and worker’s compensation cases, learned about medicine, the law and how to establish rapport with people in distress. “You did it all, and it was an incredible education in how the world works.” Not all of this education was positive. A year into his career, he took over a new territory, and when he introduced himself to auto repair shop owners, “One guy said, ‘Hey, do you want the same deal as the other guy?’ ” Romano wasn’t sure what to do. “I went to my father and said, ‘These people are offering me things.’ And he said, ‘Don’t you dare ever do anything like that.’ That’s how naive I was at that point.”

But the vast majority of those he met were “really good, decent people trying to put their lives together.” He remembered a case in which he helped a family set up a scholarship to honor their child, who had died in a car wreck. By then, Romano had moved to another company, Hanover Insurance, which had a charismatic chief executive officer named Bill O’Brien. “For him, it was all about empowering employees at the lowest level possible. And we were never told to watch or shave anything off a claim payment.” If a customer’s claim was too low, it was the adjuster’s duty to pay them more. “You really felt good about what you were doing.”

Then, after Hurricane Andrew in 1992, Hanover Insurance started closing offices in Florida. It also was a pivot point for Romano. He was mid-way into his career and eager to advance. The place to do this was Chicago, a mecca of property and casualty insurance. He would take a circuitous route to get there, though. He left Hanover and took a job at CNA insurance division in upstate New York, where he learned about a program called Colossus.

By then, the Australian creators of Colossus had sold the program to Computer Sciences Corp., now named CSC, which licensed it to Allstate and many other insurance companies.

CSC’s marketing materials have long touted Colossus as a way to help insurers “establish consistent recommended settlement ranges,” Edward Charlton, a CSC vice president, said in a statement to The Post and Courier. “Without a clearly defined process or framework in place provided by a software tool such as Colossus, claim adjusters may skip important steps or forget to ask pertinent questions of consumers,” he said.

In Romano’s mind, it made good business sense for companies to automate claim payments, though he feared something could be lost without a more personal touch. And based on his years working as an adjuster, the payouts Colossus spit out for CNA seemed fair. He excelled in his job and eventually was transferred to CNA’s bright red headquarters on Chicago’s Wabash Avenue. As he walked into the building, he looked at the skyline. All around were skyscrapers adorned with the names Prudential, Blue Cross, Kemper and Hancock, huddled like giants overlooking Lake Michigan’s southern arc.

The profit center
Allstate was created a year after the stock market crash of 1929, when Robert Wood, president of Sears Roebuck & Co., boarded a commuter train to downtown Chicago. On his ride in, a friend suggested he start an auto insurance company and sell insurance by mail. Wood eventually formed a company called Allstate Insurance Co., naming it after a tire sold in the Sears catalog. In 1950, the daughter of a sales manager came down with hepatitis. When the sales manager returned home, his wife reported, “The hospital said not to worry. We’re in good hands with the doctor.”

Thus, the iconic slogan was born: “You’re in Good Hands with Allstate,” along with the logo of a pair of hands cradling a car. (The car was later removed.) By 2000, the “Good Hands” phrase was the most recognized advertising slogan in America, according to a Northwestern University study. Allstate became one of the industry’s largest insurers, and grew even more in 1999 with the $1.2 billion acquisition of CNA’s personal insurance division.

Romano heard rumors about the deal months before it was made public. A senior vice president approached him and said, “Mark, I hear you know something about Colossus.” The executive told him Allstate was looking for someone to implement their version of Colossus on CNA’s customers.

Allstate renamed the CNA division Encompass, and Romano soon met with Allstate executives who, he said, “began indoctrinating me in their Colossus philosophy.”

Romano discovered that if he used Colossus the way Allstate did, he could save its new Encompass division millions of dollars by “turning the knobs” of the software — paying people less in claims than they would have otherwise gotten.

In South Carolina, for instance, CNA had divided the state into two territories — the “Liberal” area around Charleston and the “Conservative” region elsewhere. Allstate renamed the territories “Charleston” and “Palmetto.” By using Allstate’s Colossus tuning methods instead of CNA’s, Romano could reduce payments in the Palmetto region by 18 percent. Savings were even greater in the Charleston area — a 57 percent reduction. That meant the Allstate version of Colossus would turn a $10,000 claim in Charleston into a $4,300 payment.

“It became my responsibility and goal to save $33 million over three years for Encompass, which I did.” (In a statement to The Post and Courier, Allstate did not dispute Romano’s account but said government regulators have examined its tuning methods and found no violations of state statutes.)

Romano was so successful that Allstate transferred him from the Encompass office downtown to Allstate’s headquarters. Now, instead of downtown Chicago, his commute took him to suburban Northbrook and a 250-acre office park surrounded by fields, security fences and guard gates. “They sent me to the mothership.”

Challenging Colossus
About the same time in 2000, Rob Dietz was working as an adjuster for Farmers Insurance Group in the Seattle area. Like Romano, he felt a sense of purpose helping people put their lives back together. A former logger and rock blaster, Dietz became an adjuster, he recalled, because “it was easier to lift a pen than a chain saw, and because it served the public.” Unlike Romano, he was almost immediately appalled by Colossus.

Farmers was just beginning to implement Colossus. As part of that effort, the company asked Dietz and other experienced adjusters to examine a sample of claims and come up with fair offers to pay people for their losses. These offers would be fed into Colossus to create a benchmark of payouts tailored to that area of the Northwest. But after the group finished, a facilitator said the ranges would then be reduced by 20 percent to create even lower benchmarks.

Dietz was stunned. To him, it meant that the program was being rigged to make payments 20 percent lower than they should have been. “That’s not how I learned the tenets of good faith and fair dealing.”

Worse, after this session, he said he and his colleagues were under constant pressure to stick with Colossus-generated payments even when the adjusters thought people deserved more. He felt Colossus was turning his profession into keyboard slaves, and for a “person with logger’s fingers,” this didn’t bode well for his career prospects. He was also taken aback by the secrecy around Colossus. “I still have the old memo that says we were not to disclose the fact that we were using Colossus.”

Dietz eventually quit Farmers to work with trial lawyers, and in 2002, a Washington State attorneys group asked him and another adjuster to give a talk about Colossus. “That’s when Farmers sued me.”

Farmers asked a judge to stop the seminar, arguing that Dietz and the other adjuster would reveal confidential information. The judge declined, and Farmers eventually dropped the suit. Lawyers from all over the nation flew in for the talk. Aaron DeShaw, an attorney investigating Colossus, remembers how he and the other attorneys gave Dietz and the other adjuster a standing ovation before they opened their mouths. “The atmosphere was electric.”

Good hands, boxing gloves
This was the beginning of what would become a decade-long legal assault on Colossus and other claim-handling programs, one that would somehow bypass Romano, despite his extensive work at Allstate with the program.

One of the most aggressive pushes came from David Berardinelli, a trial lawyer in Santa Fe, N.M., known for his love of vintage Porsches and a book he wrote about his battle with Allstate, “From Good Hands to Boxing Gloves.”

He learned about Colossus while representing a husband and wife hit by an uninsured drunk driver. Allstate refused to pay their medical bills, and curious about Allstate’s hardball legal tactics, Berardinelli sought internal presentation slides and notes about how the company handled claims. In one legal fight after another, Allstate refused to give them up, saying in a court document, it was engaging in “respectful civil disobedience.” At one point, Florida insurance regulators joined the fray, threatening to prevent Allstate from writing new policies unless the company handed them over.

Allstate eventually capitulated, and the materials provided a window into a company in flux. The most incendiary documents stretched back to the early 1990s. At the time, insurers were railing about what they considered a wave of frivolous lawsuits from lawyers who used aggressive advertising campaigns to lure clients. In 1992, Allstate hired McKinsey & Company, a consultant for the nation’s leading insurance conglomerates. One goal, according to a slide, was to “radically alter our whole approach to the business of claims.”

One of the McKinsey presentation slides described how the company could become more efficient if it targeted people who didn’t have lawyers. In its “Good Hands” approach, Allstate would pay those unrepresented people within 180 days, which McKinsey said would take care of 90 percent of the claims. The 10 percent who hired lawyers or didn’t accept claim offers would get the “Boxing Gloves” treatment. In these cases, Allstate would expect to tie up payments for three to five years.

Over time, Allstate employees testified that they were trained to build rapport with customers and discourage them from hiring lawyers. Berardinelli and a growing cadre of lawyers alleged that the “good hands” strategy actually involved delaying and denying claims for several months and then making lowball offers as people felt more financial pressure. They argued that Colossus and other claim-handling programs were important parts of this profit-making plan, with some testimony showing that Allstate could reduce bodily injury payouts by $264 million a year if it used Colossus. “This immediate impact would, of course, come at the immediate expense of Allstate’s policyholders,” Berardinelli wrote in his book.

In a 2008 press statement, Allstate said the materials were part of “a complex body of work that as a whole demonstrates a careful, fact-based analysis to better enable the company to more promptly investigate and more consistently and effectively evaluate claims.” Allstate told The Post and Courier that the software “provides merely a recommendation, and is only one factor in the adjuster’s overall evaluation of the claim.” Charlton, the executive with Colossus’ maker, CSC, said that his company leaves the tuning process to insurers.

Meanwhile, other industry officials have long discounted the importance of the McKinsey documents. Robert P. Hartwig, president of the Insurance Information Institute, said the notion that the documents “forever directed the entire homeowner and auto insurance process” was “bizarre.”

Rather, he said, such programs reflect an understandable use of technology. “There are millions of claims every year and a lot of commonality between them,” he said, adding that said Colossus and Xactimate, a Colossus-like program that handles home insurance claims, “harness the computer to process large amounts of data quickly and inexpensively, and that allows insurers to provide coverage that’s very affordable.” Insurers wage a “technological arms race against each other on a daily basis,” he said, and companies with the best technology have an edge. “This is a competitive industry, and it’s not in the insurer’s interest to treat a customer poorly.”

But Berardinelli and others alleged in class-action lawsuits that insurers were doing exactly that — failing to pay customers what they were due. More documents and testimony emerged, including manuals that described how tuning Colossus was “both an art and a science” that was done “based on the desired projected savings.” One slide from CSC said, “What does Colossus Really do” and begins with a list: “Lowers indemnity payouts ... lowers loss ratios ... improves surplus/profitability.” Other documents urged employees to avoid using the word “savings” to describe the benefits of Colossus and “use a more vague term such as ‘consistency.’ ”

One of the most prominent lawsuits involved a woman from Arkansas named Georgia Hensley. Hensley was driving on a road near Texarkana on New Year’s Eve 2000, when she was struck by an underinsured driver. She broke facial bones and injured her spine. She filed a claim with her insurer, Encompass, which offered $1,000. Hensley’s lawsuit alleged Colossus and other claim-handling programs were cost-containment tools that enhance insurance company profits at the expense of customers.

Hensley’s claim had been handled by one of Romano’s underlings, and Romano was one of the first at Allstate to learn about the lawsuit.

Crisis of conscience
It landed in his email inbox on Feb. 17, 2005. Romano read the lawsuit, a class-action case that named hundreds of insurance companies that used Colossus and other claims-handling programs. He sent it upstairs to the attorneys. By then, he was beginning to feel the weight of his work.

His responsibilities had grown. His tuning directly affected how thousands of claims employees across the country did their jobs, and through them, how much tens of thousands of policyholders were paid for their losses. He was part of a small group of insurance professionals nationwide that met regularly to discuss Colossus-related issues.

These meetings often happened in warm places, including Myrtle Beach. Romano was glad to go to these particular meetings because it meant he could visit his daughter, a biology major at the College of Charleston. They grabbed sandwiches at Groucho’s on King Street and took walks to the Market, where he stocked up on Lillie’s of Charleston Low Country Loco hot sauce, grits and other Southern specialties tough to find in Chicago.

He didn’t talk about insurance, though. The issues he was wrestling with were complex, and he was more interested in how his daughter was doing. He also kept much of his worries from his wife. In 2003, she was diagnosed with multiple sclerosis, and he wanted her life as stress-free as possible. “I didn’t share my feelings about Colossus with anyone, but if I had talked about it, I would have said, ‘I’m doing some stuff that I’m not too thrilled to be doing.’ ”

In his mind, Colossus was as malleable as clay. You could mold its programs to reduce claims values across-the-board, which he described as “turning the knobs.” You could decline to enter data on high jury verdicts or unusually high injury settlements, which tricked the program into thinking an injury’s typical value was lower than it really was. You could train adjusters to code injuries in a way that didn’t account for their true severity, which also reduced payments.

In late 2007 and early 2008, even as the Hensley and similar lawsuits began to produce out-of-court settlements worth tens of millions of dollars, Romano worked on new ways to “recalibrate” and tune Colossus, projects that he said would generally “lower settlement values” and increase profits.

His migraines grew more severe. Doctors prescribed tranquilizers, ordered physical therapy sessions. Nothing helped. He couldn’t sleep. The dizzy spells became more jarring until the doctors told him to turn over his car keys. He temporarily left work and went on disability. Through this haze, he began to see other things more clearly: People were being hurt by Colossus, and it was tearing him apart. He couldn’t turn the knobs anymore.

On his last day at Allstate, he was told to hand in his laptop and badge. On the long drive home, he had no bouts of vertigo, only relief bordering on exhilaration. “It was the first step in regaining my self-respect.” He had a new quest: to help consumers better understand how the insurance industry can fail to live up to the promise of paying people in their times of need. He thought he would be part of a larger chorus, especially now that state regulators had turned their attention to Colossus.

The watchdogs
In 2009, led by New York and Illinois, state insurance regulators began the first multi-state examination of how an insurance company uses a software tool to handle claims. Working with the National Association of Insurance Commissioners, the regulators hired a private company to sift through a million pages of claims data and other Colossus-related materials. Investigators later said they spent 8,500 hours reviewing the materials and interviewing more than 40 current and former Allstate employees.

The regulators announced their findings a year later: Overall, they found no “institutional issues involving underpayment of claims” but that Allstate failed to tune the software in a consistent way across the nation. “Colossus was a black box. We looked into the black box and saw some problems,” Steve Nachman, New York’s deputy superintendent for fraud and consumer services, told reporters at the time. “It’s all about how you utilize it.”

Among other things, the regulators ordered Allstate to tell consumers when they had used Colossus to calculate a claim payment. Allstate also was fined $10 million. More than 40 states signed on to the deal, including South Carolina, which received $235,166. (The money went to the state’s general fund.) In a news release, Allstate said the findings showed their use of Colossus “provides significant benefits to the public in increased objectivity and efficiency.”

In a statement to The Post and Courier, Allstate said the investigation in fact justified “the continued use of the tuning criteria which have now been used by Allstate for more than 15 years.” Colossus critics weren’t impressed with the fine or the findings. “Ten million dollars is no big deal,” said DeShaw, the trial lawyer in Washington. “They make that in no time.” (In 2011, Allstate had $32 billion in revenue and a profit of $788 million.)

“A part of this story is the failure of state insurance regulators to police insurance companies’ conduct,” added Jay Feinman, a law professor at Rutgers University and author of “Delay, Deny, Defend,” a book that says insurers try to avoid paying claims.

Robert Hunter, a director with the Consumer Federation of America, was blunter: “It was weak.” If the investigation was so thorough, he asked aloud, why had the regulators failed to talk with Allstate’s official Colossus expert, Mark Romano?

Redemption hopes
Romano asks himself the same question. The investigation was hardly a secret in Allstate’s hallways, he recalled. He said he even knew where the examiners worked — two miles away near an executive airport. At one point, he contacted an examiner, who told him it was too late to use his information; they had all but wrapped up their work. Romano eventually called Hunter at the Consumer Federation of America.

Hunter remembers the call. “One of the first things he said was that he wanted to help consumers, which is something I liked.” Hunter had already assembled a large body of information about Colossus but was happy to learn about Romano. “Suddenly we had a guy from inside who knew how it worked.”

Romano joined the group and co-wrote a paper last summer with Hunter: “Low Ball: An Insider’s Look at How Some Insurers Can Manipulate Computerized Systems to Broadly Underpay Injury Claims.” It generated numerous stories in insurance trade journals and websites, along with scattered newspaper reports, but Romano acknowledged that “Low Ball” was designed to raise interest among regulators, not the general public, and he’s not sure it made much headway.

These black boxes have a significant impact on what people in South Carolina receive for their claims, but state insurance regulators have no plans to study Colossus or other claim handling programs. They say they leave such analyses to states where insurance companies are based. Overall, said Robert Hartwig of the Insurance Information Institute, “these issues are dead and buried, and regulators don’t pay much attention to it. The fact of the matter, they’re satisfied with the methodologies and constantly review the models.” Twenty percent of the top 30 U.S. insurers, including Allstate, use Colossus today.

Romano isn’t so sure the issue is dead. Insurance is too important to people. He’s seen how it helped make people’s lives a little easier in their time of need. He was proud to call himself an adjuster but knows he lost his way, as has the industry he once so respected. Today, Romano spends his time working on ways to inform consumers about the complexities of insurance, help people the best he can. That’s what he always wanted to do; it’s what insurance is supposed to do. His migraines have all but vanished.

Insurance companies have another controversial black box program that affects what South Carolinians pay for auto and homeowner insurance. Going by “customer rating index” and similar names, these computer models use credit information and other data to estimate whether you are more likely to file a claim. Insurers then use these scores to decide whether to hike or lower your premiums — or deny you coverage altogether.Insurance companies guard these formulas aggressively, so consumers and even regulators have little idea whether they’re being applied fairly.The Post and Courier, for instance, recently asked the state Department of Insurance for “scoring manuals,” citing the Freedom of Information Act. The insurance department then notified State Farm, Nationwide and Allstate about the request and asked for their comments.Insurers demanded that the material not be released, according to emails obtained by the newspaper. “This information is proprietary to State Farm and contains commercially valuable trade secret information that State Farm has collected and created and to which State Farm strictly controls access on a need to know basis,” a State Farm official wrote in one email. “It is understood that absent court order the Department will not release the information produced.”The state Department of Insurance denied the newspaper’s request, even though other states have released these manuals to consumer groups, including the publishers of Consumer Reports. (The newspaper is appealing the department’s determination that the information is confidential.)The result of this secrecy is that consumers have no way of knowing how their credit scores affect their insurance rates. What’s clear, however, is that the issue continues to generate controversy.Insurers cite studies that show people with poor credit histories are more likely to file claims. But many consumer advocates say these scores discriminate against some minority consumers and poor people who otherwise might be good insurance risks.Consumers Union railed against the use of these scores in an extensive study in 2006, saying, “While insurers are preoccupied with gaining a competitive advantage over one another, consumers are getting caught in the crossfire.” Their report found that people could be penalized if they simply opened up several credit card accounts in a year, or made more than two loan inquiries.

This post is an excerpt from The Post and Courier by Tony Bartelme.

Freddie Reinwald / Roofing Professional
freddie@roofingprotx.com / 214-293-0944

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