Claims Handling Practices North Carolina

September 3, 2019

Claims Adjusting Standards

North Carolina prohibits the following unfair claims settlement practices, which exist when any of the following is committed or performed “with such frequency as to indicate a general business practice” (N.C. Gen. Stat. § 58-63-15(11)(a)-(n)):

  1. Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue. N.C. Gen. Stat. § 58-63-15(11)(a).
  2. Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies. N.C. Gen. Stat. § 58- 63-15(11)(b).
  3. Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies. N.C. Gen. Stat. § 58- 63-15(11)(c).
  4. Refusing to pay claims without conducting a reasonable investigation based upon all available information. N.C. Gen. Stat. § 58-63-15(11)(d).
  5. Failing to affirm or deny coverage of claims within a reasonable time after proof-of-loss statements have been completed. N.C. Gen. Stat. § 58-63- 15(11)(e).
  6. Not attempting in good faith to effectuate prompt, fair and equitable settlements of claims in which liability has become reasonably clear. N.C. Gen. Stat. § 58-63-15(11)(f).
  7. Compelling [the] insured to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insured. N.C. Gen. Stat. § 58-63-15(11)(g).
  8. Attempting to settle a claim for less than the amount to which a reasonable man would have believed he was entitled. N.C. Gen. Stat. § 58-63-15(11)(h).
  9. Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of, the insured. N.C. Gen. Stat. § 58-63-15(11)(i).
  10. Making claims payments to insureds or beneficiaries not accompanied by [a] statement setting forth the coverage under which the payments are being made. N.C. Gen. Stat. § 58-63-15(11)(j).
  11. Making known to insureds or claimants a policy of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration. N.C. Gen. Stat. § 58-63-15(11)(k).
  12. Delaying the investigation or payment of claims by requiring an insured claimant, or the physician, of [or] either, to submit a preliminary claim report and then requiring the subsequent submission of formal proof-of-loss forms, both of which submissions contain substantially the same information. N.C. Gen. Stat. § 58-63-15(11)(l).
  13. Failing to promptly settle claims where liability has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage. N.C. Gen. Stat. § 58-63-15(11)(m).
  14. Failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement. N.C. Gen. Stat. § 58-63-15(11)(n).

Section 58-63-15 does not create a private right of action. See N.C. Gen. Stat. § 58-63- 15(11).

Hurricane Claims Standards

The North Carolina Commissioner of Insurance issues named-storm updates and bulletins on the Commission’s “HurricClaims” website: https://ncdoi.com/HurriClaims/Default.aspx

Duty of Good Faith

North Carolina’s unfair trade practices act does not create a private cause of action. N.C. Gen. State. § 58-63-1 et seq. North Carolina does recognize, however, a statutory cause of action for “unfair and deceptive acts.” N.C. Gen. Stat. § 75-1.1; see Gray v. N.C. Ins. Underwriting Ass’n, 529 S.E.2d 676, 681 (N.C. 2000).

An insurer can violate § 75-1.1 by not attempting in good faith to effectuate prompt, fair, and equitable settlements of claims for which liability has become reasonably clear. Id. at 684. An insured also may seek to recover consequential damages (§ 75-1.1) and their attorney’s fees. N.C. Gen. Stat. § 75-16.1.

North Carolina recognizes an independent common law cause of action for bad faith against a first-party insurer. Defeat the Beat, Inc. v. Underwriters at Lloyd’s London, 669 S.E.2d 48, 55 (N.C. Ct. App. 2008). The elements include (1) a refusal to pay after recognition of a valid claim, (2) bad faith, and (3) aggravating or outrageous conduct. Satisfying these elements will entitle the insured to punitive damages. Id.

The articles on our Website include some of the publications and papers authored by our attorneys, both before and after they joined our firm. The content of these articles should not be taken as legal advice.

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