Opinion ID: 1846468
Heading Depth: 1
Heading Rank: 3

Heading: Events Occurring After the Filing of the Lawsuit

Text: After the complaint was served on National, it was forwarded to Kathy West, a senior claims analyst for GRE Insurance. [4] Kathy West testified that, immediately upon reviewing the file, she knew the claim was ripe for payment; that she knew there was no basis in law or in fact for denying the claim; that when [she] reviewed this claim file shortly after receipt of the lawsuit, [she] knew there was no basis in law or fact to deny the breach of contract claim; and that when she reviewed Sockwell's claim file at that time, there was no other information that [she] needed to have before realizing that the obligation to pay the claim was ripe. She reviewed the file and made an entry in National's computer notepad, stating: I RECEIVED THE ABOVE SUIT AND REVIEWED. Adjuster denied the claim by stating the policy did not provide for UIM BENEFITS. This was incorrect. ALABAMA UM [uninsured motorist] LIMITS ALSO CONTAINS UIM COVERAGEIT IS BUILT IN. ALSO IN ALABAMA IT IS AGAINST PUBLIC INTEREST TO OFFSET THE UM/uim LIMITSit would stack. (Capitalization in original.) Kathy West testified at trial that Hawthorne should have looked at a variety of factors in order to properly adjust Sockwell's UIM claim. During West's testimony at trial, the following exchange occurred: Q [Sockwell's attorney]: And the way a claims department [adjusts a claim] is it gathers information and evidence on claims that the insurance company may owe coverage on. Correct? A [Kathy West]: That's correct. Q: So, for example, if you have a car-wreck claim, you have to gather information on the extent of the injuries that the person injured has suffered, don't you? A: Yes. Q: You get the medical bills, don't you? A: Yes. Q: You get the lost-wage information, don't you? A: Yes. Q: But you don't stop there, do you? You gather more information. A: Yes. Q: And that's because any rational adjuster dealing with an auto accident knows that under certain scenarios, the injured person is entitled to get more than just lost wages and their medical benefits paid. Correct? A: Yes. Q: And those circumstances include, for example, when someone is totally disabled from an accident. Right? A: Yes. . . . . Q: And any, any experienced claims adjuster, you would expect to know, without being told or instructed, that its people in car-wreck cases can recover elements of loss more than just wages and medical payments. Correct? A: I do know that. Yes, sir. . . . . A: I'm speaking of myself. I know that. I don't know somebody that has another 24 years' experience, I can't speak for them. . . . . Q: Ma'am, ... wouldn't it be... Wouldn't it be shocking to you that a person who had 24 years of experience adjusting claims, 5 of which were dealing with automobile-wreck cases, to find out that they claim they did not know, based upon that experience, that a person in the automobile-wreck case could recover elements of loss other than just medical payments and lost wages? . . . . Q: In fact, part of what a claims adjuster has to do, according to y'all's manual, for example, and it's not just y'all's manual but you've worked at other companies, everybody's manual says when you're adjusting an automobile-wreck case, you look for evidence of not just lost wages and medical bills but you look for their permanent impairment and disability. Correct? A: That's correct. Q: Because you know that's an element of loss they can recover. Correct? A: Yes, sir. Q: You look for their past pain and suffering, don't you? A: Yes. . . . . Q: You look for future pain and suffering. Correct? A: Yes. Q: You look for scars and disfigurement. Don't you? A: Yes. Q: You look for the trauma of having, for example, steel rods in your neck. That's an element of loss, isn't it? A: Yes. Q: You look for the loss of enjoyment of life because a person can't do the things physically they could do not just in the work context but in everyday living; isn't that right? A: Yes. . . . . Q: And those are things that you would expect any adjuster dealing with automobile cases to have knowledge of if they were doing their job even halfway appropriately. A: Yes. West also acknowledged that National's claims manual, which is given to each claims adjuster to use in performing his or her job, lists the elements of loss potentially suffered by a claimant involved in an automobile-accident case; it acknowledged that those elements include pain and suffering, emotional distress, disfigurement, and loss of the enjoyment of life. West testified that she believed the denial of Sockwell's claim based upon the workers' compensation limit-of-liability provision was invalid for two reasons. First, a provision limiting an insurer's liability in such a case has been declared void under Alabama law. See State Farm Mut. Auto. Ins. Co. v. Cahoon, supra. Thus, National should not have relied upon that provision to deny Sockwell's claim. Second, West testified that, even if the provision limiting liability if workers' compensation benefits are available could have been applied by National, Sockwell's claim still was denied improperly, because Sockwell had the right to recover certain elements of loss sustained in the automobile accident that would not have been covered under Alabama workers' compensation law and, thus, would not have been excluded under the limit-of-liability provision. West acknowledged that, in order to evaluate properly whether a claim should be paid under the limit-of-liability provision as written in the National policy, Hawthorne should have determined the elements of the loss Sockwell had suffered as a result of the automobile accident and compared those to the elements of loss payable under Alabama workers' compensation law. Under the plain language of the limit-of-liability provision, any elements of loss suffered by Sockwell, other than those payable under Alabama workers' compensation law, were reimbursable. West admitted at trial that Sockwell's medical records, which National received before it denied Sockwell's UIM claim in September 1998, established that Sockwell had endured pain and suffering and had suffered emotional distress, disfigurement, and a loss of enjoyment of life as a result of the automobile accident. Thus, Sockwell's claim was entitled to consideration and, according to West, to payment of the policy limits.