PJC Business

PJC 102.26

DTPA/I NSURANCE C ODE

Information “required by the insurer to secure final proof of loss.” The insurer must notify the claimant of the disposition of the claim within fifteen business days from “the date the insurer receives all items, statements, and forms required by the insurer to secure final proof of loss.” Tex. Ins. Code § 542.056(a). The statute does not define “proof of loss,” though it is commonly understood to mean “documentation of loss required of a policyowner by an insurance company[] [such as] a death certifi cate (or copy) [that] must be submitted to the company for a life insurance death bene fit to be paid to the beneficiary.” H. Rubin, Dictionary of Insurance Terms 416 (Barron’s Business Guides, 6th ed. 2013). This meaning comports with the statute’s description of what the insurer must timely request of the claimant. Using the same phrase as section 542.056(a), Tex. Ins. Code §542.055(a)(3) requires the insurer, within fifteen days of receipt of the notice of claim, to “request from the claimant all items, statements, and forms that the insurer reasonably believes, at that time, will be required from the claimant ” (emphasis added); under Tex. Ins. Code § 542.055(b), the insurer may make “additional requests for information if during the investigation of the claim the additional requests are necessary ” (emphasis added); and under Tex. Ins. Code §542.058, the insurer must pay a claim within sixty days after receiving “all items, statements, and forms reasonably requested and required under Section 542.055 ” (emphasis added). In short, the statute equates what the insurer must receive from the claimant with what the insurer must timely request from the claimant—items, statements, and forms that are necessary to decide the claim. Because this is consistent with the ordinary meaning of “proof of loss,” the pattern jury questions do not use that term but instead use the phrase “necessary to decide whether to accept or reject the claim” to describe what the insurer must have received to trigger its duty to notify the claimant of its decision on the claim. Definition of “business day” and “day.” The various sections of the Prompt Payment of Claims Act use either “day” or “business day” depending on the statutory deadline involved. “Business day” is defined in Tex. Ins. Code § 542.051(1). See Tex. Gov’t Code ch. 662 (listing state-recognized holidays). To avoid confusion the court may wish to define “day” for the jury as “every day, including all Saturdays, Sundays, and holidays.” The appropriate definition should be included depending on the rele vant statutory deadline. Extension of deadline—insurer unable to accept or reject claim within time period. The deadline to notify the claimant of acceptance or rejection may be extended “[i]f the insurer is unable to accept or reject the claim within the time period” and, “within that same period,” the insurer “notif[ies] the claimant of the reasons that the insurer needs additional time.” Tex. Ins. Code § 542.056(d). The insurer must then “accept or reject the claim not later than the 45th day after the date the insurer notifies a claimant under this subsection.” Tex. Ins. Code § 542.056(d). If an insurer is relying on this exception, the following questions are appropriate. If it is undisputed that the insurer gave notice of its need for more time within fifteen business days, Question 2 below may be omitted.

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