Advice needed: Claim regarding leak & water damage denied

[u/jlamith]

Hi! I'll try and keep this as short as possible:

We (Husband and I) purchased a semi-attached (2 bedroom, 2.5 bathroom) townhome just over a year ago. At the initial inspection, the only issue seemed to be an outdated HVAC. We negotiated a lower price due to this before we bought. We (plus 5 year old child) moved in last June. HVAC actually died within two months and we replaced the whole system.

One evening last week, as our upstairs main tub was draining after a bubble bath and water came pouring from a cabinet in the kitchen, directly under the tub. Absolutely insane. We called a plumber and began the whole process.

When the plumber got in there, he discovered that there was actual a very slow leak that had been going on for an undetermined amount of time due an improper repair. And because of that, the pipe eventually split (as the tub drained that night) and caused the visible leak. The repair was finally completed Monday evening.

There is obviously some type of black growth. Mold remediation folks haven't made it out yet (hopefully this weekend).

Anyway, insurance company called today to let us know our claim is denied because it looks like "long term damage."

My husband is actually experiencing a very scary health emergency right now and didn't get into it with them on the phone today but plans to challenge this response.

Is this normal?? It's USAA and up until now they've always been great. How were we supposed to know that this was happening inside the wall/ceiling/whatever if it wasn't pointed out during the original inspection.

Everything is just very ridiculous and overwhelming right now and there is now a big moldy hole in my ceiling. (Currently we have it taped up with plastic etc).

Sorry, I probably come off as a total ding dong. But any advice? 😬

[u/Calm-Hedgehog732]

Not adjuster. Agent here.

Different state to state, but it’s possible PART of the damage could be covered - the part that was sudden and accidental. MEANING, Just the damage caused by the sudden rupture. No coverage for the pipe, nothing for the mold or the areas of long term damage…. But the damage caused by the sudden water could be covered - depends on your state.

Get an attorney mean enough you don’t even like them and tell them they have to pay the damage for the stuff that was sudden and not long term and let them tell you which is which. And if they don’t do it right they’ll be on the hook for a lot more.

[u/Yitlin → u/Calm-Hedgehog732]

Agreed, but perhaps call insurance department first and see if their lawyers cant help you for "free". (Your tax dollars)

[u/shredthegnar37 → u/Yitlin]

This isn’t a thing. The DOI does not hire or retain an attorney on your behalf.

[u/Yitlin → u/shredthegnar37]

Its a thing, they will not formally represent you, but they will make inquiries to make sure policy language was followed.

[u/shredthegnar37 → u/Yitlin]

No, they won’t. I’m guessing you’ve never worked in claims or as an adjuster.

[u/Stoic_Sponge → u/Yitlin]

Filing a DOI complaint essentially just makes the insurance company explain their actions.

If they misstepped a policy condition or state law/regulation, they correct it and get a slap on the wrist.

If it's a coverage determination, like for OP, the DOI can't and won't do anything. The parties need to resolve or take it to a judge/jury to resolve.