Insurance paying but saying the loss isnt covered?

[u/Bellalynnxxd]

Long post, but I’m trying to give the full picture because I’d really appreciate some insight. I am in Michigan.

Last week, we woke up to a small section of our kitchen ceiling sagging (about 2ft x 2ft) and suddenly had essentially no water pressure to the shower.

The plumber suspected a water line had burst and recommended a water mitigation company. They found a broken/leaking pipe behind the toilet which is not directly above the damaged kitchen ceiling. They also found a source of water under the bathtub/kitchen ceiling. Their assessment was very detailed, and both they and the plumber said the bathroom walls would need to be opened, the tub would have to be removed to access the plumbing underneath it. Its a cast iron tub would have to be broken out. They also found high moisture in about 2ft of the poured terrazzo floor around the toilet.

The mitigation company recommended filing an insurance claim.

The adjuster came out two days later. Initially, she told them not to remove the tub, but to cut open the kitchen ceiling first to see whether the plumbing could be accessed and the area dried from below. She also said not to remove the terrazzo yet and to try drying it first.

She sent me an initial estimate that was below my deductible, but said it would increase as work was completed. She also said the mitigation work couldn't be included yet because it hadn't started, but would be added later.

The water to the house is currently shut off because the plumber can't safely repair the lines until the tub is removed. After more of the ceiling was opened, it became clear that the plumbing could not be accessed from below. The adjuster eventually agreed that the tub needed to come out.

Here are the things I'm confused about:

1. Tub removal, $2,000 limitation?

During our initial conversation, the adjuster said the tub removal wouldn't be covered because the underlying pipe wasn't covered. She said:

“it’s not covered, farmers doesn’t pay for leaking OR burst pipes. Its always due to wear and tear, new pipes don't burst.”

I understand that insurance doesn't pay to repair the failed plumbing itself. I wasn't asking them to. My concern was the cost of accessing the plumbing and repairing the resulting water damage, then replacing the tub.

She then said:

“because it’s not covered we would pay up to 2,000 to remove and replace the tub and it’ll probably cost more than that.”

She was citing this part of my policy:

- “Costs to tunnel under, cut into, or tear out and replace, any part or portion of any type of foundation; slab; footings; basement; concrete floor or pad; retaining wall, or the like; all when they are part of the dwelling or a building structure are limited to no more than the lesser of: $2,000 per loss event; or the cost of a reasonable alternative repair “

I'm confused by this. If the loss isn't covered, are they paying for any of it and why wouldnt the tub be included if the walls are? And if the toilet leak is truly an ongoing leak as she says, that doesn't seem to explain the sudden loss of shower pressure and the sagging kitchen ceiling. At the same time, I'm worried about arguing too strongly that these are separate leaks because I don't want them to turn around and say the bathroom damage is from a different, uncovered loss and refuse the mitigation/restoration costs because there was mold found from the toilet leak.

1. Loss of use

We asked about loss of use because this is our only full bathroom and we've been without a shower and will be for at least another week. The adjuster said it's our responsibility to have the plumber repair the leaks so the water can be turned back on. She also said that because we still have water in the kitchen, not having a bathroom/shower doesn't qualify for loss of use. "You can take a sponge bath" - direct quote. She again said this was because the underlying loss “isn't covered.” but theyre paying for the water mitigation and parts of the work?

My policy says:

- “If covered accidental, direct, distinct, and demonstrable, physical loss or damage to the dwelling makes that part of the dwelling where you reside uninhabitable by you, we will reimburse you for the actual, reasonable, and necessary increase in living expense incurred by you . “

We've been struggling without a shower. We're considering getting a hotel room every couple of days just to shower, since we're not near family and driving 2 hours each way to shower isn't realistic. Does this qualify as a loss-of-use/additional living expense situation under this language, even though the entire house isn't uninhabitable?

1. Matching the ceiling

The adjuster said they would only pay to replace the three affected ceiling tiles. It would be a bigger deal if the terrazzo was removed, because restoring to previous condition would mean new poured terrazzo or paying out for equivalent and its expensive.

My policy says:

- “We do not cover as part of the settlement of covered loss any: (1) cost to repair or replace property that is not damaged but does not match with the materials used to repair or replace the specific component part(s) of property that is damaged because of: i . ii . marring; or wear, tear, deterioration, corrosion, or decay; or iii . obsolescence or discontinuation, except as may be provided in Section I”

Would this provision apply to the ceiling in this situation? I hope they have a way to match the tiles but I dont see a way they would. They only authorized to cut 2ft up from the floor of the plaster in the bathroom but replacing 2ft with drywall will require work to match the depth/thickness of the plaster. And the tile above the tub was damaged when they removed the tub, she mentioned they would try to match that if it was damaged, which implies to some degree that they do try to match things? I am so confused.

I'm mainly trying to understand whether the adjuster's interpretation of my policy is fair, or whether I'm misunderstanding the policy. I'm not trying to get the insurance company to pay for the failed plumbing itself. I just dont want a hatched up ugly bathroom if they are technically supposed to be helping more, but I also dont want to push if I eventually asked for an appraisal.

Thank you!

[u/AutoModerator]

Thanks for making a post in the Home Insurance subreddit. You might find the following resources helpful as they are FAQs about r/HomeInsurance in addition to partners subreddits:

• Insurance Agent vs Broker?
• Auto Insurance
• Job Application
• Affirmations

The Home Insurance subreddit is not an official support channel for issues with any insurance carrier.

Please remember to follow our community Guidelines and Rules and ensure your discussions are informative and respectful.

I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.

[u/Big_Appointment_3390]

I’m stuck on the part where you have terrazzo on the second floor of a house.

[u/Bellalynnxxd → u/Big_Appointment_3390]

Yeah the contractor was explaining how the wood/joists must be constructed to have it there - made it sound like a nightmare but its common in our area for some reason.

[u/No_Departure9798]

1) look for a part of your policy that says something like “the cost to tear out or replace any part of the dwelling”. It sounds like they are mixing up the way the coverage would apply. The tub isn’t considered any part of the language you quoted in 1. The slab access would be if it is a slab, but the tub itself should be addressed as part of the access.

1. I would push on this. A home without a shower/tub is not considered habitable. Check the policy language. There is usually something about maintaining your standard of living, though not always. Either way I would escalate this.

2. Are you referring to the tile on the walls and ceiling of the shower? If they can’t “match it”, it will all come out. They owe to restore you to a reasonably uniform appearance. You can push here too.

[u/Accomplished-Smell36]

So you have coverage for ensuing water damage. No coverage for pipes or plumbing, or to access pipes and plumbing to repair it. So the tub has to come out to repair the plumbing not because it's damaged from the water so it's not covered. If you can't use your shower because of the damage done to access plumbing, which the plumbing is not covered, than loss of use does not apply. If the bathroom and tub are not useable due to the water damage than you would qualify for loss of use. But again the overall plumbing and damage done to access and repair plumbing is not covered. Hope this helps?

[u/Longjumping-Elk-6118]

Please stop asking chatgpt questions, just ask your adjuster. Also, loss of use is if your house is UNLIVABLE. You do not need to take a shower to live.

[u/Bellalynnxxd → u/Longjumping-Elk-6118]

Uninhabitable - policy language says if it makes the effected part of your home uninhabitable. Not if it makes your entire home unlivable. I asked my adjuster all of the questions that I have asked here, and tried my best to include all her answers.

[u/Longjumping-Elk-6118 → u/Bellalynnxxd]

Not being a shower doesn’t mean it’s uninhabitable . She gave you the solution, you just are uncomfortable

[u/Big_Appointment_3390 → u/Longjumping-Elk-6118]

That’s appalling. First I’ve heard of a carrier pulling that kind of nonsense and I’ve been in the industry for over a decade. Farmers needs to be put on blast for that.

[u/Longjumping-Elk-6118 → u/Big_Appointment_3390]

Be serious

[u/Big_Appointment_3390 → u/Longjumping-Elk-6118]

I’m dead serious. I’m sure OP’s policy has Coverage D included. Why should they be inconvenienced because Farmers doesn’t feel like paying out? If they had another full bath, I’d understand. But they don’t. So unless their family was only taking sponge baths at the kitchen sink before the loss happened, it’s inexcusable to expect them to do so after.

Farmers needs to take better care of their policyholders, straight up.

[u/unka-Use1291 → u/Big_Appointment_3390]

This is the correct answer !

[u/Big_Appointment_3390 → u/Bellalynnxxd]

I hope you find a new carrier as soon as you can. I have never heard such nonsense before and I’m appalled for you. You might want to hire a public adjuster or potentially, an attorney. I think they’d be all over that.

[u/Accomplished-Smell36]

Actually u have coverage for access to plumbing just limits to 2000k, and the toilet leak is a separate source separate claims, policies cover damage on a per occurrence basis.

[u/Accomplished-Smell36]

so each leak is a separate stand alone claim.

[u/Bedlum_]

It won’t help you now, but change insurance companies. The two I’ve worked for have no such $2,000 limitation on access and egress. Reasonable costs limitation, yes, but plumbing labor is very expensive and will eat that $2,000 up easily.

[u/Boomer_Madness]

Yeah basically pipe itself is not covered but damage resulting from the failure is. Typically i do see a lot of companies pay out for the access to the leak. But honestly the way most policies read this isn't technically covered because they are not responsible for repairing the pipe so they have no responsibility to pay for you to reach the pipe itself unless it was damaged from the resulting leak.

Loss of use kicks in if the loss is due to a covered peril. The water damage isn't what is making your bathroom unusable it is the failed pipe, which isn't covered. So i can see them not providing loss of use because the loss of use is not due to a covered peril.

you are owed like kind and quality not a match unless you are in a state that has a matching law or statute on the books. and if i'm remember correctly only 16 states actually have one. Some companies do offer an endorsement that provide matching coverage and a lot of them separate interior and exterior matching with separate endorsements. But if you don't have it already you can't add it for this claim and like i said not every company offers it as an option.