28 Tex. Admin. Code § 5.4211 - Appraisal Process
(a) Applicability. This
section and §§
5.4212-
5.4222 of this title describe the
appraisal process and apply when:
(1) the
association has accepted coverage for a claim, in full or in part;
and
(2) the claimant disputes the
amount of loss the association will pay for the accepted portion of the claim
within the time allowed by Insurance Code §
2210.574, concerning
Disputes Concerning Amount of Accepted Coverage, or §2210.5741, concerning
Replacement Cost Coverage Claim Processing.
(b) Appraisal explanation. The association
must include an explanation of the appraisal process, and the process for
requesting a supplemental payment, with each notice either:
(1) accepting coverage under Insurance Code §
2210.573, concerning
Filing of Claim; Claim Processing; or
(2) stating the amount of the replacement
cost payment the association will make in response to a request under Insurance
Code §
2210.5741.
(3) The explanation must include the
deadlines for demanding an appraisal and requesting a supplemental
payment.
(c) Appraisal
demand.
(1) A claimant may demand an appraisal
under Insurance Code §
2210.574 or §
2210.5741 by telling
the association that the claimant disagrees with the amount of loss the
association will pay for the accepted portion of the claim. A disagreement
includes asking for additional money or telling the association that the amount
may not be enough.
(2) A claimant
may demand an appraisal under Insurance Code §
2210.5741:
(A) at any time after the claimant receives
the claim acceptance notice described in Insurance Code §
2210.573(d)(1) or
(2), but not later than the 30th day after
the date the claimant receives the replacement cost notice described by
Insurance Code §
2210.5741(b);
(B) if the claimant has not demanded an
appraisal on the claim under Insurance Code §
2210.574;
and
(C) regardless of whether
repairs are complete.
(3)
If the association receives an appraisal demand from a claimant, the
association must, in writing, acknowledge the appraisal demand not later than
the 10th day after the date of receipt.
(4) The acknowledgment of an appraisal demand
must include an explanation of the:
(A)
appraisal process, including that the process begins when the claimant hires an
appraiser; and
(B) process for
requesting a supplemental payment, including the opportunity to seek a
supplemental payment before the appraisal process
begins.
(d)
Appraiser selection. The association and the claimant must each hire an
appraiser who is independent and qualified under §
5.4212 of this title (relating to
Appraisal Process - Appraiser Qualifications and Conflicts of
Interest).
(e) Deadline for
appraisal budget disclosure and naming an umpire. Within 15 days of the date by
which the appraisers are named by the parties, the appraisers must disclose
their projected fees to the parties and agree on an umpire. If the appraisers
cannot agree on an umpire, they may ask the department to select an umpire
under subsection (h) of this section. The deadlines in this subsection may be
extended as provided by subsection (k) of this section.
(f) Deadline for appraiser agreement. Except
as provided by subsection (k) of this section, appraisers must agree on the
amount of loss:
(1) for residential claims,
within 90 days of the date by which both appraisers were named; or
(2) for commercial claims, within 120 days of
the date by which both appraisers were named.
(g) Appraiser fee information. No later than
five days after hiring an appraiser, each party must tell the other party the
fees to be charged by the appraiser.
(h) Umpire selection.
(1) The appraisers must select an umpire who
is independent and qualified under §
5.4214 of this title (relating to
Appraisal Process - Umpire Qualifications and Conflicts of Interest).
(2) If the appraisers are unable to agree on
an umpire, either appraiser may ask the department to select an umpire. The
appraiser must submit the request under §
5.4251 of this title (relating to
Requests and Submissions to the Department). The request must include the
following information:
(A) the type of
policy;
(B) a description of the
claim and, if known, the claimed value of the covered loss;
(C) the association's claim acceptance
letter, including the amount the association will pay for the loss;
and
(D) any other information that
the department requests.
(i) Umpire participation. The selected umpire
must participate in the resolution of the dispute if the appraisers fail to
agree on a decision by the deadlines specified in subsection (e) of this
section.
(j) Deadline for appraisal
panel decision. Except as provided by subsection (k) of this section, the
appraisal panel must decide on the amount of loss:
(1) for residential claims, within 60 days of
the date by which the umpire becomes involved; or
(2) for commercial claims, within 90 days of
the date by which the umpire becomes involved.
(k) Extension of deadlines. The association
and the claimant may extend deadlines by written agreement of both parties. The
commissioner may also extend deadlines, as provided in §
5.4222 of this title (relating to
Appraisal Process - Extensions of Deadlines).
(l) Decision. If the appraisers agree on the
amount of loss, their decision is binding on the parties as to the amount of
loss the association will pay for the claim. If the appraisers cannot agree,
and the umpire participates, an itemized decision agreed to by any two of these
three is binding on the parties as to the amount of loss the association will
pay for the claim. Parties may challenge the decision only as permitted by
Insurance Code §
2210.574.
(m) New umpire. If a decision is not issued
within the deadlines established by subsection (j) of this section, or as
extended by subsection (k) of this section, the appraisers may select a new
umpire as described in subsection (h)(1) of this section, or either appraiser
may ask the department to select a new umpire as described in subsection (h)(2)
of this section.
(n) Notice for
actual cash value coverage. The association must send a notice to the claimant
for each accepted claim for damage to a structure, or part of a structure, on
which the claimant has only actual cash value coverage and an appraisal has not
been demanded.
(1) The association must send
the notice not earlier than the 45th day before but not later than the 30th day
before the deadline to demand an appraisal under Insurance Code §
2210.574.
(2) The notice must inform the claimant that:
(A) an appraisal has not been demanded;
and
(B) if the claimant disagrees
with the amount the association will pay for the accepted part of the claim or
thinks the amount may not be enough, the claimant must tell the association
before the appraisal deadline. If the claimant does not tell the association
before the deadline, the claimant cannot ask for a supplemental payment after
the deadline passes.
(C) The notice
must also inform the claimant of the deadline for demanding an appraisal and
requesting a supplemental payment.
(3) The association is required to send the
notice only one time, unless the department extends the appraisal deadline
after the association sends the notice.
Notes
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