The ‘estimate’ included in the Claim Disposition Packet relates to the association’s ‘payment’ of the claim. ‘Payment’ of a claim is not the same as ‘denial’ of a claim. The appraisal panel may not look to the estimate as a means to determine or limit coverage. See Texas Windstorm Ins. Ass’n v. Jones, 512 S.W.3d 545, 550 (Tex.App. — Houston [1st Dist.] 2016, no pet.).
In Texas Windstorm Ins. Ass’n. v. Jones, the claimant argued that because the Notice of Claim Acceptance contained the following sentence: “TWIA accepts the following portion(s) of your claim: All damages detailed on the enclosed estimate,” TWIA limited coverage acceptance to only those items set forth in the estimate.
Given the claimant’s position, the issue before the court of appeals became “whether TWIA accepted coverage for Jones’s claim in full, in which case appraisal was his exclusive remedy for disputing the accepted coverage, or whether TWIA accepted coverage for only a portion of his claim [the estimate], in which case Jones was entitled to bring suit against TWIA with regard to its partial denial of his claim.” Id. at 550
The court of appeals, addressing whether TWIA’s accepted coverage of the claim may be limited to those portions detailed in the estimate, disagreed and noted:
“TWIA’s partial payment of Jones’ claim was not a partial denial his claim. “This assertion conflates two concepts that have distinctly different meanings. A “claim,” as defined by the statute, is a request for payment. Id. § 2210.571(2). “Coverage” is the term used to describe whether or not the given policy will pay for that loss, or whether or not the claim fits within the scope of coverage.” Jones, 512 S.W.3d at 550.
The appraisal panel may not look to the estimate as a means to determine or limit coverage.
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