How Policy Exclusions Can Affect Personal Injury Claims in Florida

You were hurt. Someone else was at fault. So why is the insurance company telling you that your claim is not covered? The answer often comes down to policy exclusions, and understanding how they work can make a significant difference in the outcome of your case.

What Are Policy Exclusions and Why Do They Matter?

Insurance policies are contracts, and like any contract, they spell out what is and is not included. Policy exclusions are the specific circumstances, events, or conditions that a policy explicitly does not cover. For personal injury victims in Florida, these exclusions can be a rude surprise. You may assume that because the at-fault party has insurance, your medical bills and lost wages will be paid. That assumption is not always correct.

Florida law requires drivers to carry personal injury protection (PIP) coverage under Florida Statute § 627.736, but even PIP policies contain exclusions that can limit or eliminate your benefits. For example, injuries sustained while committing a felony, injuries related to an intentional act, or accidents involving vehicles used for certain commercial purposes may all fall outside the scope of coverage.

Common Exclusions That Can Derail a Claim

Exclusions vary widely from one policy to the next, but some show up repeatedly in Florida personal injury cases. The following are among the most common:

• Intentional acts exclusions: If the insurer argues that the harm was caused deliberately rather than through negligence, coverage may be denied entirely.
• Business use exclusions: A personal auto policy might exclude coverage if the vehicle was being used for rideshare or delivery purposes at the time of the accident.
• Household member exclusions: Some policies bar claims made by members of the policyholder’s own household, which can affect family members injured in the same vehicle.
• Workers’ compensation offsets: In workplace accidents, insurers may argue that workers’ compensation is the proper remedy and deny additional coverage.
• Alcohol or drug exclusions: Injuries connected to intoxication can trigger exclusions that wipe out coverage for the intoxicated party.

How Exclusions Are Interpreted Under Florida Law

Here is something important to know: insurance companies do not get to define exclusions however they want. Florida courts have long held that ambiguous policy language must be interpreted in favor of the insured, not the insurer. This is a doctrine known as contra proferentem, and it has real teeth in Florida courts. That means even if an insurer cites an exclusion to deny your claim, that denial may not be the final word.

Additionally, insurers have a duty to defend their policyholders against covered claims. If an insurer wrongfully refuses to defend or pay a valid claim, they can face bad faith liability under Florida Statute § 624.155. This creates real accountability for insurance companies that try to hide behind exclusions improperly.

Speak with an Attorney Before Accepting a Denial

Do not accept an insurer’s determination at face value. Insurance companies have teams of lawyers and adjusters whose job it is to minimize what they pay out. A denial letter citing an exclusion is often the beginning of a negotiation, not the end of a claim. If you or someone you love has been hurt and told that coverage does not apply, you deserve a closer look from someone who understands how Florida insurance law actually works.

We at Pita Weber Del Prado encourage you to reach out to our firm if you are facing this situation. Our Miami personal injury lawyers have experience cutting through insurance denials and fighting for the compensation our clients deserve. Contact Pita Weber Del Prado today for a free consultation.

Source:

flsenate.gov/Laws/Statutes/2024/627.736