Los Angeles Claims Adjuster Property and Causality Practice Exam

In an insurance claim, who must prove that a claim is excluded from coverage?

1. The insured

2. The insurance company

3. The government

4. The policyholder's attorney

The correct answer is: The insurance company

In an insurance claim, it is the responsibility of the insurance company to prove that a claim falls under an exclusion from coverage. This principle arises from the way insurance contracts are structured, where the insurer initially has the burden of proving that the specific terms of the policy apply to deny a claim. Under general insurance law, once a policyholder submits a claim, the insurer is obligated to investigate and substantiate any defense against the claim, including the invocation of policy exclusions. This means that if the insurer contends that certain damages or losses are not covered due to specific exclusions written into the policy, they must provide evidence and rationale for why these exclusions apply to the situation at hand. The insured or policyholder, on the other hand, typically needs to prove the validity of their claim, illustrating that the loss or damage occurred and falls within the coverage of the policy. However, should a dispute arise regarding coverage, it is the insurance company's burden to establish that the claimed incident is indeed excluded based on the policy's language. Therefore, the insurance company must provide adequate proof to justify any denial based on exclusions.