Insurance Contracts

Essential elements of an insurance contract

An insurance contract is built on utmost good faith from everyone involved. The applicant relies on the insurer’s promise to pay. The insurer relies on the applicant to provide truthful information on the application.

Insurance is also governed by contract law. For any contract to be valid and enforceable, four conditions must be met:

1. There must be consideration by both parties.
2. An offer must be made by one party, and acceptance of that offer must be made by the other party.
3. All parties to the contract must be legally capable of entering into a contract.
4. The purpose of the contract must be legal.

Consideration

For a contract to be valid, there must be an exchange of consideration (something of value).

• The insurer’s consideration is its promise to pay policy benefits if the insured suffers a covered loss (acceptance of the risk).
• The applicant’s consideration is the premium.

Premiums are calculated on an annual basis, even if the policy’s payment mode is more frequent. When a policy owner pays a premium, part of that premium covers expenses, and part is held in reserve to meet future claim commitments. These funds are invested to earn interest. The net effect is to reduce the amount of premium that would otherwise be required.

Offer and acceptance

To form a valid insurance contract, the offer must be accepted unconditionally.

Typically:

• The applicant makes the offer by submitting an application, often with the first premium.
• The insurer may accept the offer as submitted or respond with a counteroffer, such as a rated policy or modified terms.

If both parties agree to the final terms, a contract is formed. If they don’t, no contract exists.

Legal capacity

Both parties must be legally capable of entering into a contract.

• If the insurer is admitted or authorized in the state, it has legal capacity.
• The applicant has legal capacity unless he/she is a minor, mentally incompetent, intoxicated, or under the influence of narcotics.

Legal purpose

A valid contract must have a legal purpose and must not be against public policy. For example, a life insurance policy purchased with the intent to have the insured killed is an invalid contract.

For an insurance contract to be valid, there must be an insurable interest between the applicant/owner and the insured.

Sidenote

Know this...

Consideration, Offer and Acceptance, Legal Capacity, and Legal Purpose are the 4 essential elements of an insurance contract. “Meeting of the minds” is a fancy way to say “Acceptance by both parties.”

Insurance contracts are unique because the applicant must purchase the policy as written, without an opportunity to modify or clarify the contract language. Over time, courts have applied the Doctrine of Adhesion to interpret ambiguous contract terms or conditions in favor of the insured, since the insured had no chance to alter the contract at the time of application.

Insurers work hard to make contract language clear and to avoid misunderstandings about policy terms. Even so, questions and conflicts can arise. When they do, they often involve warranties and representations.

A warranty is a guarantee that a statement is truthful.

Representations are statements made on the application that are substantially true to the best knowledge of the applicant.

If an applicant makes a statement on an application that the applicant knows is false, it is a misrepresentation and may constitute fraud. If the insurer can prove that a material misrepresentation was made intentionally, it may void the contract, and the applicant may be prosecuted for insurance fraud, which state law makes a crime.

Lesson summary

An insurance contract is based on utmost good faith: the applicant relies on the insurer’s promise to pay, and the insurer relies on the truthfulness of the applicant’s statements. For a contract to be valid and enforceable, it must include consideration by both parties, offer and acceptance, legal capacity of the parties, and a legal purpose.

Consideration is the exchange of promises: the insurer promises benefits for covered losses in return for the applicant’s premium.

Offer and acceptance require unconditional agreement. The applicant typically makes the offer by completing an application, and the insurer may accept it as submitted or propose changes. Legal capacity means both parties must be able to enter into a contract. The contract’s purpose must also be legal and not against public policy. An insurable interest must exist between the applicant/owner and the insured.

• Insurance contracts have unique features:

• Applicants must accept policies as written without modification.

• The Doctrine of Adhesion favors insured parties in case of ambiguous terms.

• Insurers strive for clear contract language to prevent misunderstandings.

Warranties guarantee truthfulness, while representations are statements that are substantially true. Misrepresentations, if intentional and material, can void the contract and may constitute fraud.

Chapter vocabulary

Definitions

Acceptance

When the offer (application) is accepted, an agreement is reached.

Adhesion

Insurance policies are contracts of adhesion because the terms are written by the insurer and the insured simply “adheres.” For this reason, vague or ambiguous provisions are often interpreted by courts in favor of the insured.

Competent Party

Most entities in a contract are deemed competent except minors, those under the influence of alcohol or narcotics, and mentally incompetent individuals.

Concealment

Neither party may conceal facts that would have affected the creation of the contract.

Consideration

The exchange of values on which a contract is based. In insurance, the consideration offered by the insured is the premium. The consideration offered by the insurer is the promise to pay in accordance with the terms of the contract.

Legal Purpose

A contract/policy must be drawn for a legal purpose and not against public policy.

Misrepresentation

On the part of an insurer or its agent, falsely representing the terms, benefits, or privileges of a policy. On the part of an applicant, falsely representing the health or other condition of the proposed insured.

Offer

The terms of a contract proposed by one party to another. In insurance, submitting an application to the company is usually considered an offer.

Representations

On an application, facts that the applicant represents as true and accurate to the best of his/her knowledge and belief.

Rescission

The termination of an insurance contract by the insurer when material misrepresentation has occurred.

Utmost Good Faith

Acting in fairness and equity with a sincere belief that the act is not unlawful or harmful to others. The insurance contract requires that each party is entitled to rely on the representations of the other without attempts to conceal or deceive.

Warranty

A statement made on an application for insurance that is warranted to be true in all respects. Under the traditional rule, a warranty that proved untrue in any respect could void the contract, even if the person giving it did not know it was untrue and even if it was not material to the risk. Most states now limit that rule by statute, so a misstatement voids coverage only if it is material to the risk or fraudulent. Statements on life and health insurance applications are, in the absence of any evidence of fraud, representations rather than warranties. (Contrast with Representations.)