Georgia First-Party Insurance Claim Denial Appeal and § 33-4-6 Demand

FIRST-PARTY INSURANCE CLAIM DENIAL APPEAL AND O.C.G.A. § 33-4-6 DEMAND — GEORGIA

TABLE OF CONTENTS

1. Letterhead and Delivery Information
2. Claimant and Claim Identification
3. Statutory § 33-4-6 Demand and 60-Day Notice
4. Factual Background
5. Policy Coverage Analysis
6. Refutation of Denial Grounds
7. Identification of Bad-Faith Conduct
8. Damages and Settlement Demand
9. Election: Appraisal in the Alternative
10. Notice of Georgia DOI Complaint and Litigation
11. Litigation Hold
12. Reservation of Rights
13. Signature, Service, and Certification
14. Exhibit Index
15. Georgia Practice Notes
16. Sources and References

1. LETTERHEAD AND DELIVERY INFORMATION

[LAW FIRM NAME / CLAIMANT NAME]

[STREET ADDRESS]

[CITY, GA ZIP]

Telephone: [NUMBER] | Email: [EMAIL]

Date: [__/__/____]

PRIVILEGED AND CONFIDENTIAL — SETTLEMENT COMMUNICATION

SENT VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED

Delivery Method (select all):

☐ Certified Mail, Return Receipt Requested — Tracking No. [________________________________]

☐ FedEx/UPS Overnight, Signature Required — Tracking No. [________________________________]

☐ Hand Delivery with witness affidavit

☐ Email with read receipt — to: [________________________________]

☐ Insurer's online appeals portal — Submission ID: [________________________________]

To:

Re: Appeal of Adverse Coverage Determination and Statutory Demand under O.C.G.A. § 33-4-6

2. CLAIMANT AND CLAIM IDENTIFICATION

3. STATUTORY § 33-4-6 DEMAND AND 60-DAY NOTICE

THIS LETTER CONSTITUTES A FORMAL WRITTEN DEMAND UNDER O.C.G.A. § 33-4-6.

Insurer is on notice that, pursuant to O.C.G.A. § 33-4-6(a):

"In the event of a loss which is covered by a policy of insurance and the refusal of the insurer to pay the same within 60 days after a demand has been made by the holder of the policy and a finding has been made that such refusal was in bad faith, the insurer shall be liable to pay such holder, in addition to the loss, not more than 50 percent of the liability of the insurer for the loss or $5,000.00, whichever is greater, and all reasonable attorney's fees for the prosecution of the action against the insurer."

The 60-day cure period begins upon Insurer's receipt of this demand.

TOTAL DEMAND: $[________________________________] (itemized in Section 8 below)

If Insurer fails to pay this demand within 60 days of receipt, Claimant will (i) file a Georgia Department of Insurance consumer complaint, (ii) file suit in [COUNTY] County, Georgia, seeking the loss amount plus the statutory penalty (greater of 50% or $5,000), all reasonable attorney's fees under § 33-4-6, pre- and post-judgment interest, and costs of suit, and (iii) serve the Commissioner of Insurance and the Consumers' Insurance Advocate as required by § 33-4-6(b).

4. FACTUAL BACKGROUND

4.1 The Insurance Policy

On or about [__/__/____], Insurer issued Policy No. [POLICY NUMBER] to Claimant, providing [type of coverage] with limits of $[POLICY LIMITS] and a deductible of $[DEDUCTIBLE]. The Policy was in full force and effect at the time of the loss; all premiums had been timely paid.

4.2 The Loss

On or about [__/__/____] at approximately [time], Claimant suffered a loss covered by the Policy when [describe loss in detail — date, location, cause, nature, and extent of damage].

4.3 Notice and Cooperation

Claimant timely notified Insurer on [__/__/____]. Claimant has fully cooperated, including:

• Submitting a sworn Proof of Loss on [__/__/____];
• Providing photographs, repair estimates, contractor bids, and itemized inventories;
• Permitting inspection of the [property / vehicle / records] on [__/__/____];
• Producing all reasonably requested documents and records;
• Submitting to an Examination Under Oath on [__/__/____] (if applicable);
• Other: [________________________________].

4.4 Claim Timeline

5. POLICY COVERAGE ANALYSIS

5.1 Insuring Agreement

The Policy provides:

[quote insuring agreement verbatim]

5.2 Coverages Implicated

☐ Coverage A — Dwelling/Structure

☐ Coverage B — Other Structures

☐ Coverage C — Personal Property/Contents

☐ Coverage D — Loss of Use / Additional Living Expense

☐ Coverage E/F — Liability / Medical Payments

☐ Endorsement(s): [________________________________]

☐ Auto: ☐ Comprehensive ☐ Collision ☐ UM/UIM ☐ Med-Pay

☐ Other: [________________________________]

5.3 Conditions Precedent Satisfied

☐ Prompt notice of loss

☐ Sworn proof of loss

☐ Cooperation with investigation

☐ Mitigation of damages

☐ Production of documents

☐ Examination under oath

☐ Other policy conditions: [________________________________]

5.4 No Applicable Exclusion

The exclusion(s) cited by Insurer (analyzed in Section 6 below) do not apply to the facts of this loss. Under Georgia law, ambiguities in insurance contracts are construed against the insurer-drafter and in favor of coverage. Reed v. Auto-Owners Ins. Co., 284 Ga. 286 (2008); York Ins. Co. v. Williams Seafood of Albany, Inc., 273 Ga. 710 (2001).

6. REFUTATION OF DENIAL GROUNDS

6.1 Insurer's Stated Ground #1

Insurer asserted: [quote from denial letter]

Claimant's response: [detailed rebuttal — cite contrary policy language, factual evidence, expert reports, and authorities]

6.2 Insurer's Stated Ground #2

Insurer asserted: [quote]

Claimant's response: [rebuttal]

6.3 Insurer's Stated Ground #3

Insurer asserted: [quote]

Claimant's response: [rebuttal]

7. IDENTIFICATION OF BAD-FAITH CONDUCT

Under O.C.G.A. § 33-4-6, "bad faith" is a "frivolous and unfounded refusal to pay a claim." United States Fid. & Guar. Co. v. Biddy Lumber Co., 114 Ga. App. 358 (1966). Insurer's conduct is "frivolous and unfounded" because it lacks any reasonable or probable cause. Cotton States Mut. Ins. Co. v. Brightman, 276 Ga. 683 (2003). Specific conduct supporting a bad-faith finding includes:

☐ Denial without reasonable investigation — specifics: [________________________________]

☐ Reliance on facially inapplicable exclusions — specifics: [________________________________]

☐ Misrepresentation of policy terms or Georgia law — specifics: [________________________________]

☐ Lowball offer substantially below clearly owed amount — offered $[________], owed $[________]

☐ Repeated demands for documents already produced — specifics: [________________________________]

☐ Failure to communicate with Claimant — dates of unanswered communications: [________________________________]

☐ Violation of Ga. Comp. R. & Regs. r. 120-2-52 — failure to acknowledge within 15 days; failure to pay undisputed amounts; failure to provide written explanation

☐ Conduct also enumerated in O.C.G.A. § 33-6-34 (cited solely as evidence of bad faith under § 33-4-6; no private right of action under § 33-6-34, see § 33-6-37)

☐ Other: [________________________________]

8. DAMAGES AND SETTLEMENT DEMAND

8.1 Itemization of Loss

8.2 Settlement Demand

Claimant demands payment of $[________________________________] within sixty (60) days of Insurer's receipt of this letter.

Payment instructions:

• Payable to: [________________________________]
• Delivered to: [________________________________]
• Received no later than: [__/__/____]

8.3 Consequences if Unpaid Within 60 Days

If Insurer fails to pay within the 60-day window, Claimant will pursue:

• Contract damages (loss amount): $[________]
• Statutory bad-faith penalty under O.C.G.A. § 33-4-6 (greater of 50% of liability or $5,000): $[________]
• Reasonable attorney's fees under O.C.G.A. § 33-4-6
• Pre-judgment interest under O.C.G.A. § 7-4-2 / § 7-4-15
• Post-judgment interest under O.C.G.A. § 7-4-12
• Costs of suit

For UM/UIM disputes, the demand is also made under O.C.G.A. § 33-7-11 (25% penalty plus attorney's fees, with applicable statutory floor).

9. ELECTION: APPRAISAL IN THE ALTERNATIVE

If the dispute is solely as to the AMOUNT of the loss (not coverage), and the Policy contains an appraisal clause, Claimant hereby invokes (or demands invocation of) appraisal in the alternative:

☐ Claimant invokes the appraisal provision of the Policy. Claimant has selected [APPRAISER NAME, qualifications] as Claimant's appraiser. Insurer is requested to designate its appraiser within twenty (20) days, after which the appraisers shall jointly select an umpire. Claimant reserves all coverage and bad-faith arguments; appraisal addresses only the amount of loss.

☐ Claimant does NOT invoke appraisal because the dispute concerns coverage, not value.

10. NOTICE OF GEORGIA DOI COMPLAINT AND LITIGATION

If this demand is not satisfied within 60 days, Claimant intends to:

1. File a consumer complaint with the Georgia Office of Commissioner of Insurance and Safety Fire:

• Online portal: https://oci.georgia.gov/file-consumer-insurance-complaint
• Mailing address: Two Martin Luther King Jr. Drive, West Tower, Suite 704, Atlanta, GA 30334
• Consumer Services line: 1-800-656-2298

2. Initiate civil litigation in [STATE / SUPERIOR] COURT OF [COUNTY] COUNTY, GEORGIA seeking the contract damages, the § 33-4-6 statutory penalty, attorney's fees, interest, and costs.

3. Serve the Commissioner of Insurance and the Consumers' Insurance Advocate within 20 days of filing per O.C.G.A. § 33-4-6(b).

11. LITIGATION HOLD

Insurer is hereby directed to preserve all documents, communications, and electronically stored information relating to the claim, including:

• Complete claim file (all versions, drafts, and revisions);
• Internal emails, instant messages, memoranda, and chat logs;
• Adjuster notes, diaries, activity logs, and time entries;
• Photographs, videos, and inspection reports;
• Reserves information and reserve history;
• Underwriting file;
• Vendor and expert reports and correspondence;
• Training materials and claim-handling manuals/guidelines;
• Recordings of telephone calls;
• Metadata for all electronic documents;
• Backup tapes and archived data.

Spoliation of evidence may result in adverse-inference instructions and sanctions under Georgia law.

12. RESERVATION OF RIGHTS

Claimant expressly reserves all rights, claims, and remedies under the Policy, Georgia statutes (including but not limited to O.C.G.A. § 33-4-6, § 33-4-7, § 33-7-11), Georgia common law, federal law, and Ga. Comp. R. & Regs. r. 120-2-52. Nothing in this letter waives any claim or remedy. This communication is a settlement communication under O.C.G.A. § 24-4-408.

13. SIGNATURE, SERVICE, AND CERTIFICATION

I certify that the statements made in this letter are true and correct to the best of my knowledge, information, and belief.

Respectfully submitted, this [____] day of [_______________], 20[____].

Insured / Claimant:

Signature: _______________________________________________

Print Name: [________________________________]

Date: [__/__/____]

Counsel for Claimant (if represented):

[LAW FIRM NAME]

By: [________________________________]

[ATTORNEY NAME]

Georgia Bar No. [________]

[STREET ADDRESS] | [CITY, GA ZIP]

Telephone: [NUMBER] | Email: [EMAIL]

Date: [__/__/____]

14. EXHIBIT INDEX

☐ Exhibit A: Policy declarations page and relevant policy provisions

☐ Exhibit B: Sworn Proof of Loss

☐ Exhibit C: Adverse determination / denial letter dated [__/__/____]

☐ Exhibit D: Photographs and videos of damage

☐ Exhibit E: Repair estimates and contractor bids

☐ Exhibit F: Itemized inventory of damaged property

☐ Exhibit G: Expert reports (engineer, public adjuster, appraiser)

☐ Exhibit H: Medical records and bills (if applicable)

☐ Exhibit I: Correspondence log with Insurer

☐ Exhibit J: Damage calculation worksheet

☐ Exhibit K: Certified-mail return receipt / delivery confirmation

☐ Exhibit L: [________________________________]

15. GEORGIA PRACTICE NOTES

• § 33-4-6 demand is jurisdictional. A written demand must be received by the insurer MORE THAN 60 days before suit. Cagle v. State Farm Fire & Cas. Co., 236 Ga. App. 726 (1999). Document receipt; never rely on mailing date.
• Penalty cap. Greater of 50% of insurer's liability for the loss OR $5,000.00, plus all reasonable attorney's fees. The penalty cannot exceed 50% of the contract liability except where 50% would yield less than $5,000.
• § 33-4-6 is the exclusive first-party remedy. No common-law tort of bad faith; no separate § 13-6-11 fees; no § 51-12-5.1 punitive damages for the same conduct. United States Auto. Ass'n v. Carroll, 226 Ga. App. 144 (1997).
• § 33-6-34 — DOI enforcement only. O.C.G.A. § 33-6-37 bars private claims under the Unfair Claims Settlement Practices Act. § 33-6-34 conduct is admissible as evidence of bad faith under § 33-4-6 but cannot stand alone.
• UM/UIM — § 33-7-11. Use § 33-7-11 (25% penalty plus fees) for uninsured/underinsured motorist disputes.
• Motor-vehicle liability — § 33-4-7. For third-party liability claims arising from motor-vehicle collisions, § 33-4-7 imposes affirmative duties with separate procedures and penalty calculations.
• Regulatory standards — Reg. 120-2-52. The Department of Insurance regulations require acknowledgement within 15 days and prompt payment of undisputed amounts. Violations support bad-faith findings but do not create an independent private claim.
• Appraisal and bad faith. Invoking appraisal does not toll § 33-4-6's 60-day clock; nor does it preclude a later bad-faith claim if the appraisal award exceeds the insurer's prior offer by a significant margin.
• Statute of limitations. Six years for written insurance contracts under O.C.G.A. § 9-3-24. Some homeowners and commercial property policies contain shorter contractual limitations periods (often two years from loss); these are generally enforceable in Georgia if reasonable.
• Coverage construction. Ambiguities are construed against the insurer-drafter and in favor of coverage. Reed v. Auto-Owners Ins. Co., 284 Ga. 286 (2008).
• Suit-limitation provisions. Read the Policy for any contractual time limits (often two years from loss in property policies). Filing a § 33-4-6 demand does not toll a contractual suit-limitation clause.
• ERISA caution. If the underlying coverage is ERISA-governed (group health, group LTD, group life through employer), § 33-4-6 is preempted. Use the disability_insurance_appeal.md template instead and consult ERISA counsel.

16. SOURCES AND REFERENCES

• O.C.G.A. § 33-4-6 — Bad-faith penalty — https://law.justia.com/codes/georgia/title-33/chapter-4/section-33-4-6/
• O.C.G.A. § 33-4-7 — Affirmative duty in motor vehicle liability claims — https://law.justia.com/codes/georgia/title-33/chapter-4/section-33-4-7/
• O.C.G.A. § 33-7-11 — UM/UIM coverage — https://law.justia.com/codes/georgia/title-33/chapter-7/section-33-7-11/
• O.C.G.A. § 33-6-34 — Unfair claims settlement practices — https://law.justia.com/codes/georgia/title-33/chapter-6/article-2/section-33-6-34/
• O.C.G.A. § 33-6-37 — No private cause of action under Article 2
• Ga. Comp. R. & Regs. r. 120-2-52 — Fair and Equitable Settlement of First-Party Property Damage Claims — https://rules.sos.ga.gov/gac/120-2-52
• Cagle v. State Farm Fire & Cas. Co., 236 Ga. App. 726 (1999)
• United States Fid. & Guar. Co. v. Biddy Lumber Co., 114 Ga. App. 358 (1966)
• Cotton States Mut. Ins. Co. v. Brightman, 276 Ga. 683 (2003)
• Haezebrouck v. State Farm Mut. Auto. Ins. Co., 290 Ga. App. 420 (2008)
• United States Auto. Ass'n v. Carroll, 226 Ga. App. 144 (1997)
• Reed v. Auto-Owners Ins. Co., 284 Ga. 286 (2008)
• York Ins. Co. v. Williams Seafood of Albany, Inc., 273 Ga. 710 (2001)
• Georgia Office of Commissioner of Insurance and Safety Fire — https://oci.georgia.gov/
• Georgia DOI Consumer Complaint Portal — https://oci.georgia.gov/file-consumer-insurance-complaint
• Drew Eckl & Farnham, "Georgia Courts Continue to Uphold 'Exclusive Remedy' Rule Under O.C.G.A. § 33-4-6" — https://www.deflaw.com/insights/georgia-courts-continue-to-uphold-exclusive-remedy-rule-under-ocga-33-4-6/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. The 60-day pre-suit demand requirement of O.C.G.A. § 33-4-6 is jurisdictional. A Georgia-licensed attorney must review and customize this document before transmission.