Filing Number: 656700
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| Filing Accepted: 11/11/2022 |
| Last/Business Name
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SANCHEZ
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First Name |
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ARMAND & YESENNIA |
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| Street Address
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26583 FAIRWAY DR., UNIT A-B, |
| City, State Zip
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PUNTA GORDA,
FL
33982
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| Email Address
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LITIGATION@THEFREEMANLAWFIRMPA.COM |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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SANCHEZ |
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First Name |
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ARMAND & YESENNIA |
| Policy # * |
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AGD30428138 |
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Claim #* |
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CDP-00127712 |
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Attorney is Applicable
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| Last Name* |
FREEMAN
First Name *
BRIAN
Initial
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| Street Address* |
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4245 FOWLER STREET |
| City, State Zip* |
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FORT MYERS
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FLORIDA
33901
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| Email Address * |
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LITIGATION@THEFREEMANLAWFIRMPA.COM |
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| Insurer Type
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 Authorized Insurer
 Unauthorized Insurer
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| Insurer Name |
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| Insurer Name* |
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AMERICAN INTEGRITY INSURANCE COMPANY OF FLORIDA
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| Insurer Name* |
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| Street Address* |
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| City, State Zip* |
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,
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NAIC Company Code 12841 |
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| Name of individual responsible for violation (if any):*
DAWN BREMBS
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| Type of Insurance
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Residential Property & Casualty
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| Reason for Notice
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Claim Denial
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Claim Delay
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Unfair Trade Practice
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Other
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Bad Faith
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Statutory provision(s) which the insurer allegedly violated.
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| 624.155(1)(b)(1) |
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Not attempting in good faith to settle claims when, under all the circumstances, it could and should have done so, had it acted fairly and honestly toward its insured and with due regard for her or his interests.
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| 624.155(1)(b)(3) |
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Except as to liability coverages, failing to promptly settle claims, when the obligation to settle a claim has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.
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| 626.9541(1)(i)(3)(a) |
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Failing to adopt and implement standards for the proper investigation of claims.
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| 626.9541(1)(i)(3)(b) |
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Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.
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| 626.9541(1)(i)(3)(c) |
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Failing to acknowledge and act promptly upon communications with respect to claims.
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| 626.9541(1)(i)(3)(d) |
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Denying claims without conducting reasonable investigations based upon available information.
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| 626.9541(1)(i)(3)(f) |
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Failing to promptly provide a reasonable explanation in writing to the insured of the basis in the insurance policy, in relation to the facts or applicable law, for denial of a claim or for the offer of a compromise settlement.
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| 626.9541(1)(i)(3)(g) |
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Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
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| 626.9541(1)(i)(3)(h) |
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Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
The Insureds are in possession of a copy of the Policy and believe their Policy language relevant to the violations includes all applicable policy coverages, loss payment provisions, valuation provisions and other terms and conditions of Policy No. AGD30428138. The Insureds believe the following policy provisions are applicable:
Coverage A - Dwelling
We cover:
1. The dwelling on the Described Location shown in the Declarations, used for principally for dwelling purposes, including structures attached to the dwelling;
2. materials and supplies located on or next to the Described Location used to construct, alter or repair the dwelling or other structures on the Described Location; and
3. if not otherwise covered in this policy, building equipment and outdoor equipment used for the service of and located on the Described Location.
Coverage B - Other Structures
Coverage C - Personal Property
Coverage D - Loss of Use
Loss Payment
We will adjust all losses with you. We will pay you unless some other person is named in the policy or is legally entitled to receive payment. Loss will be payable 60 days after we receive your proof of loss and:
a. Reach an agreement with you;
b. There is an entry of final judgement; or
c. There is a filing of an appraisal award with us.
Loss Settlement. Covered property losses are settled as follows:
a. Property of the following types:
(1) Personal property;
(2) Awning, carpeting, household appliances, outdoor antennas and outdoor equipment, whether or not attached to buildings; and
(3) Structures that are not buildings;
At actual cash value at the time of loss but not more than the amount required to repair or replace.
b. Buildings under Coverage A or B at replacement cost without deduction for depreciation, subject to the following:
(1) If, at the time of loss, the amount of insurance in this policy on the damaged building is 80% or more of the full replacement cost of the building immediately before the loss, we will pay the cost to repair or replace, but not more than the least of the following amounts:
(a) The limit of liability under this policy that applies to the building;
(b) The replacement cost of that part of the building damaged for like construction and use on the same premises; or
(c) The necessary amount actually spent to repair or replace the damaged building.
(2) If, at the time of loss, the amount of insurance in this policy on the damaged building is less than 80% of the full replacement cost of the building immediately before the loss, we will pay the greater of the following amounts, but not more than the limit of liability under this policy that applies to the building:
(a) The actual cash value of that part of the building damaged; or
(b) That proportion of the cost to repair or replace, after application of deductible and without deduction for depreciation, that part of the building damaged, which the total amount of insurance in this policy on the damaged building bears to 80% of the replacement cost of the building.
(3) To determine the amount of insurance required to equal 80% of the full replacement cost of the building immediately before the loss, do not include the value of:
(a) Excavations, foundations, piers or any supports which are below the undersurface of the lowest basement floor;
(b) Those supports in (a) above which are below the surface of the ground inside the foundation walls, if there is no basement; and
(c) Underground flues, pipes, wiring and drains
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Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
During the policy period, on January 16, 2022, the Insureds’ home located at 26583 Fairway Dr., Unit A-B, Cape Coral, FL, 33982 (“Home”), owned by the named Insureds, Armand and Yesennia Sanchez ("Insureds”), suffered wind related physical and structural damage as a direct result of a tornado, an event covered under the subject insurance policy.
The Insureds timely reported the loss to their insurance carrier, American Integrity Insurance Company ("Insurer"). Since the beginning of the claims process, the Insureds fully cooperated in the Insurer's investigation of the Insureds’ tornado damage claim.
The Insureds reported a claim to the Insurer regarding the damages to the Insureds’ home and roof system. The Insurer responded to the notification of the loss and damage claim of the Insureds by assigning claim number CDP-00127712 to the Insureds’ tornado damage claim and notifying the Insureds that an inspection of their loss and reported damages would be performed. The inspection was conducted by an unnamed “roofing consultant” at the request of the Insurer. The roofing consultant’s inspection was quick and cursory of the damage to the Insureds’ home and roof system and interior damage to the Insureds’ home. The inspection concluded, with no real basis of fact “there was no wind or hail damage to the roof and no storm created openings on the roof, related to the reported storm event. There were prior repairs observed on the back, left and right slopes. There was no interior water damage reported or observed.” Although the Insureds have requested for a complete and exact copy of the unnamed roofing consultant’s report, the Insurer has failed to provide the Insureds with any copy of the report.
Due to the obvious ongoing problems at their home, the Insureds hired Archer Claims (“Archer”), to determine the extent of damage to their home and roof system as a direct result of a tornado. Archer performed a comprehensive evaluation of the damage to the Insureds’ roof system and documented numerous missing, creased, torn and damaged shingles and other tornado related damage to the Insureds’ roof system. The inspection confirmed Archers’ initial perception; the Insureds’ roof system had severe wind related physical and structural damage and required a full roof system replacement. Archer provided the Insureds with a damage estimate for a full roof system replacement, interior repairs and exterior repairs totaling $35,943.76. Archer’s damage estimate provided detailed, line-item costs for all of the necessary items and applicable taxes for the complete replacement of the Insureds’ roof system and the interior and exterior repairs. The Insurer is required under the policy to restore the Insureds’ home and roof system to its pre-loss condition.
Despite the overwhelming evidence to the Insureds’ home and roof system had been significantly structurally damaged by the tornado, all covered losses under the subject insurance policy; the Insurer delayed and unreasonably and improperly investigated and evaluated the amount of damage to the Insureds’ home and roof system. The Insurer completely denied the Insureds' claim on the basis of a completely inadequate investigation of the damage to the Insureds’ home and roof system indicating all of damage to the Insureds’ home and roof system was not tornado related and a nonsensical policy interpretation.
On July 8, 2022, the Insurer sent a letter completely denying the Insureds’ hurricane/tornado claim for damage to the Insureds’ home and roof system, providing the Insureds with a coverage determination letter that concluded; “there would be no coverage afforded due to wear and tear, marring, deterioration, inherent vice, latent defect, defect, mechanical breakdown and/or improper installation, etc., as it related to condition whether observed or not.” Additionally, the Insureds submitted a Sworn Statement In Proof of Loss (“Proof”). The Proof extensively detailed the damages to the Insureds’ home and roof system. Ultimately, the Insurer did not issue any payment to the Insureds.
Moreover, the Insurer did not perform a legally sufficient tornado damage investigation by failing to perform a substantial structural damage investigation and determination as required by the Florida Building Code. The Insurer’s failure to perform this important substantial structural damage determination further indicates the Insurer did not comply with the basic requirements inherent in the proper investigation of tornado damage claims, and instead performs inadequate, untimely and incomplete investigations in order to improperly completely deny valid tornado damage claims. The work of adjusting insurance claims in Florida engages the public trust. In the instant case, the Insurer has breached this duty through its improper complete denial and complete failure to properly investigate the tornado damage claim of the Insureds. The Insurer's failure to communicate with the Insureds and improper complete denial of the Insureds’ tornado damage claim indicates the Insurer failed to adopt and implement proper standards for the investigation, evaluation and adjustment of claims; failed to properly train, manage, supervise and promote claims adjusters so Insureds receives good faith, fair and prompt adjustment of claims; and failed to conduct a full and fair investigation of this tornado damage claim. The Insurer furthermore failed to provide full reasons and facts to the Insureds for the complete denial of their tornado damage claim resulting in the statutory violations as set forth in this notice.
The Insurer also breached its duty to the Insureds by failing to timely and promptly pay the correct indemnity owed to its Insureds. This duty is owed by the Insurer to its Insureds and is inherent in the insurance claims process. The Insureds promptly provided all necessary documentation, evidence and information for a timely resolution of their tornado damage claim, including an itemized roof damage estimate and extensive documentation of the damage to the Insurer which clearly shows the Insureds’ roof system must be completely replaced and cannot be repaired. However, to date, the Insurer has failed to provide timely and prompt payment for the Insureds’ damages.
To date, the Insureds have performed all conditions precedent required of them under the subject policy of insurance with the Insurer and under Florida law. However, the Insurer failed and refused to properly investigate the Insureds’ tornado damage claim, and failed to tender all insurance proceeds due and owing to the Insureds under the subject insurance policy. Due to the Insurer's intentional delay and complete denial of the Insureds’ tornado damage claim, the Insureds have been forced to obtain legal counsel at a significant cost and expense to attempt to recover what they are legally owed under their insurance policy with the Insurer.
The Insurer violated the statutes set forth above based on the conduct described herein. The Insurer failed and refused to timely tender insurance proceeds required by its insurance policy with its Insureds. In addition, the Insurer failed to reasonably and properly settle and resolve the Insureds’ tornado damage claim for money damages when under all the facts and circumstances, it could have and should have done so if it had acted fairly and honestly towards its Insureds. The Insurer's improper actions are well documented and have occurred with such frequency as to constitute a general business practice and were made in a reckless disregard for its Insureds’ rights. The Insurer placed its interest above and before the Insureds’ interest in this matter. Therefore, to cure the defects outlined in this Civil Remedy Notice, the Insurer must do the following:
A. Create, adopt and implement adequate standards and/or guidelines for the proper
investigation and adjustment of tornado damage claims.
B. Provide sufficient training and supervision of its employees and agents to avoid further violations as set forth in the paragraphs above from occurring in the future.
C. Immediately pay the Insureds’ tornado claim in the amount of Archer’s damage estimate of $35,943.76.
D. Immediately pay to date interest on the Insureds’ tornado damage claim to the Insureds.
E. Agree to pay the Insureds’ reasonable attorney fees and costs pursuant to Fla. Stat. 627.428 which to date totals $15,000.00.
F. Pay all other and further coverages allowed by law to fully compensate the Insureds for their tornado damage claim.
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The submitter hereby states that this notice is given in order to perfect the rights of the
person(s) damaged to pursue civil remedies authorized by Section 624.155, Florida Statutes.
Before submitting a Notice using this system, please verify that all text has been entered
correctly and completely. Once the Notice has been submitted, the text cannot be changed
or deleted.
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DFS-10-363
Rev. 10/14/2008
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