Civil Remedy Notice of Insurer Violations
Login

Filing Number:     660416
Filing Accepted:  12/8/2022
         Print Filing
Complainant
Last/Business Name *  
BEVERLY THOMAS AND JAMES THOMAS   First Name  
Street Address * 9312 RIVER OTTER DRIVE
City, State Zip * FORT MYERS, FL 33912
Email Address * WITHHELD
Complainant Type: * Insured
Insured
Last/Business Name*   BEVERLY THOMAS AND JAMES THOMAS   First Name  
Policy # * EDH4086639-03 Claim #* 954889-00
Attorney
Attorney is Applicable
Last Name* RAMPERSAD First Name * JEEVAN Initial
Street Address* 501 E. LAS OLAS BLVD SUITE 200/300
City, State Zip* FORT LAUDERDALE , FL 33301
Email Address * JEEVAN@KWGLEGAL.COM
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   EDISON INSURANCE COMPANY
NAIC Company Code 12482
 
Name of individual responsible for violation (if any):* UNKNOWN
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Denial
Claim Delay
Unfair Trade Practice
* Statutory provision(s) which the insurer allegedly violated.
 
624.155(1)(b)(1) 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.
624.155(1)(b)(3) 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.
626.9541(1)(i)(3)(a) Failing to adopt and implement standards for the proper investigation of claims.
626.9541(1)(i)(3)(b) Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.
626.9541(1)(i)(3)(d) Denying claims without conducting reasonable investigations based upon available information.
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

Loss settlement provision.
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

The carrier has not attempted in good faith to settle the insureds’ claim when, under all the circumstances, it could and should have done so, had it acted fairly and honestly toward its insureds and with due regard for its interests. The carrier has done everything possible to delay the claim and refuses to provide any sort of status of the claim. Furthermore, the carrier is required to properly investigate and adjust claims and cannot place that burden upon the insureds. This was made clear by the appellate court and the Florida Supreme Court in Allstate Indemnity Co. v. Ruiz, 899 So. 2d 1121 (Fla. 2005)(“The Legislature has clearly chosen to impose on the insurance companies a duty to use good faith and fair dealing in processing and litigating the claims of their insureds…”). The carrier was immediately put on notice of the insureds’ claim. Subsequently, the insureds have obtained an estimate in the amount of $168,276.99 that would be needed to restore the property back to its pre-loss condition. In response to the claim, the carrier issued a denial stating that in the carrier’s unilateral determination the damages did not stem from a covered peril. The carrier offered no other alternative explanation for what caused these damages in its denial. Thereafter, the insureds have continued to follow-up with the carrier multiple times regarding the status of the claim throughout the claim process. The insureds have complied with all the carrier’s requests to date and the carrier has still failed to treat this claim with good faith. More than sixtyeight (68) days have passed since the original date of loss. The carrier has still refused to pay the fully covered amount owed under the policy. The carrier is aware of the full loss package and has not taken any meaningful ensuing action since issuing its denial. It is clear that the carrier is not treating the insureds with good faith claims conduct; failing to pay a claim clearly owed; not adjusting the claim and evaluating the loss properly, promptly and fairly to provide full and prompt indemnity to the insureds; failing to implement proper standards for the adjustment and investigation of claims and placing the company’s interests before the insureds’ interests; not training, supervising or managing adjusters properly so that prompt and full payments are made; refusing to pay the full amount owed to the insureds despiteKatranis, Wald & Garner, PLLC 501 E. Las Olas Blvd Suite 200/300, Fort Lauderdale, FL 33301 Telephone: (754) 231-8107 | Service@KWGLegal.com the fact that the damages are covered under the policy; looking for ways to delay full recovery or any recovery to the insureds; and refusing to provide coverage for the insureds’ loss in a timely manner. The Carrier’s actions are in violation of Florida Statutes §§ 624.155(1)(b)(1), 624.155(1)(b)(3), 626.9541(1)(i)(3)(a), 626.9541(1)(i)(3)(b), 626.9541(1)(i)(3)(d), and Fla. Stat. §627.70152(4) making a carrier’s response to a 10-day letter with a pre-suit settlement offer, request for mediation, or demand for appraisal mandatory. Therefore, to cure the defects outlined in this Civil Remedy Notice, the carrier must: 1) Pay the complete covered loss in the amount of $168,276.99 less the applicable deductible; 2) Pay the insureds’ attorneys’ fees and costs as they have been forced to retain counsel; and 3) Pay the statutory interest on the amount of unpaid damages from the date of loss to the date payment is finally made. A copy of this letter and filed form submitted to the FDFS has been printed out and mailed. Please do not hesitate to contact the undersigned or Shanna O’Neal at (754) 231-8107 if you have any questions or concerns. Sincerely, Jeevan Rampersad, Esq. Jeevan Rampersad Attorney at Law
Comments
User Id Date Added Comment
jbosch@qpwblaw.com 01-17-2023 VIA DFS WEBSITE Jeevan S. Rampersad, Esq. 501 E. Las Olas Blvd., Suite 200/300 Fort Lauderdale, Florida 33301 Complainant: James and Beverly Thomas (“Complainant[s]” or “Insured[s]”) Claim No: EDI954889 (“Subject Claim”) Policy No: EDH4086639-03 (“Policy”) Loss Location: 9312 River Otter Dr, Fort Myers, FL 33912 (“Property”) CRN Filing No: 660416 CRN Acceptance Date: 12/08/2022 RE: CIVIL REMEDY NOTICE - DFS FILING NUMBER 660416 Dear Mr. Rampersad: The undersigned counsel represents Edison Insurance Company (“Edison”) in regard to the alleged dispute as to Subject Claim number EDI954889 involving a roof claim with a date of loss on or about September 28, 2022, made under the Policy of insurance Edison issued the Insureds bearing the number EDH4086639-03. This correspondence constitutes Edison Insurance Company’s response to the second Civil Remedy Notice of Insurer Violations (“Notice” or “CRN”) you filed on December 8, 2022 on behalf of James and Beverly Thomas regarding the claim listed above. Edison believes that the Civil Remedy Notice should be rejected and returned by the Department of Financial Services as it completely misstates the facts surrounding this claim. ALLEGED STATUTORY VIOLATIONS 624.155(1)(b)(1): 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. Edison specifically denies the Insureds’ allegation that it has violated the above referenced statute. Edison did not violate these provisions. Edison conducted a thorough investigation in good faith and found that the loss was not covered. There was no obligation to issue payment under any policy provision. The CRN does not include any facts to support this allegation. 624.155(1)(b)(3): 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. Edison specifically denies the Insureds’ allegation that it has violated the above referenced statute. Edison did not violate these provisions. Edison conducted a thorough investigation in good faith and found that the loss was not covered. There was no obligation to issue payment under any policy provision. The CRN does not include any facts to support this allegation. 626.9541(1)(i)(3)(a): Failing to adopt and implement standards for the proper investigation of claims. Edison specifically denies the Complainants’ allegation that it has violated the above referenced statute. The CRN does not include any facts to support this allegation. 626.9541(1)(i)(3)(b): Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue. Edison specifically denies the Complainants’ allegation that it has violated the above referenced statute. The CRN does not include any facts to support this allegation. 626.9541(1)(i)(3)(c): Denying claims without conducting reasonable investigations based upon available information. Edison specifically denies the Insureds’ allegation that it has violated the above referenced statute. Edison did not violate these provisions. Edison conducted a thorough, reasonable, comprehensive investigation in good faith and found that the loss was not covered. There was no obligation to issue payment under any policy provision. The CRN does not include any facts to support this allegation. In addition to the allegations specifically denied above, Edison generally denies all allegations presented in this CRN, as Edison has not violated any statute, Code or Rule. SPECIFICITY REQUIREMENTS Florida Statute requires that a CRN state the facts and circumstances giving rise to the alleged violations with specificity sufficient to allow an insurer to “cure” the alleged violations within the sixty-day statutory period. See Fla. Stat. § 624. 155(3)(b)(2). See also Lane v. Westfield Ins. Co., 862 So. 2d 774, 777 (Fla. 5th DCA 2003), Talat Enterprises, Inc. v. Aetna Cas. & Sur. Co., 753 So. 2d 1278, 1283 (Fla. 2000). However, here, the CRN is deficient and defective in that it fails to state with sufficient specificity the necessary facts in support of the Insureds’ contentions, including but not limited to, those that would be necessary for Edison to “cure” the alleged violations. Further, the subject CRN provides what appears to be several boilerplate and conclusory statements, which fail to describe any accurate facts constituting violations of the statutes cited therein. Thus, because the allegations in the CRN are incomplete and incorrect, they fail to provide actual notice of the specific allegations and the actions that Edison could undertake to cure any alleged violations. 316, Inc. v. Maryland Cas. Co., 625 F. Supp. 2d 1187, 1193 (N. D. Fla. 2008). Blanket references to policy provisions and statutes without specification deems the Civil Remedy Notice deficient. Julien v. United Property and Casualty Insurance Co., (Fla. 4th DCA 2020). For the reasons set forth herein, Edison hereby objects to the subject CRN and states it does not intend to waive, ratify or otherwise accept the deficiencies in the CRN, and reserves the right to contest the legal adequacy of the CRN hereinafter as appropriate. As to the content of the CRN, it is important to note that said CRN is a nullity and should be rejected because the CRN fails to comply with the specific requirements mandated by Florida Statutes §624.155. Specifically, Fla. Stat. § 624.155(3)(b)(2) requires the Complainant to set forth with specificity, sufficient factual allegations to state a prima facie case of an insurer violation, so as to put the insurer on notice and be afforded the opportunity to cure the deficiency. However, the Insured failed to do so in the subject CRN and instead only included conclusory statements, which lack even minimal specificity and/or lack the underlying factual basis to support them. The Insureds’ failure to describe any actual facts or circumstances to support the alleged statutory violations in the CRN precludes Edison from evaluating what error, if any, allegedly occurred during the claim process. Furthermore, contrary to the requirement to “describe the facts and circumstances giving rise to the insurer’s violation as you understand them at this time,” the purpose of which is “to enable the insurer to investigate and resolve [the] claim,” the CRN itself only provides unsupported and incorrect allegations with no basis in fact or circumstances. Consequently, the CRN lacks the requisite minimal specificity and Edison is unable to determine what specifically the Complainants are claiming was done by or on behalf of Edison that constitutes the bad faith alleged. Due to the absence of specific and accurate information regarding the alleged acts or omissions by Edison which allegedly give rise to any violation of the Civil Remedy Statute, Edison is limited in its ability to set forth specific facts to address and/or refute these unsubstantiated assertions. Notwithstanding, Edison explicitly denies violations of any applicable Florida Statute in the adjustment of the Subject Claim and realleges and re-asserts its specific denials to the alleged violations in the subject CRN as set forth above, including but not limited to its specific denials of the allegations that it has not attempted in good faith to settle the Insureds’ claim and that it failed to acknowledge and act promptly upon communications related to the Subject Claim. Moreover, Edison specifically denies that it denied the Subject Claim without conducting a reasonable investigation, that it failed to implement standards for the proper investigation of claims, and that it misrepresented pertinent facts relating to coverages at issue. Accordingly, without waiver of its objections, rights and defenses, Edison maintains that it has acted and continues at all times to act in good faith during the investigation and adjustment of the Insureds’ claim. Further, Edison wishes to dispel even the inference of any statutory violation and reiterates below the various reasons which clearly show the proper handling of the Subject Claim by Edison. Moreover, as stated in Demase v. State Farm Florida Insurance Company (Fla. 5th DCA November 14, 2022), as a condition precedent to bringing a first-party bad faith case, an insured must provide timely notice of the alleged violation to the authorized insurer and to the DFS. BACKGROUND FACTS Aside from the fact that the allegations contained in the subject CRN lack specific facts, the tenor and inferences of statutory violations are wholly without merit and Edison denies each and every one. Below are some of the relevant facts regarding the Subject Claim that the Insureds failed to include in the CRN. On October 10, 2022, the Insured reported broken tiles on the roof, damage to the wall near the window and exterior damage to the subject property which allegedly took place on September 28, 2022. Edison immediately sent correspondence acknowledging receipt of the claim. This correspondence included information on mediation and claims handling and the Florida homeowner claim bill of rights. On October 12, 2022, Edison received an email from APEX roofing with a roof replacement estimate of $66,210.10 along with an assignment of benefits and hold harmless agreement dated October 10, 2022. In this email, APEX also requested claim documents and a certified copy of the policy. On October 14, 2022, just four days after the loss was reported, a field adjuster inspected the subject property on behalf of Edison. It is important to note that the field adjuster did not observe storm damage to the concrete tile roofing or roof accessories or any of the exterior as reported by the Insured. on October 17, 2022, Edison received a letter of representation from Insureds’ counsel seeking a certified copy of the policy and claim documents. On November 3, 2022, and again on November 5, 2022, Edison sent the policy to the insured’s representatives. On November 22, 2022, Insureds’ counsel filed one CRN complaining that a coverage determination had not yet been made. Please note, this CRN was prematurely filed before the 90-day statutory period to make a coverage determination making. As such, on November 26, 2022, Edison issued correspondence denying coverage for the subject claim stating, “There was no peril-related wind damage found and no peril-created opening found during our inspection of the roof. There is no coverage for the interior damages caused by water, unless there is a peril-created opening that allows the water to enter.” Again, this correspondence was provided well within the 90-day statutory period to make a coverage determination making Insureds’ primary basis for the first CRN both premature and now null and void. After receipt of the timely coverage determination, on December 8, 2022, counsel for Insureds filed the subject, second CRN and a Notice of Intent to Litigate along with photos and an estimate for $168,277.00 from Exact Building Consultants for interior and exterior damages as well as replacement of the roof. This second CRN was filed simply because the Insureds disagreed with the findings of the investigation. It does not include any instance of bad faith on the part of Edison. INACCURACY OF ALLEGATIONS IN THE SUBJECT CRN The case specific facts related to Edison’s handling of the Subject Claim provided above implicitly address many of the vague allegations contained within the Insureds’ CRN and further establish that Edison undertook a thorough investigation in accordance with applicable statutory requirements and professional standards of care. It is important to note that the Insureds have not provided of factual support for any of the above allegations. Instead, the facts support that Edison promptly contacted the Insureds, inspected the claim shortly after it was reported and issued a timely coverage determination based on a thorough investigation. The circumstances support that Edison conducted a thorough, prompt investigation with the information provided. The Insureds accuse Edison of misrepresenting pertinent facts and delaying the claim without any basis. In reality, the Insureds simply disagree with the findings of the investigation and are alleging bad faith in a scenario where Edison conducted a comprehensive, prompt investigation in good faith. Also, the Notice fails to set forth any specific policy language alleged to have been violated. Instead, the notice simply states, “Loss Settlement Provision.” This policy provision is not applicable to the subject claim as there is no coverage and no obligation to settle according to the terms of the policy. Furthermore, contrary to the requirement to “describe the facts and circumstances giving rise to the insurer’s violation as you understand them at this time”, the purpose of which is “to enable the insurer to investigate and resolve [the] claim”, the Civil Remedy Notice itself only provides completely false allegations with no basis in fact or circumstances. Furthermore, as previously mentioned, the tenor and inferences of the allegations are without merit and Edison denies each and every one. Some of the relevant facts that Insureds’ counsel failed to include in the notice have been set out above. Here, the loss was simply not covered after a full investigation. Simply reporting a claim does not automatically entitle the Insureds to payment and the lack of payment does not trigger bad faith. In their Notice, the Insureds make multiple blanket statements that appear to just be copied and pasted and not based on any facts. Edison treated the Insureds with good faith claims conduct; Edison implement proper standards for the adjustment and investigation of claims and did not place the company’s interests before the Insureds’ interests; Edison properly trained, supervised or managed adjusters properly; and Edison did not in any way look for ways to delay meaningful communication with the retained legal counsel of the Insureds towards the resolution of the claim. Edison conducted a full and fair investigation of the claim and provided full reasons and facts to the claimant for denial of the claim. As clearly set forth above and contrary to the allegations set forth in the Notice, Edison’s investigation and adjusting of its Insureds’ claim was prompt, thorough, and complete. Furthermore, the Insureds have included absolutely no facts or evidence to support any claims in the Notice. They state the carrier was immediately put on notice when that is not correct. They repeatedly state the claim was owed without any basis for same. They suggest that Edison should have to explain the cause of the damage which is incorrect. There is no specific instance of bad faith. Rather, there is just a disagreement about coverage. The claim was properly adjusted and the Insureds do not actually have any concrete facts to support a bad faith allegation. The Civil Remedy Notice states that Edison can rectify these violations in the following ways: “ 1) Pay the complete covered loss in the amount of $168,276.99 less the applicable deductible; 2) Pay the insureds’ attorneys’ fees and costs as they have been forced to retain counsel; and 3) Pay the statutory interest on the amount of unpaid damages from the date of loss to the date payment is finally made. However, mere disagreement as to coverage does not equate to bad faith. The Civil Remedy Notice does not show how Edison has failed to comply with the statutory provisions alleged to have been violated. Evidently, this Civil Remedy Notice was filed in bad faith, as it is being used as an improper mechanism designed solely for the purpose of intimidating Edison into paying the Insureds for a loss that is not covered by the subject policy. For the aforementioned reasons, Edison categorically denies that it has acted with bad faith in connection with this claim. CONCLUSION The purpose of a CRN is to provide the insurer an opportunity to “cure” the alleged wrongdoing. Talat Enterprises, Inc. v. Aetna Casualty and Surety Co. , 753 So. 2d 1278 (Fla. 2000). However, the CRN here does not serve this purpose because it does not provide any means as to how Edison can “cure” the alleged defects except to pay a claim that is not covered by the policy. This failure to provide a proper opportunity to cure renders the CRN improper. Longpoint Condominium Associations v. Allstate Insurance Co. , 2005 WL 131580 (N. D. Fla. June 2, 2005). Moreover, the method for curing the violations alleged in a civil remedy notice are not determined by the insured. In Talat Enterprises, Inc. v. Aetna Casualty and Surety Co. , 753 So. 2d 1278 (Fla. 2000), the Florida Supreme Court accepted and quoted the reasoning of the court below in its opinion which stated in relevant part, as follows: Section 624. 155 does not impose on an insurer the obligation to pay whatever the insured demands. . . . Section 624. 155(2)(d) would have no effect or purpose under such an interpretation. The law does not support such an expansive and illogical reading of Fla. Stat. Ann. §624. 155(2)(d). . . . To cure an alleged violation and to avoid a civil action, an insurer must pay the claim . . . before the sixty days expire. Talat, 753 So2d at 1282 citing Talat Enterprises Inc. v. Aetna Cas. & Sur. Co., 952 F. Supp. 773, 777-778 (M. D. Fla. 1996). Here, Edison properly adjusted the Subject Claim as it investigated the loss within the statutory time frame and the Insureds have produced no evidence that they are entitled to any additional damages. Edison denies all of the allegations contained in the subject CRN, which is defective and improper, as Edison has not violated any of the subject statutes. Edison further states that the accusations made against it in the subject CRN are patently false. In closing, Edison first believes that the Civil Remedy Notice should be rejected and returned by the Department of Financial Services due to its failure to comply with Florida Statute §624.155 and Florida Case law. Due to the lack of any factual and circumstantial basis to support the allegations therein, Edison respectfully requests, through this response, that the DFS return and reject the CRN for lack of specificity pursuant to Florida Statutes. Regardless of the rejection, Edison denies all allegations contained in the Civil Remedy Notice and submits there are no violations. While this response is meant to be comprehensive, Edison’s response above is based upon the limited information provided in the Civil Remedy Notice and the information we have to date. If the Insureds feel that we are not in possession of all the facts, please inform us immediately. Please note that Edison’s response is not necessarily exhaustive and does not preclude us from asserting any other valid reason for seeking rejection and return of the Civil Remedy Notice. Also, this letter or any act or failure to act on the part of Edison or any agent or representative of Edison should not be construed as a waiver of any rights or defenses available to it by contract or at law as all such rights and defenses are hereby specifically reserved. We trust that this response addresses the allegations of insurer violation alleged in the Civil Remedy Notice of Insurer Violation. Should you have any questions regarding this matter or need anything further, please do not hesitate to contact the undersigned. Very Truly Yours, QUINTAIROS, PRIETO, WOOD & BOYER, P.A. Maya Thomas, Esq. Jose Bosch, Esq.
Acknowledgement
* 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.




DFS-10-363
Rev. 10/14/2008