Civil Remedy Notice of Insurer Violations
Login

Filing Number:     663907
Filing Accepted:  12/21/2022
         Print Filing
Complainant
Last/Business Name *  
NELSON   First Name   JEFFREY
Street Address * 6619 SUMMER COVE DR
City, State Zip * RIVERVIEW, FL 33578
Email Address * JEFFNELSON11@YAHOO.COM
Complainant Type: * Insured
Insured
Last/Business Name*   NELSON   First Name   JEFFREY
Policy # * EDH4074332-02 Claim #* EDI942210
Attorney
Attorney is Applicable
Last Name* ROBERTS First Name * KRISTINA Initial
Street Address* 1045 9TH AVE. N
City, State Zip* ST. PETERSBURG , FLORIDA 33705
Email Address * KROBERTS@KOVARLAWGROUP.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):* CATHERIN TERPENING
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Denial
Unsatisfactory Settlement Offer
Unfair Trade Practice
Other : Failure to Properly Investigate
Other : Failure to properly apply and understand the policy
* 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.
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.
626.9541(1)(i)(3)(i) Failing to pay personal injury protection insurance claims within the time periods required by s. 627.736(4)(b).
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

SECTION I – PERILS INSURED AGAINST COVERAGE A - Dwelling $304,600.00 COVERAGE A – Dwelling We cover: 1. The dwelling on the “residence premises” shown in the Declarations, including structures attached to the dwelling; and 2. Materials and supplies located on or next to the “residence premises” used to construct, alter or repair the dwelling or other structures on the “residence premises.” This coverage does not apply to land, including land on which the dwelling is located. This coverage does not apply to loss to “screened enclosures,” aluminum framed carports or awnings due to hurricane damage. Section I Perils Insured Against COVERAGE A – DWELLING and COVERAGE B – OTHER STRUCTURES 1. We insure for sudden and accidental direct loss to property described in Coverages A and B only if that loss is a physical loss to covered property. This includes the peril of “catastrophic ground cover collapse” as provided in Part A. below. 2.We do not insure, however, for loss; b. caused by: (9) Any of the following: (f) Settling, shrinking, bulging or expansion, including resultant cracking of pavements, patios, foundations, walls, floors, roofs or ceilings; Under Paragraphs 2.a and 2.b. above, any ensuing loss to property described in Coverages A and B not excluded or otherwise precluded in this Policy is covered. Section I-Exclusions 1. k. Existing Damage. (1) Damages which occurred prior to policy inception regardless of whether such damages were apparent at the time of the inception of this policy or discovered at a later date; or (2) Claims for damages arising out of workmanship, repairs or lack of repairs arising from damage which occurred prior to policy inception. However, any ensuing loss arising out of workmanship, repairs or lack of repairs, caused by a Peril Insured Against, to property described under Section I – Property Coverages, is covered unless the loss is otherwise excluded in the policy. This exclusion does not apply in the event of a total loss caused by a Peril Insured Against. 2. We do not insure for loss to property described in Coverages A and B caused by any of the following. However, any ensuing loss to property described in Coverages A and B not excluded or excepted in this policy is covered. a. Weather conditions. However, this exclusion only applies if weather conditions contribute in any way with a cause or event excluded in paragraph 1. above to produce the loss; c. Faulty, inadequate or defective: (1) Planning, zoning, development, surveying, siting; (2) Design, specifications, workmanship, repair, construction, renovation, remodeling, grading, compaction; (3) Materials used in repair, construction, renovation or remodeling; or (4) Maintenance; of part or all of any property whether on or off the “residence premises.”
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

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. This is a first party property claim for wind damage as a result of Hurricane/Tropical Storm Eta that made landfall in Tampa Florida on November 11, 2020. On November 12, 2020, the homeowner found water damage throughout the first floor of the home, specifically in the living room. She found wet flooring and buckled flooring throughout. Mr. Nelson immediately called Edison to report the damage. The Nelsons also called their water softener company to see if there was something wrong with the water softener. The company found nothing wrong with the water softener. Edison sent out a field adjuster and a Leak Detection company but never sent out an engineer prior to coming to their coverage determination. On November 18, 2020, the Field adjuster, Kevin Brown, inspected the property and found elevated moisture throughout the first-floor walls and flooring as well as growth on the windowsill. The Field Adjuster also observed water damage to the laminate wood floors in the living room and cracks in the stucco. Mr. Brown was unable to make a determination as to how the damage occurred, however, he did determine that there were no maintenance issues at the property [See Mr. Brown Depo. Transcript 13:9-17; in case number 21-CA-000411 in the Circuit Court of Hillsborough County]. The insureds testified that they never had a problem with water intrusion in the property before the storm. See Page 14 lines 11-16 of Angela Nelson Deposition Transcript. See also, page 53, lines 11-22 of Jeff Nelson Deposition Transcript in case number 21-CA-000411 in the Circuit Court of Hillsborough County. Neither Mr. Brown nor ALD did a proper test to determine where the leaking occurred at the property. However, ALD concluded that the cracks in the stucco caused the water to penetrate the interior of the property and cause the water damage. Based on that conclusion, Edison made the determination that the loss was not covered under the policy and issued a denial letter to the insured on December 3, 2020 stating that “the source of damage was rainwater penetrating the building envelope through cracks or stucco openings, missing window caulking and possible ground water from rain events seeping through the foundation. There were no openings from a covered peril, that allowed the rain water to enter the home. Maintenance issues, wear and tear, expansion are also not covered under the terms of your policy. Based on the terms of your policy, we have determined there is no coverage for this claim.” The Desk adjuster, Catherin Terpening, knew that there was no determination as to the causation of the stucco cracking when she decided to deny the claim. [Terpening depo 34:11-25; 35:1-5; 41:9-12; 42:14-18 in case number 21-CA-000411 in the Circuit Court of Hillsborough County] Specifically she stated the following: 18 Q: Was -- the causation of the stucco 19 cracking, was that ever deter -- the specific 20 causation, was that ever determined? 21 A: I couldn't say. Pg 34 lines 18-21. 2 Q: Okay. So what was the cause of those 3 cracks that is excluded by the policy? 9 A: -- walls, floors -- in the policy, shows 10 cracking, just not something that we insure for, 11 to my -- I don't understand -- I need a cause 12 when there's cracking. Pg 41 Lines 2-3 and 9-12. Clearly the Desk adjuster simply saw that there were cracks in the stucco, did not go further to make a determination as to how the cracks occurred and simply denied the claim based on that. However, the policy requires that there be a determination made as to how the cracks occurred because the damage is only excluded if the cracks were caused by Settling, shrinking, bulging or expansion. There was no determination made as to how the cracks occurred at the residence, they could have occurred due to a peril insured against, such as a storm, however, Edison never took the time to find out and instead just denied the claim in full based on some cracking in the stucco. In failing to properly investigate the claim and follow their own policy language in determining whether the loss was in fact excluded, Edison has violated Fla. Stat. 624.155(1)(b)(1). 626.9541(1)(i)(3)(d): Denying claims without conducting reasonable investigations based upon available information. The leak detection company came to the conclusion that the water intrusion came from cracking in the stucco of one of the exterior walls. While the water damage was throughout the entire living room, the leak detection company focused their inspection on the cracks in the stucco on the side of the house. ALD only did one (1) test and they did not try to simulate a storm like environment when they inspected the home. ALD took a syringe and placed it next to a crack in the stucco and came to the conclusion that because the water from the syringe went into the crack in the stucco that there was necessarily a leak into the interior. However, this is a concrete masonry unit building on the first floor and the leak detection company did not determine how the water would have penetrated the concrete blocks to then get into the interior of the property and damage the flooring. ALD never came to a conclusion or determination as to how the cracks in the stucco occurred, or when they occurred. Further, they never inspected the windows to determine if the windows were a likely source of the water intrusion. Edison did not have an engineer inspect the property for peril induced openings. Instead, Edison relied on the conclusory statements of American Leak Detection and their field adjuster. When Edison denied this claim, they had no evidence that the cracks were not a peril created opening. The Desk Adjuster that wrote the denial letter wasn’t even aware that she was required to have a causation of the cracks to be able to deny them as not being covered under the policy. [Terpening depo 34:11-25; 35:1-5; 41:9-12; 42:14-18 in case number 21-CA-000411 in the Circuit Court of Hillsborough County] Specifically she stated the following: 18 Q: Was -- the causation of the stucco 19 cracking, was that ever deter -- the specific 20 causation, was that ever determined? 21 A: I couldn't say. Pg 34 lines 18-21. 2 Q: Okay. So what was the cause of those 3 cracks that is excluded by the policy? 9 A: -- walls, floors -- in the policy, shows 10 cracking, just not something that we insure for, 11 to my -- I don't understand -- I need a cause 12 when there's cracking. Pg 41 Lines 2-3 and 9-12. Clearly the Desk adjuster simply saw that there were cracks in the stucco, did not go further to make a determination as to how the cracks occurred and simply denied the claim based on that. However, the policy requires that there be a determination made as to how the cracks occurred because the damage is only excluded if the cracks were caused by Settling, shrinking, bulging or expansion. There was no determination made as to how the cracks occurred at the residence, they could have occurred due to a peril insured against, such as a storm, however, Edison never took the time to find out and instead just denied the claim in full based on some cracking in the stucco. In fact, no one made a determination as to how the cracks occurred. This was testified to by the Edison corporate representative on page 23 lines 8-11 of his deposition transcript in case number 21-CA-000411 in the Circuit Court of Hillsborough County. The Edison Corporate representative specifically stated, “I am unaware of any causation to determine the cracks in the stucco.” ALD never testified as to the cause of the cracking and didn’t do any testing to determine the cause. The field adjuster never determined a cause of the damage at the property which means that he didn’t make a determination as to how the cracking occurred. See Brown Depo Transcript Page 17 lines 22-25 and page 18 Lines 1-2 of case number 21-CA-000411 in the Circuit Court of Hillsborough County. Mr. Brown was asked if he was retained to determine the cause of the damages that he observed at the property and he responded, “No, that’s why I actually retained American Leak Detection to—to determine the source or cause of the damage.” Edison did not determine how the cracks occurred prior to erroneously denying this claim. Edison never made a conclusion as to how the cracks in the stucco occurred. The Field adjuster, Mr. Brown, testified that he unable to make determination as to how the damage occurred. See Page 13, Lines 13-17 and 21-25 Page 14 line 1 of Mr. Brown’s Deposition Transcript. The Leak Detection company, American Leak Detection, never concluded as to how the stucco cracks occurred either. They did not determine as to whether the cracks in the exterior wall allowed water to penetrate to the interior of the property. See Page 17, Lines 17-25 and Page 18 Lines 1-6 of the Deposition of Todd Dickson in case number 21-CA-000411 in the Circuit Court of Hillsborough County. Edison did not hire an engineer prior to making their claim decision and prior to litigation being filed to determine how the stucco cracks occurred or how the water damage occurred. The Desk Adjuster that made the determination that this was not a covered loss had no idea that she was even required to have a determination as to how the cracks occurred before she made a determination as to whether the loss was covered. Ms. Terpening testified that she was unsure if a causation of the stucco cracking was made (Page 34 of Ms. Terpening’s Deposition Transcript). Ms. Terpening stated that she was unaware that she needed to have a cause of the cracks in order to deny the damage. She thought, that because the determination from ALD was that the water entered through cracks, that the cracks were automatically denied under the policy. See Ms. Terpening’s testimony on page 41 of her deposition transcript. When Edison denied this claim without determining how the damage occurred including how the cracking in the stucco occurred, they violated Fla. Stat. 626.9541(1)(i)(3)(d). 626.9541(1)(i)(3)(b): Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue. The Desk adjuster misrepresented the insurance policy provision regarding exclusions under the policy when she stated that the stucco cracks were excluded without first finding out how the cracks occurred. The Desk adjuster, Catherin Terpening, knew that there was no determination as to the causation of the stucco cracking when she decided to deny the claim. [Terpening depo 34:11-25; 35:1-5; 41:9-12; 42:14-18 in case number 21-CA-000411 in the Circuit Court of Hillsborough County] Specifically she stated the following: 18 Q: Was -- the causation of the stucco 19 cracking, was that ever deter -- the specific 20 causation, was that ever determined? 21 A: I couldn't say. Pg 34 lines 18-21. 2 Q: Okay. So what was the cause of those 3 cracks that is excluded by the policy? 9 A: -- walls, floors -- in the policy, shows 10 cracking, just not something that we insure for, 11 to my -- I don't understand -- I need a cause 12 when there's cracking. Pg 41 Lines 2-3 and 9-12. Clearly the Desk adjuster simply saw that there were cracks in the stucco, did not go further to make a determination as to how the cracks occurred and simply denied the claim based on that. However, the policy requires that there be a determination made as to how the cracks occurred because the damage is only excluded if the cracks were caused by Settling, shrinking, bulging or expansion. The policy specifies: Section I Perils Insured Against COVERAGE A – DWELLING and COVERAGE B – OTHER STRUCTURES 1. We insure for sudden and accidental direct loss to property described in Coverages A and B only if that loss is a physical loss to covered property. This includes the peril of “catastrophic ground cover collapse” as provided in Part A. below. 2.We do not insure, however, for loss; b. caused by: (9) Any of the following: (f) Settling, shrinking, bulging or expansion, including resultant cracking of pavements, patios, foundations, walls, floors, roofs or ceilings; There was no determination made as to how the cracks occurred at the residence, they could have occurred due to a peril insured against, such as a storm, however, Edison never took the time to find out and instead just denied the claim in full based on some cracking in the stucco. Therefore, when the desk adjuster made the decision to deny this claim without knowledge of how the cracking occurred, she misrepresented the policy provision and the facts of the case to the insured in violation of Fla. Stat. 626.9541(1)(i)(3)(b). 626.9541(1)(i)(3)(a): Failing to adopt and implement standards for the proper investigation of claims. The leak detection company came to the conclusion that the water intrusion came from cracking in the stucco of one of the exterior walls. While the water damage was throughout the entire living room, the leak detection company focused their inspection on the cracks in the stucco on the side of the house. ALD only did one (1) test and they did not try to simulate a storm like environment when they inspected the home. ALD took a syringe and placed it next to a crack in the stucco and came to the conclusion that because the water from the syringe went into the crack in the stucco that there was necessarily a leak into the interior. However, this is a concrete masonry unit building on the first floor and the leak detection company did not determine how the water would have penetrated the concrete blocks to then get into the interior of the property and damage the flooring. ALD never came to a conclusion or determination as to how the cracks in the stucco occurred, or when they occurred. Further, they never inspected the windows to determine if the windows were a likely source of the water intrusion. Edison did not have an engineer inspect the property for peril induced openings. Instead, Edison relied on the conclusory statements of American Leak Detection and their field adjuster. When Edison denied this claim, they had no evidence that the cracks were not a peril created opening. The Desk Adjuster that wrote the denial letter wasn’t even aware that she was required to have a causation of the cracks to be able to deny them as not being covered under the policy. [Terpening depo 34:11-25; 35:1-5; 41:9-12; 42:14-18 in case number 21-CA-000411 in the Circuit Court of Hillsborough County] Specifically she stated the following: 18 Q: Was -- the causation of the stucco 19 cracking, was that ever deter -- the specific 20 causation, was that ever determined? 21 A: I couldn't say. Pg 34 lines 18-21. 2 Q: Okay. So what was the cause of those 3 cracks that is excluded by the policy? 9 A: -- walls, floors -- in the policy, shows 10 cracking, just not something that we insure for, 11 to my -- I don't understand -- I need a cause 12 when there's cracking. Pg 41 Lines 2-3 and 9-12. Clearly the Desk adjuster simply saw that there were cracks in the stucco, did not go further to make a determination as to how the cracks occurred and simply denied the claim based on that. However, the policy requires that there be a determination made as to how the cracks occurred because the damage is only excluded if the cracks were caused by Settling, shrinking, bulging or expansion. There was no determination made as to how the cracks occurred at the residence, they could have occurred due to a peril insured against, such as a storm, however, Edison never took the time to find out and instead just denied the claim in full based on some cracking in the stucco. In fact, no one made a determination as to how the cracks occurred. This was testified to by the Edison corporate representative on page 23 lines 8-11 of his deposition transcript in case number 21-CA-000411 in the Circuit Court of Hillsborough County. The Edison Corporate representative specifically stated, “I am unaware of any causation to determine the cracks in the stucco.” ALD never testified as to the cause of the cracking and didn’t do any testing to determine the cause. The field adjuster never determined a cause of the damage at the property which means that he didn’t make a determination as to how the cracking occurred. See Brown Depo Transcript Page 17 lines 22-25 and page 18 Lines 1-2 of case number 21-CA-000411 in the Circuit Court of Hillsborough County. Mr. Brown was asked if he was retained to determine the cause of the damages that he observed at the property and he responded, “No, that’s why I actually retained American Leak Detection to—to determine the source or cause of the damage.” Edison did not determine how the cracks occurred prior to erroneously denying this claim. Edison never made a conclusion as to how the cracks in the stucco occurred. The Field adjuster, Mr. Brown, testified that he unable to make determination as to how the damage occurred. See Page 13, Lines 13-17 and 21-25 Page 14 line 1 of Mr. Brown’s Deposition Transcript. The Leak Detection company, American Leak Detection, never concluded as to how the stucco cracks occurred either. They did not determine as to whether the cracks in the exterior wall allowed water to penetrate to the interior of the property. See Page 17, Lines 17-25 and Page 18 Lines 1-6 of the Deposition of Todd Dickson in case number 21-CA-000411 in the Circuit Court of Hillsborough County. Edison did not hire an engineer prior to making their claim decision and prior to litigation being filed to determine how the stucco cracks occurred or how the water damage occurred. The Desk Adjuster that made the determination that this was not a covered loss had no idea that she was even required to have a determination as to how the cracks occurred before she made a determination as to whether the loss was covered. Ms. Terpening testified that she was unsure if a causation of the stucco cracking was made (Page 34 of Ms. Terpening’s Deposition Transcript). Ms. Terpening stated that she was unaware that she needed to have a cause of the cracks in order to deny the damage. She thought, that because the determination from ALD was that the water entered through cracks, that the cracks were automatically denied under the policy. See Ms. Terpening’s testimony on page 41 of her deposition transcript. When Edison denied this claim without determining how the damage occurred including how the cracking in the stucco occurred, they violated Fla. Stat. 626.9541(1)(i)(3)(a). 626.9541(1)(i)(3)(i): Unfair claim settlement practices. Edison sent out a field adjuster and a Leak Detection company but never sent out an engineer prior to coming to their coverage determination. On November 18, 2020, the Field adjuster, Kevin Brown, inspected the property and found elevated moisture throughout the first-floor walls and flooring as well as growth on the windowsill. The Field Adjuster also observed water damage to the laminate wood floors in the living room and cracks in the stucco. Mr. Brown was unable to make a determination as to how the damage occurred, however, he did determine that there were no maintenance issues at the property [See Mr. Brown Depo. Transcript 13:9-17; in case number 21-CA-000411 in the Circuit Court of Hillsborough County]. The insureds testified that they never had a problem with water intrusion in the property before the storm. See Page 14 lines 11-16 of Angela Nelson Deposition Transcript. See also, page 53, lines 11-22 of Jeff Nelson Deposition Transcript in case number 21-CA-000411 in the Circuit Court of Hillsborough County. Neither Mr. Brown nor ALD did a proper test to determine where the leaking occurred at the property. However, ALD concluded that the cracks in the stucco caused the water to penetrate the interior of the property and cause the water damage. Based on that conclusion, Edison made the determination that the loss was not covered under the policy and issued a denial letter to the insured on December 3, 2020 stating that “the source of damage was rainwater penetrating the building envelope through cracks or stucco openings, missing window caulking and possible ground water from rain events seeping through the foundation. There were no openings from a covered peril, that allowed the rain water to enter the home. Maintenance issues, wear and tear, expansion are also not covered under the terms of your policy. Based on the terms of your policy, we have determined there is no coverage for this claim.” The leak detection company came to the conclusion that the water intrusion came from cracking in the stucco of one of the exterior walls. While the water damage was throughout the entire living room, the leak detection company focused their inspection on the cracks in the stucco on the side of the house. ALD only did one (1) test and they did not try to simulate a storm like environment when they inspected the home. ALD took a syringe and placed it next to a crack in the stucco and came to the conclusion that because the water from the syringe went into the crack in the stucco that there was necessarily a leak into the interior. However, this is a concrete masonry unit building on the first floor and the leak detection company did not determine how the water would have penetrated the concrete blocks to then get into the interior of the property and damage the flooring. ALD never came to a conclusion or determination as to how the cracks in the stucco occurred, or when they occurred. Further, they never inspected the windows to determine if the windows were a likely source of the water intrusion. Edison did not have an engineer inspect the property for peril induced openings. Instead, Edison relied on the conclusory statements of American Leak Detection and their field adjuster. When Edison denied this claim, they had no evidence that the cracks were not a peril created opening. The Desk Adjuster that wrote the denial letter wasn’t even aware that she was required to have a causation of the cracks to be able to deny them as not being covered under the policy. [Terpening depo 34:11-25; 35:1-5; 41:9-12; 42:14-18 in case number 21-CA-000411 in the Circuit Court of Hillsborough County] Specifically she stated the following: 18 Q: Was -- the causation of the stucco 19 cracking, was that ever deter -- the specific 20 causation, was that ever determined? 21 A: I couldn't say. Pg 34 lines 18-21. 2 Q: Okay. So what was the cause of those 3 cracks that is excluded by the policy? 9 A: -- walls, floors -- in the policy, shows 10 cracking, just not something that we insure for, 11 to my -- I don't understand -- I need a cause 12 when there's cracking. Pg 41 Lines 2-3 and 9-12. Clearly the Desk adjuster simply saw that there were cracks in the stucco, did not go further to make a determination as to how the cracks occurred and simply denied the claim based on that. However, the policy requires that there be a determination made as to how the cracks occurred because the damage is only excluded if the cracks were caused by Settling, shrinking, bulging or expansion. There was no determination made as to how the cracks occurred at the residence, they could have occurred due to a peril insured against, such as a storm, however, Edison never took the time to find out and instead just denied the claim in full based on some cracking in the stucco. In fact, no one made a determination as to how the cracks occurred. This was testified to by the Edison corporate representative on page 23 lines 8-11 of his deposition transcript in case number 21-CA-000411 in the Circuit Court of Hillsborough County. The Edison Corporate representative specifically stated, “I am unaware of any causation to determine the cracks in the stucco.” ALD never testified as to the cause of the cracking and didn’t do any testing to determine the cause. The field adjuster never determined a cause of the damage at the property which means that he didn’t make a determination as to how the cracking occurred. See Brown Depo Transcript Page 17 lines 22-25 and page 18 Lines 1-2 of case number 21-CA-000411 in the Circuit Court of Hillsborough County. Mr. Brown was asked if he was retained to determine the cause of the damages that he observed at the property and he responded, “No, that’s why I actually retained American Leak Detection to—to determine the source or cause of the damage.” Edison did not determine how the cracks occurred prior to erroneously denying this claim. Edison never made a conclusion as to how the cracks in the stucco occurred. The Field adjuster, Mr. Brown, testified that he unable to make determination as to how the damage occurred. See Page 13, Lines 13-17 and 21-25 Page 14 line 1 of Mr. Brown’s Deposition Transcript. The Leak Detection company, American Leak Detection, never concluded as to how the stucco cracks occurred either. They did not determine as to whether the cracks in the exterior wall allowed water to penetrate to the interior of the property. See Page 17, Lines 17-25 and Page 18 Lines 1-6 of the Deposition of Todd Dickson in case number 21-CA-000411 in the Circuit Court of Hillsborough County. Edison did not hire an engineer prior to making their claim decision and prior to litigation being filed to determine how the stucco cracks occurred or how the water damage occurred. The Desk Adjuster that made the determination that this was not a covered loss had no idea that she was even required to have a determination as to how the cracks occurred before she made a determination as to whether the loss was covered. Ms. Terpening testified that she was unsure if a causation of the stucco cracking was made (Page 34 of Ms. Terpening’s Deposition Transcript). Ms. Terpening stated that she was unaware that she needed to have a cause of the cracks in order to deny the damage. She thought, that because the determination from ALD was that the water entered through cracks, that the cracks were automatically denied under the policy. See Ms. Terpening’s testimony on page 41 of her deposition transcript. When Edison denied this claim without determining how the damage occurred including how the cracking in the stucco occurred, they violated Fla. Stat. 626.9541(1)(i)(3)(i). Therefore, to cure these defects outlined in this Civil Remedy Notice, Edison Insurance Company must: 1) Create and implement adequate guidelines, policies and procedures for advertising, negotiating, and entering into their Insurance Policies including requiring their desk adjusters understand and use the policy provisions correctly in determining coverage; 2) Edison must make sure that their adjusters are hiring and relying on the proper experts before coming to a coverage decision; 3) Edison Insurance Company must pay for the work performed at this property to put the property back to pre-loss conditions in the amount of $29, 628.06 minus the deductible, which comes to $23, 536.06. This notice is given in order to perfect the right to pursue the civil remedy authorized by this section. A copy of this form has been submitted to the DFS. Further, a copy of this form has been emailed to Edison Insurance Company’s attorney. Moreover, a copy of this form has been printed out and mailed via U.S. Mail to Edison Insurance Company.
Comments
User Id Date Added Comment
jbosch@qpwblaw.com 02-14-2023 VIA POSTED ONLINE Florida Department of Financial Services Division of Insurance Regulation Bureau of Consumer Assistance/Civil Remedy Section Larson Building, 200 East Gaines Street Tallahassee, Florida 32399-0322 RE: Insureds: Jeffrey Nelson and Angela Moore Complainant: Jeffrey Nelson Policy No.: EDH4074332-02 Claim No.: EDI942210 DFS File No.: 663907 Acceptance Date: December 21, 2022 To Whom It May Concern: This correspondence shall serve as the formal response of Edison Insurance Company (hereinafter “Edison”) to the Civil Remedy Notice of Insurer Violation (hereinafter “Notice”) filed by Kristina Roberts, Esq. on behalf of Jeffrey Nelson (hereinafter “Complainant” or “Insured”), which was accepted by the Department of Financial Services (hereinafter “Department”) on December 21, 2022. The Department file number is 663907. We note, at the outset, that the section of the Notice requiring the Complainant to describe the facts and circumstances giving rise to the insurer’s purported violation(s) contains only conclusory allegations, with little to no supporting facts fully illustrating Complainant’s assertions of any wrongful conduct by Edison. The allegations, with some semblance of factual allegations, are blanket statements which proffer allegations without any information corroborating said allegations. Section 624.155, Florida Statutes, requires specificity in civil remedy notices. In interpreting this statute, courts have emphasized the importance of filing specific civil remedy notices. The civil remedy notice is “crucial to the procedural integrity of an action” under the Statute. Allstate Ins. Co. v. Clohessy, 32 F. Supp.2d 1328, 1333 (M.D. Fla. 1998). “It is without a doubt, a condition that must be satisfied in order for one to perfect the right to sue under the statute.” Id. “In creating this statutory remedy for bad-faith actions, the Legislature provided this sixty day window as a last opportunity for insurers to comply with their claim-handling obligations when a good-faith decision by the insurer would indicate that contractual benefits are owed.” Talat Enterprises, Inc. v. Aetna Cas. & Sur. Co., 753 So.2d 1284 (Fla. 2000). Thus, the CRN cannot be “vague and ‘shotgun’ in nature,” rather than “the type of specific notice required by the statute that would allow [the insurer] an opportunity to cure.” Heritage Corp. of South Florida v. National Union Fire Ins. Co. of Pittsburgh, PA, 580 F. Supp. 2d 1294, 1299 (S.D. Fla. 2008). Because it is in derogation of the common law, Section 624.155(1)(b), Florida Statutes must be strictly construed. Talat, 753 So. 2d at 1283 (citing Baxter v. Royal Indem. Co., 285 So.2d 652 (Fla. 1st DCA 1973). To perfect the right to sue under the statute, the insured must specifically notify the insurer of any and all alleged violations claimed. Talat Enterprises, Inc. v. Aetna Casualty & Surety Co., 952 F. Supp. 773, 776 (M.D. Fla. 1996). If the Complainant honestly believse that there was any type of violation, Edison requests that the Complainant provide full and specific information with respect to each alleged violation, including the name of each individual involved, the date of each violation, a description of each violation, and copies of documentation referencing each violation. As it stands now, the Notice is insufficient for the purpose of allowing Edison to fully respond and/or remedy the alleged violations, if any. Due to the lack of any substantive factual and circumstantial basis to support each of the allegations presented, Edison requests, through this response, that the Department of Financial Services return the Notice for lack of specificity pursuant to Florida Statutes. Regardless, Edison does not consider there to have been any manner of violation and questions the validity of the Notice. Edison further denies each and every allegation contained in the Notice and denies any improper or dilatory conduct in its response to, or handling of this claim. Edison has at all times acted promptly and diligently, and in good faith, acted fairly and honestly toward its insureds, the Complainants, in its claim response and review and adjustment of the claim throughout the claims handling process. To the extent that this reply does not fully address and respond to the allegations set forth by the Notice, such deficiency is the direct result of the lack of specificity and the overall vague nature of the factual circumstances allegedly giving rise to the allegations therein. To illustrate Edison’s full, diligent and complete investigation of the claim, Edison proffers the following sequence of claim handling contradicting every allegation of violations cited and referenced by the Complainants. Edison Insurance Company received first notice of this loss on November 13, 2020 with a reported date of loss of November 12, 2020. The loss was reported by the insured, Jeffrey Nelson, reporting that they “found standing water and are not sure of the source of the water. The water was pooling in the living room. The Insured had two contractors take a look at the issue. The contractors were Jeffrey Vogt of CIS Restoration and Chris with Roto-Rooter. Per the inspection, they reported damage to the floor and using a thermal camera, Roto-Rooter saw damage to the kitchen cabinet base.” The claim was immediately thereafter assigned to independent adjuster, Kevin Brown of Florida Peninsula Claim Services for further handling and investigation. Mr. Brown conducted his inspection on November 18, 2020 – just 5 days after first reporting. The property was confirmed to be a two-story dwelling constructed in 2003. Construction of the property is block and exterior wall systems are stucco. The dwelling is a four-bedroom, two-bathroom home measuring at approximately 1,961 SF of living space. The inspection was conducted in the presence of the insured and his fiancé, Angela Moore. During his inspection, Mr. Brown found damage to the laminate wood floors in the living room. Signs of water damage observed included buckling, bulging, and cracking. As the cause and origin was not readily apparent, Mr. Brown diligently and property retained the services of American Leak Detection to determine the cause of the loss. Continuing his thorough investigation, Mr. Brown obtained the recorded statement of Angela Moore who stated that she has lived at the property for approximately two years. She stated that she woke up one morning the week prior to go to work in the living room and found that there was water on the floor below her clear floormat. She called Culligan to inspect where the leak was coming from. Miss Moore also called Roto Rooter. The leak detection company believed that the water was coming through a crack in the exterior. There was no personal property damaged by the loss. Moving on, Mr. Brown observed elevated moisture levels around the damaged area. The area drywall between the windowsill and the baseboard did not show elevated moisture readings. Mr. Brown notated that it was unlikely that the water was coming in at the windowsill and then skipping the drywall between the windowsill and the baseboards. The exterior of the property also demonstrated more cracks along the wall. American Leak Detection (hereinafter “ALD”) inspected the property on or around November 23, 2020. The inspection was conducted by Todd Dickson. A complete electronic leak detection was performed on all pressurized plumbing. No active pressurized plumbing leaks were present at the time. Electronic listening equipment did not register any audible leak sounds that would indicate the presence of a pressurized plumbing leak. All water facilities in the kitchen including the sink drain arm, dishwasher, and icemaker supply line were tested and/or inspected with no evidence of active leaks found. Visual inspection of the exterior of the home adjacent to the damaged areas was conducted and ALD found multiple settling cracks in the block wall. The areas around the house outlet and cable line were also found to be poorly sealed. When tested, the above-mentioned areas were found to be leaking. The water damage was opined by ALD to be a result of the rainwater intrusion from above the slab level entering into the above-mentioned areas entering the inside of the home causing the surrounding damage. After having considered the inspections that took place by Mr. Brown and ALD as well as examination of the information gathered to that date, Edison properly determined that coverage would not be afforded for the insureds’ loss. Edison sent correspondence to the insureds dated December 3, 2020 communicating the coverage determination and citing specific facts and policy language corroborating their decision. The coverage letter specifically stated that the damages observed were caused by rainwater penetrating the building through cracks or stucco openings that were not caused by any covered peril first damaging the property. Furthermore, there were damages caused by wear and tear, expansion and other causes that were not covered by the policy. The claim was thereafter closed. Based on the foregoing sequence of events composing of and illustrating Edison’s thoroughness in investigation and diligent efforts in assisting its insureds utilizing highly qualified individuals, at no time has Edison acted dishonestly or unfairly towards its insured/Complainant. All actions have been towards a just and equitable resolution. Accordingly, the allegations proffered against Edison by the Complainant are wholly unfounded and without merit, are not factually supported, and are denied. Further, the Notice provides blanket statement allegations against Edison which are unfounded and unsupported by factual information in non-compliance with the mandates of Florida Statutes and established Florida case law. Moreover, there are errors in the Insured’s Civil Remedy Notice that are clearly erroneous and are illustrative of boilerplate language furthering Edison’s challenge that the Insured’s Notice is lacking specific facts relative to the Insured’s claim and Edison’s investigation of this particular loss. For example, insured alleges that Edison failed to adopt and implement proper standards for investigation, evaluation and adjusting of claims, failed to properly train, manage, supervise and promote claims adjuster conduct and that the insurer has engaged in secret claims practices. The foregoing are blanket statements without support as insured does not provide any semblance of fact to corroborate any claims of improper claims handling and investigation. These allegations are alleged in the absence of any facts or information supporting same and failing to provide a basis for insured’s accusations against Edison. As the foregoing are unfounded, they must be stricken from consideration. A review of the remainder of the Notice clearly illustrates that the insured’s sole basis for the Notice is simply that they disagree with the coverage determination issued by Edison and nothing more which is improper under Florida law. Conclusion: The Notice submitted by the Complainant to the Department failed to comply with the requirements of F.S. §624.155 and should be rejected by the Department. Edison has handled the claim of its Insured/Complainant, with diligence, and has at all times acted fairly in the administration of the claim and has treated its Insured with honesty and with due regard to the Insured’s interests, and has done so in compliance with the policy of insurance and Florida law. Simply because the Complainant may disagree with Edison’s investigation of the claim and/or Edison’s findings to date, does not establish that Edison acted in bad faith. Moreover, the method for curing the violations alleged in a civil remedy notice is not determined by the Insureds. Section 624.155 does not impose on an insurer the obligation to pay whatever the Insureds’ demands. See, Talat Enterprises, Inc. v. Aetna Casualty and Surety Co., 753 So.2d 1278 (Fla. 2000). Edison denies all of the allegations contained in the Civil Remedy Notice. Edison has fully responded to the subject defective and improper Civil Remedy Notice. Edison has not violated any of the subject statutes and the accusations made against it in the subject Civil Remedy Notice are false. Due to the lack of any factual and circumstantial basis to support such allegations, we request, through this response, that the Department of Financial Services return the Notice for lack of specificity pursuant to Florida Statutes. Edison continues to reserve all of its rights under the policy, at law and in equity. In the event this matter is not pursued further, the Department may consider this letter to be Edison’s report on the final disposition of any alleged violation. If anyone at the Department has any question concerning this matter, please contact Edison or the undersigned, for further response. Very truly yours, QUINTAIROS, PRIETO, WOOD & BOYER, P.A.
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