Filing Number: 682593
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| Filing Accepted: 3/17/2023 |
| Last/Business Name
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ELITE CLAIMS CONSULTANTS LL
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First Name |
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21301 S TAMIAMI TRAIL, SUITE 320 #195 |
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ESTERO,
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33928
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| Email Address
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CLAIMS@ELITE-CLAIMS.COM |
| Complainant Type:
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Third Party |
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| Last/Business Name* |
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YANCEY |
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First Name |
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JOHN AND CAROL |
| Policy # * |
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00084749993A |
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Claim #* |
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000847499-019 |
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Attorney is Applicable
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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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UNITED SERVICES AUTOMOBILE ASSOCIATION
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| Insurer Name* |
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NAIC Company Code 25941 |
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| Name of individual responsible for violation (if any):*
REED GOODWIN, JACOB STUCHELL, CODY PEARSON AND ANY OTHER INDIVIDUAL INVOLVED IN THE SUPERVISING, MANAGEMENT AND ADJUSTING OF THE CLAIM
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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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Unsatisfactory Settlement Offer
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Unfair Trade Practice
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Other
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promissory estoppel
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Claim Delay
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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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| 626.9541(1)(i)(2) |
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A material misrepresentation made to an insured or any other person having an interest in the proceeds payable under such contract or policy, for the purpose and with the intent of effecting settlement of such claims, loss, or damage under such contract or policy on less favorable terms than those provided in, and contemplated by, such contract or policy.
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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)(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)(i) |
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Failing to pay personal injury protection insurance claims within the time periods required by s. 627.736(4)(b).
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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.
INSURER has failed to provide a Certified Copy of Policy.
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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.
This complaint is made on behalf of JOHN AND CAROL YANCEY ("INSURED"). In consideration for the premium paid to it by the INSURED, United Services Automobile Association (INSURER) issued Insurance Policy number 00084749993A. On or around September 28, 2022, while the Policy was in full force and effect, the INSURED suffered a loss at the insured property located at 15170 Yellow Wood Drive, Alva, FL 33920 ("the Property"). The loss caused direct physical damage to the Property. The loss was sudden and accidental, and therefore, a covered peril under the policy.
On or about October 7, 2022, the INSURED first notified the Insurer of the loss due to wind with a date of loss of September 28, 2022 and the Insurer assigned claim number 000847499–019 to the INSURED'S loss.
INSURER inspected the property and provided INSURED with an estimate for damages prepared by INSURER’S Independent Adjuster ALLCAT. INSURER’S estimate included wind damage to the roof, among other damages. The inspection was completed by Independent Adjuster Cody Pearson.
The INSURED then retained a Florida licensed contracting company, First Service (CONTRACTOR) to evaluate the property and make necessary repairs. The INSURED elected to execute an Assignment of Benefits in favor of CONTRACTOR to streamline the claim process and allow CONTRACTOR to make necessary temporary repairs while the rightful benefits were pursued. CONTRACTOR conducted a thorough investigation, including a repair estimate created by CONTRACTOR totaling $128,510.
An Assignment of Benefits, the estimate for damages in the amount of $135,620.47 and the written request for the policy was submitted to INSURER on December 8, 2022. INSURER assigned DESK ADJUSTER Reed Goodwin and later re-assigned the claim to DESK ADJUSTER Jacob Stuchell.
On January 26, 2023, INSURER issued a subsequent estimate for damages which removed the prior coverage of damaged roof tiles. The letter signed by DESK ADJUSTER Goodwin accompanying this estimate conveniently stated the following: “Additionally, the initial field report has been returned, and at this time the cost of repairs is less than the Insured's deductible. Please find enclosed a copy of our estimate. Also, given that non-covered damages were noted to the roof, specifically mechanical damage to the tiles in the form of foot fall damage, and slippage of tiles, which indicates improper installation, a partial denial letter has been requested and will be sent to your office and our insured.”.
An email from DESK ADJUSTER Goodwin also accompanied that estimate, offering the following explanation for the removal of previously covered damages: “Please find enclosed a copy of USAA's estimate of repairs. Unfortunately our re-inspection did not identify any additional storm caused damages. It appears I made a clerical error during our initial correspondences, and sent you an incorrect copy of our estimate that had been previously rejected. USAA has identified no storm caused damages to the roof of this dwelling. As such, coverage has not been extended. Please refer to the partial denial letter issued to the insured on 12/19 and 12/22.”.
This implausible “clerical error” excuse is an example of bad faith, and it is suspicious that this “clerical error” was only discovered after INSURER received a Letter of Representation from a Public Adjuster and Assignment of Benefits from their chosen Contractor.
In response, a rebuttal letter was sent to INSURER as follows: “After a thorough review of this report, strong evidence suggests that it downplays the facts while making claims and cherry picking data to the contrary. There is considerable information in this report that is not relevant and even misleading. This report offers hypothetical scenarios for everything but hurricane damage for a weather event which has been acknowledged nationally and internationally. This does not qualify as a report exemplifying the scientific method but a commercial product tailored to exclude covered damages.
Key evidence is overlooked, but still present through the bias. It neglects the more logical considerations such as:
The natural conclusion of a broken tile with “clean” and recent breaks is that it was recently broken. Drawing a conclusion of who broke the tile or when is not possible. This is a clear misrepresentation of the facts. This pattern is prevalent throughout the report.
The basic physics of how much additional force the canted edge of a tile would bear (photo 11) or effect a focused impact would have on the edge of a fluttering tile (screw head, foreign object, canted tile, etc) - that either could break the tile were neglected.
Those are empirical observations one would expect an engineer to identify.
Wind speed maps provided for this property place this loss in one of the zones of highest sustained wind speeds produced at landfall (100-115 mph). Curiously, this report chose to cite top wind speeds of 49 MPH as being 11 miles from the loss. The lower speeds were emphasized as a point of interest in this report. Yet, on the page above, those data were cited as having hours and days of missing readings. While a disclaimer states that weather data was included as an indicator of weather events, citing the lowest wind speed was given no such disclaimer. This is presumed to be material evidence supporting the conclusion of this report and would technically be a material misrepresentation. Satellite maps show a vastly different picture. An objectively oriented report might consider the wider range of data, an alternate source of information or a weighted average.
In an apparent effort to impugn craftsmanship or indicate manufacturing flaws, photo 11 shows a raised tile that is not cracked. They did not endeavor to bring to light why that tile was raised (inherent product characteristics?) or what might happen were it to be raised and dropped, repeatedly. The implication is that the tile or installation was flawed. The fact remains, any tile not seated perfectly flat is more vulnerable to wind uplift. That is a stark omission from an analytical report on effects of potential wind damage at this loss. It is also worth noting that the cracked mortar above the high tile could be a result of wind lift on the tile in the picture. Neglecting the possibility that hurricane force winds may have created damage, this report concludes that installation or inspection contractors damaged tiles either long ago or very recently and the storm really wasn’t all that bad.
For all of the possibilities proposed that were not hurricane damage, they are each speculation. The hurricane, the sustained winds and the widespread damages are indisputable. The statistical probability of any leading suggestions or conclusions this report has made are insignificant compared to the probability that Hurricane Ian caused damage to this roof.
It is agreed that this property was only miles from where this storm made landfall and that this storm system was historical in size and damages caused.
Roof damage was acknowledged by USAA on their initial inspection and coverage was extended. USAA committed to repairing roof damage but revoked that coverage, later providing a skewed report USAA solicited by the insurer, which focuses on excluded damages; presenting a narrow set of observations over objective facts.
USAA has committed promissory estoppel by providing 2 conflicting positions. A desk adjuster, sight unseen, chose to amend the covered roof damage that was assessed by their in-person field adjuster. On 12/6/22 coverage was extended for damaged roof tile. On 12/8/2 the insured secured a contractor based on this coverage. On 12/12/22 we confirmed our contract with the insured. On 12/16/23 USAA retracted their coverage, overruling the field adjusters report. To obfuscate this violation, USAA solicited a report to further their position.
I request that coverage for roof damage be reinstated, as it was when the insured acted on your promise of coverage, and that negotiation as to the extent of that damage move forward.”
INSURER did not respond, and failed to communicate.
On February 24, 2023, an additional correspondence was sent to INSURER as follows: “Roof damage was acknowledged by USAA on their initial inspection and coverage was extended. USAA committed to repairing roof damage but revoked that coverage, later providing a skewed report which focuses on excluded damages; presenting a narrow set of observations over objective facts.
USAA has committed promissory estoppel by withdrawing their coverage decision upon the insured retaining professional assistance with their claim. A desk adjuster, sight unseen, chose to amend the covered roof damage that was assessed by their on-site field adjuster. On 12/6/22 coverage was extended for damaged roof tile. On 12/8/2 the insured secured a contractor based on this coverage. On 12/12/22 we confirmed our contract with the insured. On 12/16/23 USAA retracted their coverage, overruling the field adjusters report. To obfuscate this violation, USAA solicited a report to further their position withdrawing the coverage previously extended.
We find that your response and approach to the adjustment of this claim are not in good faith. I am providing notice that we will be filing a CRN for promissory estoppel and unfair settlement practices due to your initial extension, and later withdrawal, of coverage for roof damage. The timeline in which this series of events occurred will also be noted to support the argument of an unfair settlement offer as well.”.
INSURER did not respond, and failed to communicate.
On March 1, 2023, additional correspondence was sent to INSURER as follows: “In regards to the above claim, please address why coverage was extended for this loss between 12/622 and 12/16/22. Per our note below, this was not retracted until our LOR was submitted to USAA. We respectfully request that this claim remain open and this concern be addressed.
Roof damage was acknowledged by USAA on their initial inspection and coverage was extended. USAA committed to repairing roof damage but revoked that coverage, later providing a skewed report which focuses on excluded damages; presenting a narrow set of observations over objective facts.
USAA has committed promissory estoppel by withdrawing their coverage decision upon the insured retaining professional assistance with their claim. A desk adjuster, sight unseen, chose to amend the covered roof damage that was assessed by their on-site field adjuster. On 12/6/22 coverage was extended for damaged roof tile. On 12/8/2 the insured secured a contractor based on this coverage. On 12/12/22 we confirmed our contract with the insured. On 12/16/23 USAA retracted their coverage, overruling the field adjusters report.”.
INSURER did not respond and as such, continued their pattern of failing to communicate.
In a phone call to INSURER, it was communicated that the claim had been closed and the identity of a new DESK ADJUSTER was revealed and a voice mail was left for Jacob Stuchell. The following communication was also sent: “Hi Jacob, I left a message to discuss this claim and wanted to follow up with another email. I was informed the claim has been closed. We request it remains open and are providing critical information substantiating covered damages to this roof.
Attached is a USAA estimate extending coverage for storm damage to this roof. Please confirm the attachment has been reviewed and provide a claim status update.
Please contact me to discuss our options and the extent of repairs needed to address the damages.”.
Again, INSURER failed to respond and continued in their pattern of failing to communicate.
On March 7, 2023, another voicemail was left for Desk Adjuster Stuchell along with the following email communication: “Hi Jacob, I just left another voicemail. I wanted to tag my last few emails to see if we might get a response. It appears this claim has been closed to avoid having a conversation about it. That would be a violation of the insured's rights. Leaving the insured no alternative besides ADR for settlement where coverage is owed is also a violation. Based on coverage USAA extended, the results of any ADR measure are predictable.
Please reinstate the USAA estimate for covered roof damages to avoid ADR escalation.”.
Numerous opportunities were provided to INSURER to avoid escalation and the filing of a Civil Remedy Notice.
On March 8, 2023, Desk Adjuster Stuchell responded via email however no phone contact was ever made in spite of numerous attempts to reach Mr. Stuchell.
Finally, on March 15, 2023, phone contact was made with Mr. Stuchell, wherein he stated INSURER had no response to our rebuttal and they were standing on their determination. Mr. Stuchell further stated that the initial estimate which included coverage for damaged roof tiles was released in error and the engineer’s report is the basis for their determination of coverage.
Having made no attempt to request additional information from INSURED, or conduct anything that resembles a proper and thorough investigation of the claim prior to issuing a bad faith and unjust denial, INSURER is in blatant violation of F.S. 626.9541(1)(i)(3)(g) by failing to promptly notify the INSURED of any additional information necessary for the processing of a claim and F.S. 626.9541(1)(i)(3)(d) by denying claims without conducting reasonable investigations based upon available information.
It should be noted that no details or explanation for the denial was provided by INSURER other than the biased and results-driven engineer report. This defies logic, ignores the facts, and is evidence of either incompetence or bad faith. This would hardly qualify as a reasonable explanation and as such INSURER has violated F.S. 626.9541(1)(i)(3)(f) for 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.
INSURER’S adjuster inspected the house and included wind damage to the roof in the estimate. INSURER issued their initial determination of coverage including wind damage to the roof. After INSURED retained a contractor and a Public Adjuster became involved, INSURER removed the wind damage to the roof from their subsequent estimate and then hired an engineer to write up a report to justify it.
Because their second adjuster/engineer failed to complete a fair investigation of this claim, INSURER has violated F.S. 626.9541(1)(i)(3)(a) in that it failed to adopt and implement standards for the proper investigation of claims. INSURER acted in bad faith by hiring adjusters who will not find damage and that is gross violation of bad faith. This conduct also violates F.S. 626.9541(1)(i)(3)(d) in that it denies claims without conducting reasonable investigations based upon available information.
INSURER has denied covered damages in claims without conducting reasonable investigations of claims based upon available information by seeking out adjusters/engineers who will only report to them facts that are contrary to indemnifying their INSURED. The INSURER does not consider information provided to them by INSUREDS adjuster/engineer report and does not reference any information in their reports that is counter to their results-oriented adjuster/engineering report. Specifically, said adjuster/engineers do not include any reference in their reports that address wind generated tile uplift because that would lend credence to the INSURED’s claim that their roof was damaged by wind and an opening was created in the roof. Because of this, INSURER is in violation of F.S. 626.9541(1)(i)(3)(d) in that it essentially denied claims without considering all the facts.
Further, INSURER has committed promissory estoppel by providing two conflicting positions and withdrawing their initial coverage decision upon the insured retaining professional assistance with their claim. A desk adjuster, sight unseen, chose to amend the covered roof damage that was assessed by their on-site field adjuster. On 12/6/22 coverage was extended for damaged roof tile. On 12/8/2 the insured secured a contractor based on this coverage. On 12/12/22 we confirmed our contract with the insured. On 12/16/23 USAA retracted their coverage, overruling the field adjusters report.
Throughout this process, INSURER failed to communicate and manage the adjusting of this claim. Under section 627.70131(1)(a), Florida Statutes, INSURER has 14 calendar days to review and acknowledge receipt of communication regarding the claim.
INSURER’s conduct is an egregious example of bad faith.
INSURER’S determinations of coverage do not follow policy guidelines and does not show a desire to return the Property to a pre-loss condition as detailed and required under the Policy. INSURER has specifically ignored aspects of the INSURED'S claim for which coverage exists. The entire purpose of insurance is to indemnify the INSURED of a covered loss. Despite this, INSURER has failed to issue adequate payment to the INSURED. INSURER’S delay in this matter subjects the insured property to further damage. The INSURED'S damages will continue to exacerbate so long as INSURER refuses to provide full indemnification for the covered loss.
The INSURED has provided INSURER with all information available with respect to the loss. To date, INSURER has failed and/or refused to provide the INSURED with all the insurance benefits due and owing, despite knowing that the INSURED has sustained covered damages to their insured property. Despite the INSURED'S repeated pleas, INSURER has not tendered the full amount needed to repair the Property or issued all payments to the INSURED due under the Policy. Instead, INSURER is apparently attempting to ignore further coverage with an end goal of denying the claim.
As INSURER must admit, it is implied within every insurance policy a fiduciary duty, a duty of good faith and fair dealings. In an insurance contract, each party is prevented from interfering with the other's right to benefit from the contract. The obligations of good faith and fair dealings encompass qualities of decency and humanity inherent in its responsibilities as a fiduciary. INSURER is bound to conduct itself with the utmost good faith for the benefit of the INSURED. However, INSURER has failed to comply with the obligations in connection with this claim and has never looked at the claim or the contract for insurance with good faith and fair dealing. Instead, INSURER has looked for ways not to pay the claim in full and these actions have been to the detriment of the INSURED.
The adjusters assigned to this claim have a duty to adjust and treat all claims equally. Since the beginning of this claim, the representatives on behalf of INSURER have approached this investigation in a manner prejudicial to the INSURED. INSURER is using either untrained or improperly trained adjusters in connection with this claim. INSURER should have been adjusting the loss with the INSURED, but instead, it was looking for ways not to pay the claim in full. If INSURER handles all the claims in the way the INSURED'S claim was adjusted, then it is improperly handling all claims.
INSURERS conduct has been reckless and unfair to the INSURED. This is evidenced by the lack of a determination of coverage for the INSURED'S claim, the failure of INSURER to evaluate the claim in total, and the failure of INSURER to acknowledge or respond to multiple inquiries regarding the INSURED'S claim.
INSURER has refused and/or failed to comply with the Policy's cooperation and/or "Loss Payment" provision. Under the Policy, INSURER was to timely tender insurance benefits to the INSURED. INSURER has failed and/or refused to timely tender all owed insurance benefits. This is a breach of the Policy.
INSURER has refused and/or failed to cooperate and/or "Adjust the Loss" by cooperating with the INSURED during the claims adjustment process in compliance with the Policy's "Loss Payment" provision. This is a breach of the Policy.
INSURER has a contractual obligation to make a perfunctory investigation, not ignoring evidence that would support the INSURED'S claim. This is a breach of the Policy.
INSURER has a contractual obligation not to look the other way when confronted with facts revealing the possibility of additional coverage and resisting reasonable interpretations of its policy. This is a breach of The Policy.
The concept of insurance is that insurance is the insurer's granting of timely and prompt indemnity or security against a contingent loss. Florida Statute 5624.02 defines "insurance" as a contract whereby one undertakes to indemnify another or pay or allow specified amount or a determinable benefit upon determinable contingencies. Inherent is the fact that payment must be made timely and promptly so that the INSURED may mitigate their damages and to put them back into the position they were in prior to the loss as quickly as possible. INSURER has breached this duty.
INSURER has refused and/or failed to tender all insurance proceeds to the INSURED upon demand. INSURER refusal and/or failure to settle the insurance claim when under all circumstances it could have and should have done so had it acted fairly and honestly towards the INSUREDS is wrongful conduct. Furthermore, the INSURED contends that INSURER’s adjusters and/or representatives financially benefit by such wrongful conduct.
In Florida, the work of adjusting insurance claims engages the Public Trust. INSURER has breached this duty by its adjustment of its INSURED'S claim of loss.
INSURER’s handling and adjustment of its INSURED'S claim of loss and the conduct of the adjusters, supervisors, management and individuals associated with or retained by INSURER in this claim to date evidence that INSURER has failed to create and implement adequate guidelines for proper investigation to evaluate claims handling and for training and supervision of employees resulting in statutory violations set forth above. INSURER has also failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the INSUREDS' insurance claim for damages. To date, notwithstanding the INSURED'S pleas for assistance, INSURER has refused to pay the full amount of its INSURED'S claim.
Therefore, INSURER has violated some of the most basic adjustment principles in its adjustment of the INSURED'S claim, including:
1) failure to pay claim in full;
2) failure to promptly investigate claim;
3) failure to properly investigate claim;
4) failure to adjust loss;
5) failure to act in due diligence and good faith to resolve claim;
6) placing financial interest of INSURER before that of policy holders and claimants;
7) failure to properly train, evaluate and manage adjusters;
8) looking for ways to deny coverage, pay less, delay payment and otherwise "low ball" or "stone wall" claim;
9) The reasons for this may be attributed to improper training, supervision, and/or motivation of adjusters and claims supervisors to promptly and fairly investigate, adjust and pay full benefits available to all beneficiaries. The insurer may have failed to adopt proper standards of investigation and adjustment of losses or is otherwise not implementing those standards because full payment and prompt payment for the loss is not occurring.
Therefore, to cure the defects outlined in this Civil Remedy Notice, INSURER must:
Create and implement adequate guidelines for proper investigation and evaluation as to claims handling and for the training and supervision of employees, which will avoid future statutory violations as set forth above, and to avoid this from occurring in the future;
Create and implement adequate guidelines for the proper investigation and evaluation of these types of claims, and for the training and supervision of employees with regard to these types of claims to ensure INSURER’S claims handling procedures with regard to these types of losses are adequate to stop further Insureds from being treated unfairly and wrongfully;
Assist the INSURED in mitigating their damages;
Immediately tender all undisputed insurance proceeds to the INSURED, while continuing to adjust the loss with the INSURED and CONTRACTOR;
Tender all amounts due and owing the INSURED in accordance with the estimate submitted by CONTRACTOR totaling $135,620.47;
Act fairly and honestly towards the INSURED and CONTRACTOR and with due regard for their best interests in attempting to settle the INSURED'S claim, including by providing the INSURED and CONTRACTOR with copies of reports, declarations pages, certified copies of policies, or estimates being relied upon to support the coverage determination;
Immediately tender all insurance benefits due and owing to the INSURED under the Policy pursuant to the relevant policy provisions provided therein that would reasonably place the INSURED back to their pre-loss condition, including, but not limited to all interest due and owing under applicable Florida Statutes.
Reimburse the INSURED for costs associated with having to hire their own representation on their 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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