Civil Remedy Notice of Insurer Violations
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Filing Number:     686982
Filing Accepted:  4/6/2023
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Complainant
Last/Business Name *  
SUAREZ   First Name   JUAN
Street Address * 8859 NW 188TH TERRACE
City, State Zip * HIALEAH, FL 33018
Email Address * JSUAREZ14@GMAIL.COM
Complainant Type: * Insured
Insured
Last/Business Name*   SUAREZ   First Name   JUAN
Policy # * BFL623132-04 Claim #* CFL23596452
Attorney
Attorney is Applicable
Last Name* KRAPF First Name * GRANT Initial W
Street Address* 2790 SUNSET POINT RD
City, State Zip* CLEARWATER , FL 33759
Email Address * GRANT@KRAPFLEGAL.COM
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   PEOPLE'S TRUST INSURANCE COMPANY
NAIC Company Code 13125
 
Name of individual responsible for violation (if any):* ANGELA FRAZIER-WATSON, AND ANY OTHER INDIVIDUAL FROM, OR AGENT OF, PEOPLE'S TRUST INSURANCE COMPANY WHO WAS INVOLVED IN THE CLAIM.
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Denial
Unsatisfactory Settlement Offer
Unfair Trade Practice
Other : Not treating the Insured with good faith claims conduct ?
Other : Looking for ways to deny full recovery to the Insured
Other : Failing to properly investigate the Insured’s loss
Other : Failing to provide the Insured with the full benefits awarded under the contract of insurance in a t
Other : Not training, supervising, or managing adjusters properly so that prompt and full payments are made,
Other : Not adjusting claims and evaluating loss properly
Other : Failing to implement proper standards for the adjustment and investigation of claims ?
Other : Failing to provide a loss run statement
Other : Violating Fla. Stat. §627.70152(4)(a)
Other : Making material misrepresentations
* 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)(2) 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.
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)(c) Failing to acknowledge and act promptly upon communications with respect to claims.
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.

627.444(2)(a) Notwithstanding any other law, an insurer shall provide to an insured within 15 calendar days after an individual or entity designated by the insurer receives the insured’s written request, either: A loss run statement. Reference to specific policy language: The violations alleged are statutorily based and do not rely on any specific policy language.
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

People's Trust Insurance Company (the “Insurer”) has committed the following in handling the Insured’s claim: 1) failing to act in due diligence and good faith to resolve claims; 2) placing the financial interest of Insurer before that of the Insured; 3) looking for ways to deny benefit payments and otherwise “low ball” or “stone wall” claims; 4) not adjusting the claims promptly and fairly; 5) not attempting in good faith to settle claims; 6) conducting inadequate investigations; 7) failing to employ policies and procedures to conduct adequate investigations; 8) failing to acknowledge and act promptly upon communications with respect to claims; 9) failing to provide a loss run statement; 10); violating Fla. Stat. §627.70152(4)(a); and 11) making material misrepresentations. On or about September 17, 2022, while the subject policy was in full force and effect, the insured property suffered a loss caused by a windstorm. The Insured timely submitted a claim to the Insurer for wind damages and ensuing damage therefrom. Thereafter, the Insurer assigned claim number CFL23596452 to the loss and sent a field adjuster to inspect the property. Then in a letter dated February 16, 2023, the Insurer notified the Insured that it was denying coverage for the loss citing “observed cracked/broken tiles due to age-related wear and tear as well as a prior repair to the roof which is noted in the underwriting inspection completed March 12, 2018” as the reasons for the denial. Notably, the Insurer failed to hire the unbiased experts necessary to adequately inspect the property and determine the cause of loss. In arriving at these abovementioned conclusions, the Insured issued a coverage decision that misrepresents the loss. Denying coverage for the damage was wrongful as the damages are covered under the policy. Given the denial, the Insured’s disagreement with the coverage decision, and the scope and nature of the damage resulting from the windstorm, the Insured sought help from a public adjuster, a professional restoration service, a licensed forensic firm, and a licensed mold assessor to assist in resolving the claim. After assessing the damage and the true scope of repairs, an estimate was prepared identifying covered damage of $8,462.38 in costs for remediation, $12,482.89 in costs for dwelling rebuild, $95,871.98 in costs for the dwelling roofing system, and $7,580.32 in costs for the exterior of the dwelling. In addition to these projected costs, the Insured has been given an invoice in the amount of $4,231.80 for a roof tarp installation. These materials support the existence of a covered loss under the policy. On March 10, 2023, the Insured, through legal counsel, requested a copy of the loss run statement from the Insurer. Upon an Insurer receiving a written request for a loss run statement, the Insurer is required, within fifteen (15) calendar days, to provide either a loss run statement or information on how to obtain a loss run statement at no charge through a consumer reporting agency. To date the Insurer and its agents have not acknowledged this request, nor has a loss run statement been provided, nor has the Insurer provided information on how to obtain a loss run statement at no charge through a consumer reporting agency. Thus, the Insurer and its agents failed to comply with Fla. Stat. § 627.444(2)(a). On March 13, 2023, the Insured’s legal filed a notice of intent to initiate litigation in this matter, and the Insurer responded by making an offer of $9,800.00 to settle the matter. This offer, after an initial denial, is compelling evidence of bad faith as the Insurer is acknowledging that there is money owed on the claim without opening any coverage. Consequently, the Insurer has violated Fla. Stat. §627.70152(4)(a) as that statute offers only three options as a response and a settlement offer is not one of them. The Insured needs a new roof to comply with the Florida Building Code, because more than 25% of Insured’s tile roof is damaged. However, the Insurer is refusing to pay for a full roof replacement despite knowing its obligation to do so. Florida Building Code section 611.1.1 states that not more than 25% of the total roof area or roof section of any existing building or structure shall be repaired, replaced, or recovered in any 12-month period unless the entire roofing system or roof section conforms to requirements of this code. The Insurer knows, or should have known, that over 25% of the roof is damaged due to wind and that it is responsible for replacing the roof. Instead of abiding by its obligation to indemnify the Insured for the loss, Insurer and its adjusters are misrepresenting the damage to avoid coverage, thereby prioritizing the Insurer’s financial interest. Although the Insurer and Insured are in dispute about how the roof was damaged, the Insurer knows or should know that when independent perils converge and no single cause can be considered the sole or proximate cause, it is appropriate to apply the concurring cause doctrine. Sebo v. Am. Home Assurance Co., 208 So. 3d 694, 697 (Fla. 2016). The concurring cause doctrine states that coverage may exist where an insured risk constitutes a concurrent cause of the loss even when it is not the prime or efficient cause. Id. at 698. A covered peril that meets with an uncovered peril may still provide for coverage under a policy when the covered peril triggered the events that eventually led to the loss. Id. at 697. The conduct outlined above is done within the Insurer’s routine course of the business. There may be further wrongful conduct which has not been made known to the Insured at this moment. Certain conduct or actions may be discovered throughout discovery or cannot be verified without a review of the Insurer’s claim file and standards and procedures for the adjustment and investigation of claims. In short, the Insurer and its agents have engaged in bad faith practices such as conducting cursory and inadequate investigations, breaching the policy by denying coverage for a loss that should have been covered under the subject policy, failing and/or refusing to promptly acknowledge communications from the Insured, and withholding the full benefits available under the policy. Doing so has frustrated the Insured’s ability to get indemnified for this claim. In Florida the work of adjusting insurance claims engages the public trust. The Insurer has breached this trust and its duty to the Insured by not acting with due regard for the Insured’s interests and safety. The Insurer’s actions amount to but are not limited to the following: 1. Claim denial 2. Not treating the Insured with good faith claims conduct 3. Looking for ways to deny recovery to the Insured 4. Not adjusting claims and evaluating loss properly, promptly and fairly to provide full and prompt indemnity to the Insured 5. Not training, supervising or managing adjusters properly so that prompt and full payments are made, but rather placing the company’s interests before the Insured's’ interests 6. Conducting inadequate investigations 7. Failing to provide a loss run statement 8. Violating Fla. Stat. §627.70152(4)(a) 9. Making material misrepresentations Therefore, to cure the defects outlined in this civil remedy notice, the Insurer must: (1). Admit full coverage for the Insured’s loss. (2). Tender full benefits owed to the Insured under the insurance contract. (3). Pay all attorney’s fees, costs, and interest. ? (4). Provide the Insured with a loss run statement. A copy of this form submitted to the FDFS has been sent via e-mail to the following parties providing them notice of the filing of the civil remedy notice. Please e-mail any response to this civil remedy notice to badfaith@krapflegal.com. Via E-mail: People's Trust Insurance Company claimsadmin@pti.insure
Comments
User Id Date Added Comment
bfrankel@gmail.com 05-15-2023 People’s Trust Insurance Company (“PTI”) responds as follows to Civil Remedy Notice of Insurer Violations #686982 (“CRN”) filed on behalf of Juan Suarez. As a preliminary matter, PTI notes that the proper purpose for submitting a valid CRN to the Florida Department of Financial Services (“DFS”), as set forth in Florida Statute §624.155, is to provide detailed notice of specific, factually supported statutory bad faith violations along with an opportunity to cure any such alleged violations. The proper purpose is not to dispute coverage decisions, nor seek recovery of claimed attorneys’ fees and costs. Florida Statute §624.155(3)(b) requires that every CRN “shall state with specificity” the language of statutes allegedly violated, facts and circumstances giving rise to alleged violations, names of individuals involved in alleged violations, specific policy language relevant to those alleged violations, and any other information the DFS may require. A compliant CRN must also offer a specific cure based solely upon the terms and conditions of the insurance policy contract. See, e.g., Talat Enterprises, Inc. v. Aetna Cas. & Surety Co., 753 So. 2d 1278 (Fla. 2000). In other words, a CRN is legal invalid if it alleges violations without detailed factual support, cites the entire policy or generic types of provisions as “specific policy language” allegedly giving rise to supposed violations, relies on material omissions or misunderstandings of fact or law, or if it demands claimed extracontractual damages in the proposed cure as done here. Notwithstanding, to comply with statutory obligations, PTI provides the following details to support its categorical denial of every alleged statutory violation raised in this CRN. In short, PTI implemented compliant standards to adjust claims, without limitation, including: performing reasonable loss investigations; accurately representing all relevant facts and policy provisions; acknowledging and promptly acting upon communications from and on behalf of policyholders; promptly advising when additional information is needed and why; setting forth detailed written policy grounds supporting coverage decisions; paying undisputed damages if and when required; timely accepting or rejecting sworn proofs of loss upon receipt; and attempting in good faith to settle claims as appropriate without using coverage under one policy portion in order to influence settlements under another and without making any material misrepresentations. PTI implemented those standards in general, and fully adhered to them while adjusting this Claim. On January 6, 2023, PTI first received notice of the subject loss for damage reportedly caused by Hurricane Ian 101 days earlier on September 27, 2022. PTI quickly began investigating the loss under claim #CFL23596452, and mailed the Insured information on what to expect during the adjusting process along with a Homeowner Claims Bill of Rights. PTI sent a field adjuster to inspect and document the nature and extent of reported damages that were preserved and made available for inspection on January 20, 2023. Then on February 16, 2023, PTI issued its written coverage determination letter setting forth the policy language and factual grounds upon which the decision was made. PTI denied the loss, in sum, because it resulted from age-related wear and tear, which is not a covered Peril Insured Against under this named perils Policy. This CRN followed, impermissibly demanding claimed extracontractual damages as part of the proposed cure, without limitation, including that PTI pay claimed attorneys’ fees and costs, thereby rendering it legally invalid. See, e.g., Talat Enterprises, Inc. v. Aetna Cas. & Surety Co., 753 So. 2d 1278 (Fla. 2000). In closing, PTI adjusted this Claim without committing any statutory bad faith violations, and continues to treat all policyholders fairly and honestly by adhering to standards and practices it set which far exceed statutory requirements. As always, PTI will gladly consider any additional information provided by or on behalf of the Insured and trusts the foregoing explains the relevant facts and circumstances of this Claim and addresses the allegations raised in this CRN. Sincerely, Robert Gertzman Robert B. Gertzman, Esq. Managing Director of Claims Counsel People’s Trust MGA
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.

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