Civil Remedy Notice of Insurer Violations
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Filing Number:     698730
Filing Accepted:  6/7/2023
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Complainant
Last/Business Name *  
RAMIREZ   First Name   SONDRA
Street Address * 4144 101ST AVENUE E
City, State Zip * PARRISH, FL 34219
Email Address * SJANCOLA@GMAIL.COM
Complainant Type: * Insured
Insured
Last/Business Name*   RAMIREZ   First Name   SONDRA
Policy # * 79-CW-Y872-2 Claim #* 59-39M4-12J
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*   STATE FARM FLORIDA INSURANCE COMPANY
NAIC Company Code 10739
 
Name of individual responsible for violation (if any):* CHARLES BERRY, ANDY MERKLE, ALYSSA WILEY, TIA CUNNINGHAM, AND ANY OTHER INDIVIDUAL FROM, OR AGENT OF, STATE FARM FLORIDA INSURANCE COMPANY WHO WAS INVOLVED IN THE CLAIM.
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Denial
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 : Denying a claim which it knew or should have known the policy and Florida law provided coverage for
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)(d) Denying claims without conducting reasonable investigations based upon available information.
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

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.

State Farm Florida Insurance Company (the “Insurer”) has committed the following in handling the Insured’s claim: 1) failure to act in due diligence and good faith to resolve claims; 2) placing the financial interest of Insurer before that of the policyholder and 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) denying a claim which it knew or should have known the policy and Florida law provided coverage for; and 9) making material misrepresentations. On or about July 14, 2022, while the subject policy was in full force and effect, the insured property suffered a loss caused by wind. The areas impacted are believed to be to the roof. The Insured timely submitted a claim on July 1, 2022, to the Insurer for wind damages and ensuing damage therefrom. Thereafter, the Insurer assigned claim number 59-39M4-12J to the loss and assigned a field adjuster to inspect the property. The Insurer has not identified the identity of this adjuster. Given the nature of the claim, the Insured retained a public adjuster. After assessing the damage and the true scope of repairs, the public adjuster produced an estimate identifying $35,296.10 in covered damage to the dwelling. The foregoing estimate, photographs, and a letter of representation from the public adjuster were sent to the Insurer. Then in a letter dated October 30, 2022, the Insurer surprisingly notified the Insured that it was denying coverage for the loss The Insurer’s coverage decision is incorrect. Denying coverage for the damage was a breach of the policy as the damages are covered under the policy. Upon receiving notice of the loss, the Insurer had the duty to provide the full benefits under the policy. This includes providing the Insured with a proper investigation and the funds necessary to return the home to its pre-loss condition. The Insurer breached the policy and its duty to the Insured by misrepresenting the loss and issuing a wrongful denial. The Insurer based this denial the following language from the denial correspondence dated October 30, 2022: “the damages to your roof and exterior are a result of wear, tear, and deterioration. It was determined that the damages to your interior are the result of repeated leaking. This indicates the damages are from multiple events.” A few sentences later, the Insurer makes a contradicting statement claiming that “it is not possible to establish when and how often the observed damages to your dwelling interior occurred.” As the discovery process will uncover, the Insurer’s adjuster intentionally ignored the damage observed and has failed to make truthful and unbiased reports of the facts following the investigation. However, the Insured’s damage stems from wind and the resulting damage therefrom. 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 Insurer intentionally ignored covered damage to undervalue the reported loss and pay the Insured as little as possible. This is an underhanded attempt to place the financial interests of the Insurer over those of the Insured and to delay and frustrate the Insured’s ability to have his claim adjusted promptly to begin restoring his property.? The Insured need a new roof in order to comply with the Florida Building Code, because more than 25% of the Insured’s roof is damaged. The Insurer is refusing to pay for a full re-roof despite knowing it is obligated to do so. Florida Building Code section 708.1.1 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 foregoing wrongdoings of the Insurer are done in the routine course of its 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 is not acting with due regard for the Insured’s interests or safety. In Florida the work of adjusting insurance claims engages the public trust. The Insurer has breached this trust and its duty to the Insured. The Insurer and its agents conducted cursory and inadequate investigations and wrongfully denied coverage for a loss that should have been covered under the subject policy. Moreover, the Insurer has engaged in bad faith practices designed to delay claims and prevent the Insured from recovering what is rightfully owed under the subject policy of insurance. The Insurer’s actions and inactions have continued to frustrate and delay the resolution of the Insured claim. 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. Placing the financial interest of the Insurer over that of the health and safety of the Insured 7. Denying a claim which it knew or should have known the policy and Florida law provided coverage for 8. Conducting inadequate investigations 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). Implement policies and procedures to ensure that all insureds are treated with equal fairness to the investigation of claims. (5). Implement policies and procedures to ensure that all estimates and instructions comply. with the Florida Statutes. (6) Conduct an adequate inspection that accounts for the proper nature and severity of the damages to the Insured's home. 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: Attorney for State Farm Florida Insurance Company Katherine Shadwick, Esquire kshadwick@rpslaw.net
Comments
User Id Date Added Comment
grant@krapflegal.com 12-04-2023 The details herein have been amicably resolved between the parties; therefore, we withdraw this Civil Remedy Notice.
kvsfilings@rpslaw.net 07-27-2023 This correspondence constitutes State Farm Florida Insurance Company’s (“State Farm”) response to the Civil Remedy Notice of Insurer Violation filed on behalf of Sondra Ramirez regarding the claim listed above. While State Farm welcomes the opportunity to respond to this Civil Remedy Notice of Insurer Violation and specifically denies each and every allegation contained therein, the Civil Remedy Notice should be rejected and returned by the Department of Financial Services as it fails to comply with the specific information requirements laid out in Florida Statute § 624.155 and applicable case law. The Civil Remedy Notice requires the Complainant to, “pursuant to section 624.155, F.S. please indicate all statutory provisions alleged to have been violated.” The Notice filed in this matter includes numerous statutory provisions that could all possibly be claimed against an insurance company, regardless of whether they are relevant or applicable to the alleged facts contained in the Notice. Furthermore, despite the requirement to provide “specific policy language that is relevant to the violation,” the Notice filed in this matter declines to recite any specific policy language, instead asserting that the violations are statutorily based and do not rely on any specific policy language. Because the Civil Remedy Notice fails to identify any specific statutes or policy language, State Farm is unable to properly respond, and the Notice should be rejected and returned. Julien v. United Property & Cas. Ins. Co., 2021 WL 824438 (Fla. 4th DCA 2021). Without waiving the objection above, State Farm explicitly denies any alleged violation of Florida Statutes § 624.155(1)(b)(1), § 624.155(1)(b)(3), § 626.9541(1)(i)(2), § 626.9541(1)(i)(3)(a), § 626.9541(1)(i)(3)(b), § 626.9541(1)(i)(3)(d) or any other insurance statute or any provisions of the insurance policy issued to the Insured. State Farm further specifically denies any allegation that it has in any way not acted in good faith to settle the claim, failed to promptly settle the claim, failed to adopt and implement standards for the proper investigation of claims, misrepresented facts of policy provisions, or denied the claim without conducting a reasonable investigation. Moreover, contrary to the requirement to “describe the facts and circumstances giving rise to the insurer’s violation as you understand them,” the purpose of which is to “enable the insurer to investigate and resolve the claim,” the Civil Remedy Notice itself provides only unsupported, conclusory and incorrect allegations with no basis in fact or circumstance. Talat Enters. v. Aetna Cas. & Syr. Co., 753 So. 2d 1279 (Fla. 2000). Further, while providing minimal factual detail behind the allegations as to how State Farm has violated these statutes, the tenor and inferences of the allegations are wholly without merit and State Farm denies each and every one. Below are some of the facts regarding the claim that are not included in the Notice. At the outset, the CRN claims that the Insured’s property sustained damage on July 14, 2022, but that the Insureds reported the claim on July 1, 2022. However, the claim was actually reported to State Farm on September 22, 2022, two months after the alleged date of loss. That same day, State Farm made contact with the Insured who reported that heavy rain and high winds damaged the roof of the property and caused interior water staining to the dining room ceiling. The Insured also reported that there was heavy rain, high winds and hail on August 5, 2022, and she went outside and saw that the roof was “having issues” over the dining room and that was when she noticed the interior water damage. She indicated that she actually could not remember the exact date and attributed the delay in reported to having family issues. On September 28, 2022, State Farm scheduled an inspection to occur with the Insureds’ public adjuster on October 28, 2022. On October 18, 2022, State Farm received an estimate for a roof replacement and interior repairs from the public adjuster totaling $35,296.10. The inspection occurred on October 28, 2022, which revealed wear, tear and deterioration to the roof. There were unbonded, creased, and missing shingles present on multiple slopes, and a previous repair was present on the front slope. There were multiple missing screens but the public adjuster said these were not from this date of loss. The interior had water staining in the foyer and gym, which appeared to be from multiple rain events. The foyer stain appeared to be the result of failed flashing, and the gym staining was directly below the prior repair on the front slope. The public adjuster indicated he chose the date of loss based on the most recent storm. Based upon all the information received, it was determined that the roof damage was the result of wear, tear and deterioration and regarding the interior, State Farm had been prejudiced in its investigation of this claim due to the delay in reporting and was unable to determine when or how often any of the observed damages occurred and appeared to be from repeated leaking. On October 31, 2022, State Farm sent the coverage determination letter outlining the denial to the Insureds as well as correspondence regarding the Insureds right to participate in DFS Mediation. It is clear that the Insureds disagree with State Farm regarding the coverage determination. However, the Notice has transformed this disagreement into a series of unsubstantiated allegations against State Farm, including claims that State Farm acted in bad faith, intentionally ignored covered damage and improperly denied the Insureds’ claim, while the claim file reflects that State Farm promptly and efficiently inspected the reported loss as soon as it was reported by the Insureds. Ultimately, the sole basis for all of these allegations, which are otherwise unsupported by any evidence, is the fact that the Insured disagrees with State Farm regarding the coverage determination. The record clearly shows that State Farm adjusted the loss in good faith. When the Insureds reported the claim, State Farm promptly dispatched its adjuster to investigate the loss and adjust the claim. The adjuster observed that there was no wind or hail related damage to the roof and confirmd that while there was water staining to the interior, it appeared to be caused by repeated leaking and the delay in reporting prevented State Farm from being able to fully evaluate what the damage was from the reported date of loss. State Farm further sent the Insureds appropriate information from the Department of Financial Services regarding their right to mediation should they disagree with State Farm’s coverage determination. These are not the actions of an insurer that has acted in bad faith. In closing, State Farm first believes that the Civil Remedy Notice should be rejected and returned by the Department of Financial Services due to its failure to comply with Florida Statute § 624.155 and applicable case law. Lane v. Westfield Ins. Co., 862 So. 2nd 774, 228 (Fla. 5th DCA 2003). Notwithstanding the rejection of the Notice, State Farm denies all allegations contained in the Civil Remedy Notice and submits that there are no violations. While this response is meant to be comprehensive, State Farm’s response above is based upon the limited information provided in the Civil Remedy Notice, and the information we have to date. If the Insureds or their counsel feel that we are not in possession of all the facts, we hereby request to be informed of those facts immediately. State Farm requests copies of all documents the insured and their counsel rely on in support of the positions outlined in the Notice. Please note that State Farm’s response is not necessarily exhaustive and does not preclude us from asserting any other valid reason for seeking rejection and return of the Civil Remedy Notice. This letter or any act or failure to act on the part of State Farm or any agent or representative of State Farm should not be construed as a waiver of any rights or defenses available to State Farm by contract or at law, including, but not limited to, proper notice and service by the insured. All such rights and defenses are hereby specifically reserved.
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