Filing Number: 784011
|
| Filing Accepted: 9/22/2024 |
| Last/Business Name
*
|
|
|
SAND CASTLE BEACH CLUB ASSOCIATION, INC.
|
|
First Name |
|
|
|
| Street Address
*
|
|
905 ESTERO BOULEVARD |
| City, State Zip
*
|
|
FORT MYERS BEACH,
FL
33931
|
| Email Address
*
|
|
SSUTTON1055@COMCAST.NET |
| Complainant Type:
*
|
|
Insured |
|
| Last/Business Name* |
|
SAND CASTLE BEACH CLUB ASSOCIATION, INC. |
|
First Name |
|
|
| Policy # * |
|
OP21002187 |
|
Claim #* |
|
TP220766 |
|
Attorney is Applicable
|
| Last Name* |
KENNEDY
First Name *
PATRICK
Initial
D
|
| Street Address* |
|
11327 30TH CV E |
| City, State Zip* |
|
PARRISH
,
FL
34219
|
| Email Address * |
|
PATRICK@KENNEDYINSURANCELAW.COM |
|
|
| Insurer Type
*
|
|
 Authorized Insurer
 Unauthorized Insurer
|
|
|
| Insurer Name |
|
|
| Insurer Name* |
|
UNDERWRITERS AT LLOYD'S, LONDON
|
| Insurer Name* |
|
|
| Street Address* |
|
|
| City, State Zip* |
|
,
|
|
NAIC Company Code |
|
|
| Name of individual responsible for violation (if any):*
JOHN ANDRES
|
| Type of Insurance
*
Commercial Property & Casualty
|
|
|
| Reason for Notice
*
|
|
|
Unfair Trade Practice
|
|
|
Claim Delay
|
|
|
*
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)(c) |
|
Failing to acknowledge and act promptly upon communications with respect to claims.
|
|
| 626.9541(1)(i)(3)(g) |
|
Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
|
|
| 626.9541(1)(i)(3)(j) |
|
Altering or amending an insurance adjuster’s report without:
(I) Providing a detailed explanation as to why any change that has the effect of reducing the estimate of the loss was made; and
(II) Including on the report or as an addendum to the report a detailed list of all changes made to the report and the identity of the person who ordered each change; or
(III) Retaining all versions of the report, and including within each such version, for each change made within such version of the report, the identity of each person who made or ordered such change;
|
|
*
Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
Sum Insured: USD 2,562,528 any one loss occurrence.
Sub Limits: Mould: USD 50,000 per occurrence and in the annual aggregate
Sewer Back Up: USD 50,000 per occurrence and in the annual aggregate
Wind Driven Rain: USD 100,000 per occurrence and in the annual aggregate
Ordinance or Law Coverage B&C USD 1,000,000 Combined
Coverage: All Risks of Direct Physical Loss or Damage but Excluding Flood, Earthquake, Sinkhole and Catastrophic Ground Collapse.
Premium: USD 55,630 (for 100%) per annum.
LMA 3022 (Amended), including:
60 days Notice of Cancellation.
Service of Suit Clause naming Lloyds America Inc.
Replacement Cost Valuation
Ordinance or Law Coverage CP 04 05 04 02
Pre-Existing Damage Exclusion.
Roof Replacement Warranty
Cosmetic Damage Exclusion
Location(s) Insured:
905 Estero Boulevard, Fort Myers Beach, FL 33931
As per schedule of values held on file by Oxford Insurance Brokers.
Section 5 Sum Insured:
USD 2,562,528 any one loss occurrence
Sub Limit:
Mold: USD 50,000 per occurrence and in the annual aggregate
Sewer Back Up: USD 50,000 per occurrence and in the annual aggregate
Wind Driven Rain: USD 100,000 per occurrence and in the annual aggregate
Ordinance or Law Coverage B&C USD 1,000,000 Combined
Section 6 Deductible(s):
USD 5,000 each and every loss occurrence except 5% of Total Insured Values per building per occurrence in respect of Calendar Year Hurricane Deductible subject to a minimum of USD 25,000 per occurrence. All Other Wind which is USD 25,000 per occurrence.
Section 9.3 Values Declared (100%):
USD 2,562,528
Section 9.3
Co-insurance Percentage:
Nil – Agreed Values Clause
Section 9.13 Service of Suit Nominee:
Lloyd’s America, Inc.
Attention: Legal Department
280 Park Avenue, East Tower, 25th Floor
New York, NY 10017
Section 2
INSURING CLAUSE
Subject to the Exclusions, Conditions and Limitations contained herein, this Policy insures the Property specified in the Schedule against Risks of Direct Physical Loss or Damage occurring during the Period of Insurance as shown in the Schedule.
Section 4
LOCATION(S) INSURED
This Policy insures at the location(s) as stated in the Schedule and declared to and agreed by the Underwriters.
Section 5
Section 9
CONDITIONS
1. Due Diligence
The Insured shall use due diligence and do and concur in doing all things reasonable to avoid or diminish any loss of or damage to the Property Insured.
5. Valuation (see also condition 3. “Values Declared”)
For the assessment of premium and for adjustment in the event of loss or damage insured under this Policy the basis of valuation shall be as follows:
(a) on finished goods, sold but not delivered, at the sale price less all unincurred charges;
(b) on all other stock, whether finished goods or stock in process, at the value of raw materials and labour expended plus the proper proportion of overhead charges;
(c) property of others, at the amount for which the Insured is liable but in no event to exceed the actual cash value;
(d) tenants’ improvements and betterments, at the actual value if repaired or replaced by the Insured. If repaired or replaced by others for the use of the Insured, there shall be no liability hereunder;
(e) on documents not specifically excluded (except film, tape, disc, drum, cell and other magnetic recording or storage media for electronic data processing), to not exceeding the cost of blank material plus the cost of labour incurred by the Insured for transcribing or copying such records;
(f) on film, tape, disc, drum, cell, and other magnetic recording or storage media for electronic data processing, to not exceed the cost of such media in unexposed or blank form;
(g) all other property except Real Property, at the actual cash value. In the event of loss hereunder, then the actual cash value shall be that which existed immediately prior to the loss.
(h) on all Real Property as stated in the Schedule, at the replacement cost which is further defined as follows:
It is understood that, in the event of damage, settlement shall be based upon the cost of repairing, replacing or reinstating (whichever is the least) with material of like kind and quality without deduction for depreciation, subject to the following provisions:-
1) the repair, replacement or reinstatement (all hereinafter referred to as “replacement”) shall be on the same site and intended for the same occupancy as the destroyed or damaged property;
2) the replacement must be executed with due diligence and dispatch;
3) until replacement has been effected the amount of liability under this Policy in respect of loss shall be limited to the actual cash value at the time of loss.
12. Arbitration
If the Insured and the Underwriters fail to agree in whole or in part regarding any aspect of this Policy, each party shall, within ten (10) days after the demand in writing by either party, appoint a competent and disinterested arbitrator and the two chosen shall before commencing the arbitration select a competent and disinterested umpire. The arbitrators together shall determine such matters in which the Insured and the Underwriters shall so fail to agree and shall make an award thereon, and if they fail to agree, they will submit their differences to the umpire and the award in writing of any two, duly verified, shall determine the same.
The Parties to such arbitration shall pay the arbitrators respectively appointed by them and bear equally the expenses of the arbitration and the charges of the umpire.
Section 10
DEFINITIONS
1. Loss Occurrence
The words “Loss Occurrence” shall mean all individual losses or damage arising out of and directly occasioned by one event. However, if the following causes are insured by this Policy the duration and extent of any “Loss Occurrence” so defined shall be limited to:
(a) 72 consecutive hours as regards a hurricane, a typhoon, windstorm, rainstorm, hailstorm and/or tornado;
(b) 72 consecutive hours as regards earthquake, tsunami or seaquake, and/or volcanic eruption;
(c) 72 consecutive hours and within the limits of one city, town or village as regards riots, civil commotions and malicious damage;
(d) 72 consecutive hours as regards any “Loss Occurrence” which includes individual loss or losses from any of the causes mentioned in a), b) and c) above;
and no individual loss from whatever insured cause, which occurs outside these periods or areas, shall be included in that “Loss Occurrence”.
The Insured may choose the date and time when any such period of consecutive hours commences and if any event is of greater duration than the above period, the Insured may divide that event into two or more “Loss Occurrences” provided no two periods overlap and provided no period commences earlier than the date and time of the happening of the first recorded individual loss to the Insured in that event during the Period of Insurance.
E. Loss Payment
1. All following loss payment Provisions, E.2. through E.5., are subject to the apportionment procedures set forth in Section B.3. of this endorsement.
2. When there is a loss in value of an undamaged portion of a building to which Coverage A applies, the loss payment for that building, including damaged and undamaged portions, will be determined as follows:
a. If the Replacement Cost Coverage Option applies and the property is being repaired or replaced, on the same or another premises, we will not pay more than the lesser of:
(1) The amount you would actually spend to repair, rebuild or reconstruct the building, but not for more than the amount it would cost to restore the building on the same premises and to the same height, floor area, style and comparable quality of the original property insured; or
(2) The Limit of Insurance shown in the Declarations as applicable to the covered building.
b. If the Replacement Cost Coverage Option applies and the property is not repaired or replaced, or if the Replacement Cost Coverage Option does not apply, we will not pay more than the lesser of:
(1) The actual cash value of the building at the time of loss; or
(2) The Limit of Insurance shown in the Declarations as applicable to the covered building.
3. Unless Paragraph E.5. applies, loss payment under Coverage B – Demolition Cost Coverage will be determined as follows:
We will not pay more than the lesser of the following:
a. The amount you actually spend to demolish and clear the site of the described premises; or
b. The applicable Limit of Insurance shown for Coverage B in the Schedule above.
4. Unless Paragraph E.5. applies, loss payment under Coverage C – Increased Cost of Construction Coverage will be determined as follows:
a. We will not pay under Coverage C:
(1) Until the property is actually repaired or replaced, at the same or another premises; and
(2) Unless the repairs or replacement are made as soon as reasonably possible after the loss or damage, not to exceed two years. We may extend this period in writing during the two years.
COMPLAINTS PROCEDURE
We are dedicated to providing you with a high quality service and we want to ensure that we maintain this at all times. If you feel that we have not offered you a first class service please write and tell us and we will do our best to resolve the problem.
If you have any questions or concerns about your policy, any problems concerning any aspect of your insurance or the handling of a claim you should, in the first instance contact your broker.
If you are unable to resolve the situation and wish to make a complaint, you can refer it to the Complaints Department at Lloyd’s who may, in certain circumstances, be able to review the matter.
The name, address and contact details of the Complaints Department at Lloyd’s is amended to read as follows:
Policyholder & Market Assistance
Lloyd's Market Services,
One Lime Street,
London
EC3M 7HA
Telephone: +44 (0)207 327 5693
Fax: +44 (0)207 327 5225
E-mail: complaints@lloyds.com
In the event that the Complaints Department is unable to resolve your complaint, it may be possible for you to refer it to the Financial Ombudsman Service. Further details will be provided at the appropriate stage of the complaints process.
COSMETIC DAMAGE EXCLUSION
Notwithstanding anything to the contrary contained elsewhere in the Policy to which this Endorsement is attached, it is understood and agreed that:
1) Cosmetic Damage to Roof Surface belonging to Roofs, Car Ports, and HVAC Units,
caused by the perils of Windstorm or Hail is excluded.
2) For the purpose of this Endorsement:
a) Roof Surface means shingles, tiles, cladding, metal or synthetic sheeting or similar
materials covering the roof
b) Car Ports means a roofed structure that is used as a shelter for an automobile.
c) HVAC Units means the apparatus that is used for controlling the temperature of an
enclosed space or units of a building
d) Cosmetic Damage means loss or damage that alters the physical appearance but does
not result in the failure to perform the intended function of keeping out the elements
over an extended period of time
For the purpose of this endorsement, wind and hail also includes any damage as a result of a named storm.
All other terms and conditions remain unchanged.
“ALL IN” ENDORSEMENT
This endorsement modifies insurance provided under this Policy.
The following is added to the coverage of this Policy:
Buildings coverage applies to property within condominium units in accordance with this provision:
Buildings coverage is extended to include the following property contained within condominium units which is owned by the Assured or unit owner:
1) fixtures, installations and additions comprising a part of the building;
and
2) refrigerators, air conditioners, cooking ranges, dishwashers and clothes washers and dryers comprising a part of the building, contained within the units, and owned by the Assured or unit owner.
CHOICE OF LAW AND JURISDICTION
Choice of law: All matters shall be governed by and construed in accordance with the substantive laws of the State of Florida.
Choice of jurisdiction: Subject to the provisions of the Service of Suit Clause contained within the policy wording.
F.S. §627.70131(5):
(5) For purposes of this section, the term “insurer” means any residential property insurer.
(6)(a) When providing a preliminary or partial estimate of damage regarding a claim, an insurer shall include with the estimate the following statement printed in at least 12-point bold, uppercase type: THIS ESTIMATE REPRESENTS OUR CURRENT EVALUATION OF THE COVERED DAMAGES TO YOUR INSURED PROPERTY AND MAY BE REVISED AS WE CONTINUE TO EVALUATE YOUR CLAIM. IF YOU HAVE QUESTIONS, CONCERNS, OR ADDITIONAL INFORMATION REGARDING YOUR CLAIM, WE ENCOURAGE YOU TO CONTACT US.
(b) When providing a payment on a claim which is not the full and final payment for the claim, an insurer shall include with the payment the following statement printed in at least 12-point bold, uppercase type: WE ARE CONTINUING TO EVALUATE YOUR CLAIM INVOLVING YOUR INSURED PROPERTY AND MAY ISSUE ADDITIONAL PAYMENTS. IF YOU HAVE QUESTIONS, CONCERNS, OR ADDITIONAL INFORMATION REGARDING YOUR CLAIM, WE ENCOURAGE YOU TO CONTACT US.
(7)(a) Within 90 days after an insurer receives notice of an initial, reopened, or supplemental property insurance claim from a policyholder, the insurer shall pay or deny such claim or a portion of the claim unless the failure to pay is caused by factors beyond the control of the insurer which reasonably prevent such payment. Any payment of an initial or supplemental claim or portion of such claim made 90 days after the insurer receives notice of the claim, or made more than 15 days after there are no longer factors beyond the control of the insurer which reasonably prevented such payment, whichever is later, bears interest at the rate set forth in s. 55.03. Interest begins to accrue from the date the insurer receives notice of the claim. The provisions of this subsection may not be waived, voided, or nullified by the terms of the insurance policy. If there is a right to prejudgment interest, the insured shall select whether to receive prejudgment interest or interest under this subsection. Interest is payable when the claim or portion of the claim is paid. Failure to comply with this subsection constitutes a violation of this code. However, failure to comply with this subsection does not form the sole basis for a private cause of action.
55.03 Judgments; rate of interest, generally.—
(1) On December 1, March 1, June 1, and September 1 of each year, the Chief Financial Officer shall set the rate of interest that shall be payable on judgments or decrees for the calendar quarter beginning January 1 and adjust the rate quarterly on April 1, July 1, and October 1 by averaging the discount rate of the Federal Reserve Bank of New York for the preceding 12 months, then adding 400 basis points to the averaged federal discount rate. The Chief Financial Officer shall inform the clerk of the courts and chief judge for each judicial circuit of the rate that has been established for the upcoming quarter. The interest rate established by the Chief Financial Officer shall take effect on the first day of each following calendar quarter. Judgments obtained on or after January 1, 1995, shall use the previous statutory rate for time periods before January 1, 1995, for which interest is due and shall apply the rate set by the Chief Financial Officer for time periods after January 1, 1995, for which interest is due. Nothing contained herein shall affect a rate of interest established by written contract or obligation.
(2) Any judgment for money damages or order for a judicial sale and any process or writ directed to a sheriff for execution shall bear, on its face, the rate of interest that is payable on the judgment. The rate of interest stated in the judgment, as adjusted in subsection (3), accrues on the judgment until it is paid.
(3) The interest rate is established at the time a judgment is obtained and such interest rate shall be adjusted annually on January 1 of each year in accordance with the interest rate in effect on that date as set by the Chief Financial Officer until the judgment is paid, except for judgments entered by the clerk of the court pursuant to ss. 55.141, 61.14, 938.29, and 938.30, which shall not be adjusted annually.
(4) A sheriff shall not be required to docket and index or collect on any process, writ, judgment, or decree, described in subsection (2), and entered after the effective date of this act, unless such process, writ, judgment, or decree indicates the rate of interest. For purposes of this subsection, if the process, writ, judgment, or decree refers to the statutory rate of interest described in subsection (1), such reference shall be deemed to indicate the rate of interest.
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)(g) Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
F.S. 626.9541(1)(i)(3)(j)(I):
j. Altering or amending an insurance adjuster’s report without:
(I) Providing a detailed explanation as to why any change that has the effect of reducing the estimate of the loss was made.
(II) Including on the report or as an addendum to the report a detailed list of all changes made to the report and the identity of the person who ordered each change; or
(III) Retaining all versions of the report, and including within each version, for each change made within such version of the report, the identity of each person who made or ordered such change.
F.S. 626.9541(1)(i)(3)(c) Failing to acknowledge and act promptly upon communications with respect to claims.
F.S.§627.70131 – Insurer’s duty to acknowledge communications regarding claims; investigation.
(1)1(a) Upon an insurer’s receiving a communication with respect to a claim, the insurer shall, within 7 calendar days, review and acknowledge receipt of such communication unless payment is made within that period of time or unless the failure to acknowledge is caused by factors beyond the control of the insurer. If the acknowledgment is not in writing, a notification indicating acknowledgment shall be made in the insurer’s claim file and dated. A communication made to or by a representative of an insurer with respect to a claim shall constitute communication to or by the insurer.
(2) Such acknowledgment must be responsive to the communication. If the communication constitutes a notification of a claim, unless the acknowledgment reasonably advises the claimant that the claim appears not to be covered by the insurer, the acknowledgment must provide necessary claim forms, and instructions, including an appropriate telephone number.
(6)(a) When providing a preliminary or partial estimate of damage regarding a claim, an insurer shall include with the estimate the following statement printed in at least 12-point bold, uppercase type: THIS ESTIMATE REPRESENTS OUR CURRENT EVALUATION OF THE COVERED DAMAGES TO YOUR INSURED PROPERTY AND MAY BE REVISED AS WE CONTINUE TO EVALUATE YOUR CLAIM. IF YOU HAVE QUESTIONS, CONCERNS, OR ADDITIONAL INFORMATION REGARDING YOUR CLAIM, WE ENCOURAGE YOU TO CONTACT US.
(b) When providing a payment on a claim which is not the full and final payment for the claim, an insurer shall include with the payment the following statement printed in at least 12-point bold, uppercase type: WE ARE CONTINUING TO EVALUATE YOUR CLAIM INVOLVING YOUR INSURED PROPERTY AND MAY ISSUE ADDITIONAL PAYMENTS. IF YOU HAVE QUESTIONS, CONCERNS, OR ADDITIONAL INFORMATION REGARDING YOUR CLAIM, WE ENCOURAGE YOU TO CONTACT US.
(7)(a) Within 90 days after an insurer receives notice of an initial, reopened, or supplemental property insurance claim from a policyholder, the insurer shall pay or deny such claim or a portion of the claim unless the failure to pay is caused by factors beyond the control of the insurer which reasonably prevent such payment. Any payment of an initial or supplemental claim or portion of such claim made 90 days after the insurer receives notice of the claim, or made more than 15 days after there are no longer factors beyond the control of the insurer which reasonably prevented such payment, whichever is later, bears interest at the rate set forth in s. 55.03. Interest begins to accrue from the date the insurer receives notice of the claim. The provisions of this subsection may not be waived, voided, or nullified by the terms of the insurance policy. If there is a right to prejudgment interest, the insured shall select whether to receive prejudgment interest or interest under this subsection. Interest is payable when the claim or portion of the claim is paid. Failure to comply with this subsection constitutes a violation of this code. However, failure to comply with this subsection does not form the sole basis for a private cause of action.
|
| |
*
Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
Please consider this as the Civil Remedy Notice of Insurer Violations (“CRN”) of Sand Castle Beach Club Association, Inc. (“Insured”) as against Certain Underwriters at Lloyd’s, London (“Lloyd’s”) for multiple violations of Florida Statutes and breaches of the policy of insurance. This notice is given to perfect the right to pursue the civil remedies authorized by F.S. §624.155.
The following facts shall serve to outline the unreasonable delays and acts of improper claims handling by Lloyd’s, resulting in a deficient investigation of the Insured’s insurance claim.
The Insured timely submitted an insurance claim to Lloyd’s for damage to the insured property resulting from wind. It is undisputed that “Wind” is a covered cause of loss under the Insured’s insurance policy with Lloyd’s. To date, Lloyd’s has made no payment to the Insured and has presented an estimate that has a valuation of the covered wind damage as below deductible.
The Insurer’s engineering report prepared by ProNet identifies, locates, and provides photos of three (3) punctures to the TPO membrane of the roof. As a result, the Insurer’s estimate included only a single line item for “TPO Roof Repair” with a quantity of three (3) and a unit cost of $750.00 each. This is an insufficient adjustment as there is no explanation of the actual method of repair offered other than ProNet’s unspecified, unverified reference to “typical industry standard repair techniques” nor consideration of any consequential damages, such as moisture penetration and migration confirmed via core sampling by the Insured’s roof vendor, CentiMark, due to storm-created openings in the TPO roofing.
The adjustment of the claim by Lloyd’s is deficient, which is clear when reviewing the photographs of the property produced by both the Insured’s representatives (ProNet) as well as the Insurer’s adjuster, John Andres of Gulf Coast Claims Service (“GCCS”). As a result, the Insured’s recovery has been unjustly delayed by Lloyd’s actions in violation of Florida law as further explained herein.
On June 9, 2023, the Insured’s public adjuster, Matthew Higgins, and the Insurer’s adjuster, John Andres, held a teleconference wherein Mr. Higgins verbally informed Mr. Andres that additional wind-related roof damages not identified, acknowledged, or referenced in the ProNet report nor estimated for repair in the GCCS estimate had been identified during Mr. Higgins’ June 7, 2023 inspection. Mr. Higgins advised that a photo report depicting these omitted roof wind damages would be forthcoming. The Roof Damage Overview photo report with damage location map was produced by Mr. Higgins to Mr. Andres on June 14, 2023. Insurer’s representatives unilaterally deferred reinspection of the additionally discovered and reported damages despite notice and failed to continue the adjustment of the claim after the Insured’s requests. Insurer cannot ignore the Insured’s presentation of objective evidence in rebuttal to its initial coverage determination, where said evidence clearly shows that further adjustment in favor of the Insured is required, without being liable for its inaction. Insurer’s inaction is a failure to adjust the loss with its Insured, a failure to pay undisputed monies as soon as it becomes apparent that monies are owed, and a failure under the Loss Payment provision section of the insurance policy to adjust and pay the Insured’s claim.
E. Loss Payment
1. All following loss payment Provisions, E.2. through E.5., are subject to the apportionment procedures set forth in Section B.3. of this endorsement.
2. When there is a loss in value of an undamaged portion of a building to which Coverage A applies, the loss payment for that building, including damaged and undamaged portions, will be determined as follows:
a. If the Replacement Cost Coverage Option applies and the property is being repaired or replaced, on the same or another premises, we will not pay more than the lesser of:
(1) The amount you would actually spend to repair, rebuild or reconstruct the building, but not for more than the amount it would cost to restore the building on the same premises and to the same height, floor area, style and comparable quality of the original property insured; or
(2) The Limit of Insurance shown in the Declarations as applicable to the covered building.
b. If the Replacement Cost Coverage Option applies and the property is not repaired or replaced, or if the Replacement Cost Coverage Option does not apply, we will not pay more than the lesser of:
(1) The actual cash value of the building at the time of loss; or
(2) The Limit of Insurance shown in the Declarations as applicable to the covered building.
3. Unless Paragraph E.5. applies, loss payment under Coverage B – Demolition Cost Coverage will be determined as follows:
We will not pay more than the lesser of the following:
a. The amount you actually spend to demolish and clear the site of the described premises; or
b. The applicable Limit of Insurance shown for Coverage B in the Schedule above.
4. Unless Paragraph E.5. applies, loss payment under Coverage C – Increased Cost of Construction Coverage will be determined as follows:
a. We will not pay under Coverage C:
(1) Until the property is actually repaired or replaced, at the same or another premises; and
(2) Unless the repairs or replacement are made as soon as reasonably possible after the loss or damage, not to exceed two years. We may extend this period in writing during the two years.
Further, Insurer ignoring and refusing to reinspect the Insured property and its failure to make any adjustment of the claim based on the information presented by the Insured are violations of Florida law as pertaining to substantive communication and failure to notify the Insured of additional information that the Insurer deems necessary to continue its adjustment. These failures and violations by the Insurer have left the Insured with no choice but to file this CRN and escalate the claim to legal counsel.
F.S. 626.9541(1)(i)(3)(c) Failing to acknowledge and act promptly upon communications with respect to claims.
626.9541(1)(i)(3)(a) Failing to adopt and implement standards for the proper investigation of claims.
626.9541(1)(i)(3)(g) Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
On January 12, 2024, the Insured’s public adjuster, Matthew Higgins, submitted an estimate of damages to the Insurer in the amount of $447,770.16. With its submission, the Insured’s representative submitted a roof report, many photographs, and an assessment of the roof by CentiMark. The Insurer failed to substantively respond to this submission, besides standing on its current position and offering no payment to the Insured in further support of the allegations made herein regarding the Insurer’s failure to adjust, substantively communicate or provide the Insured with information regarding what the Insurer would require to continue its adjustment of the claim.
On January 14, 2024, Mr. Andres confirmed receipt of the Insured’s public adjuster estimate, CentiMark roof report, and photos. Mr. Andres also alleged that some of the scope contained within the Insured’s public adjuster estimate was flood related with no specificity. Despite the Insured’s public adjuster’s request that such items of scope believed to be flood related be specifically identified for clarification, no additional response was provided. The Insurer’s inaction and lack of communication in this instance is yet another example of the Insurer’s failure to adjust, failure to substantively communicate, and failure to provide the Insured with information regarding what additional information may be required for the Insurer to continue its claim adjustment.
626.9541(1)(i)(3)(a) Failing to adopt and implement standards for the proper investigation of claims.
626.9541(1)(i)(3)(c) Failing to acknowledge and act promptly upon communications with respect to claim
626.9541(1)(i)(3)(g) Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
F.S. §627.70131 Insurer’s duty to acknowledge communications regarding claims; investigation.—
(1)1(a) Upon an insurer’s receiving a communication with respect to a claim, the insurer shall, within 7 calendar days, review and acknowledge receipt of such communication unless payment is made within that period of time or unless the failure to acknowledge is caused by factors beyond the control of the insurer. If the acknowledgment is not in writing, a notification indicating acknowledgment shall be made in the insurer’s claim file and dated. A communication made to or by a representative of an insurer with respect to a claim shall constitute communication to or by the insurer.
(2) Such acknowledgment must be responsive to the communication. If the communication constitutes a notification of a claim, unless the acknowledgment reasonably advises the claimant that the claim appears not to be covered by the insurer, the acknowledgment must provide necessary claim forms, and instructions, including an appropriate telephone number.
On March 25, 2024, Mr. Andres stated via e-mail that, “Based on my inspection and the engineers the roof was repairable. We are so far below the windstorm deductible I don’t see anything I can do.” Despite clear deficiencies in the Insurer’s representatives’ investigations, reporting, and estimated scope of damage as evidenced by photographic documentation provided by the Insured’s public adjuster; the lack of an explanation of how Insurer’s representatives’ proposed scope of unspecified, unverified “typical industry standard repair techniques” returns wind-damaged property to its pre-loss condition; and the failure and/or refusal to update Insurer’s estimate of repair; it is plainly evident that no good-faith effort has been made to continue to adjust the Insured’s claim.
Mr. Andres’ email is also clear evidence that the Insurer knew additional adjustments should be made in favor of the Insured, but because the Insurer did not believe that the Insured would be satisfied with a repair scope of estimation, the Insurer refused to adjust the claim whatsoever. This inaction necessitated the filing of this CRN as the Insured has no clear option as to how to obtain proper indemnification for its covered loss.
On May 13, 2024, the Insured’s representative submitted the Insured’s Sworn Statement in Proof of Loss, supporting documentation thereof inclusive of a replacement cost value and actual cash value estimate of repair, and additional photographs from their June 7, 2023 and August 23, 2023 inspections. A detailed explanation of the roof damages and claimed scope of repair were provided to assist the adjuster and Insurer in understanding why the Insurer has clearly undervalued and underestimated the scope of the covered damage. Furthermore, the previously provided Roof Damage Overview photo report with damage location map clearly showed at least three (3) additional punctures in the TPO membrane, punctures to roof penetration pipe boots, and numerous cuts/gouges/scratches throughout the protective TPO roof surface which were ignored or overlooked by the Insurer’s adjuster and/or ProNet. The deficiencies of the ProNet report and the adjuster’s estimate are undeniable. These punctures and cuts/gouges/scratches are documented, photographed, and have been discussed with the Insurer’s representative in writing and verbally but continue to be ignored by the Insurer. The Insurer has a duty to amend its estimate and pay undisputed monies as soon as it knows it owes those payments. As explained throughout this CRN, the Insurer’s refusal to amend its estimate in any way, even when on notice of clearly accurate information being produced to the Insurer with respect to covered damage, is evidence of bad faith claims handling and is violative of Florida law.
626.9541(1)(i)(3)(a) Failing to adopt and implement standards for the proper investigation of claims.
626.9541(1)(i)(3)(c) Failing to acknowledge and act promptly upon communications with respect to claims.
626.9541(1)(i)(3)(g) Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
On May 20, 2024, and in what appears to be a blatant attempt to deflect and avoid confronting documented facts, Mr. Andres responded via e-mail claiming that requested flood damage information previously requested had not been received when, in fact, it had been provided on June 14, 2023 in the same e-mail as the Roof Damage Overview photo report which was confirmed received. As evidence of the submission of requested flood damage information and what appears to be a repetitive pattern of overlooking or ignoring information, a copy of the June 14, 2023 e-mail from Mr. Higgins to Mr. Andres was provided later that very day, May 20, 2024. This request by the Insurer evidences disorganization and a lack of adjustment associated with documents that were provided nearly one (1) full year prior. Clearly, the adjustment of the claim was logically delayed based upon the Insurer’s inattention as the documents submitted 11 months prior were not reviewed by the Insurer for 11 months and not until the Insurer requested these same previously provided documents was it apparent that the Insurer had completely failed to consider these documents in its adjustment to date. This request shows a failure to act promptly with respect to claims and a failure to adopt and implement standards to properly inspect claims, the act of which clearly delayed the proper adjustment of Insured’s claim.
F.S. 626.9541(1)(i)(3)(c) Failing to acknowledge and act promptly upon communications with respect to claims.
626.9541(1)(i)(3)(a) Failing to adopt and implement standards for the proper investigation of claims.
Mr. Andres’ May 20, 2024 e-mail continues by subjectively mischaracterizing the Insured’s Sworn Statement in Proof of Loss as “hostile.” Mr. Andres then authored a letter dated May 23, 2024 confirming “receipt of a document which purports to be a proof of loss” and “expressly reject[ing] any and all statements contained in the purported Proof of Loss with reference to the amount of sound value and the amount of loss…” No explanation or evidence of why the Insured’s Sworn Statement in Proof of Loss has been subjectively mischaracterized as “hostile” or “purported” or why it has been “expressly rejected” has been received to date. Insurer’s rejection of the Insured’s proof of loss and its characterization of the proof of loss as “hostile” shows the antagonistic and non-cooperative way with which the Insurer has been handling the Insured’s claim. When coupled with the Insurer’s refusal to re-inspect the loss, the Insured is left with no option but to escalate the claim. As a result, the Insured’s costs, including but not limited to interest and attorney’s fees, are recoverable in any bad faith cause of action that may emanate from this CRN filing.
Mr. Andres’ May 20, 2024 e-mail also asserts that, “The insured has all the pertinent information on this claim,” however Insurers’ representatives’ apparent and repetitive pattern of overlooking or ignoring information provides no solace to the Insured that such information provided is either complete or accurate. Continuing, Mr. Andres contends that, “We do not adjust our losses by photos that are non-conclusive.” It is unclear which photos have been subjectively and unilaterally deemed “non-conclusive” by Mr. Andres and/or the Insurer and on what basis. The Insured requests that all alleged “non-conclusive” photos provided by or to Insurer’s representatives be identified.
Responsive to and on the same date as Mr. Andres’ May 20, 2024 e-mail, Mr. Higgins reminds of the previously provided flood damage information; requests copies of the admittedly “preliminary estimate and engineering report” allegedly provided to Insured before the March 25, 2023 distribution of the “final estimate & engineering report;” reminds of Insurer’s unilateral decision to defer reinspection upon notice of additional damages; re-requests all original “raw” photos of higher, unreduced resolution taken by Insurer’s representatives; and reiterates Insured’s roofing vendor, CentiMark’s, professional findings and recommendations.
On May 30, 2024, Mr. Andres provided Mr. Higgins via e-mail a “.zip” folder containing 163 “raw” “.jpg” images taken by ProNet. Of these 163 photos, only 22 are included within the ProNet March 23,2023 report. Of these 163 photos, 43 are taken from and depict the roof surfaces, however only 6 are included within the ProNet March 23,2023 report. Of note, the 163 “raw” photos range in data size as indicated in in their metadata from 34 kilobytes (KB) to 111 kilobytes (KB) compressed and 37 kilobytes (KB) to 114 kilobytes (KB) uncompressed, indicative of a low-quality, low-resolution digital image consistent with the lowest selectable setting of most modern-day digital cameras. It is unclear as to whether these “raw” photos or those specimens included in the ProNet final report were originally taken either intentionally or inadvertently by ProNet on such a low setting or if the images have been intentionally reduced in size and quality post-production that makes the numerous and widespread instances of cut/gouges/scratches to the TPO roof membrane caused by wind-borne debris more difficult to visually identify.
What is clear is that ProNet:
1.) intentionally identified, captured in 5 photos, and quantified via measuring tape at least 5 specific, conclusively identifiable, and distinct instances of cut/gouges/scratches to the TPO roof membrane caused by wind-borne debris--NONE OF WHICH WERE PUBLISHED IN THE PRONET REPORT;
2.) intentionally identified, captured in 6 photos without quantification at least 5 specific, conclusively identifiable, and distinct instances of cut/gouges/scratches to the TPO roof membrane caused by wind-borne debris--NONE OF WHICH WERE PUBLISHED IN THE PRONET REPORT;
3.) unintentionally or inadvertently identified, captured in 5 photos, and quantified via measuring tape at least 3 specific, conclusively identifiable, and distinct instances of cut/gouges/scratches in conjunction with punctures to the TPO roof membrane caused by wind-borne debris--3 OF WHICH WERE PUBLISHED IN THE PRONET REPORT;
4.) unintentionally or inadvertently identified, captured in 3 distant overview photos without quantification at least 3 suspected instances of cut/gouges/scratches to the TPO roof membrane caused by wind-borne debris--1 OF WHICH WAS PUBLISHED IN THE PRONET REPORT.
The Insured finds it highly suspicious, disingenuous, and misrepresentative that ALL intentionally identified, specific, conclusively identifiable, and distinct instances of cut/gouges/scratches to the TPO roof membrane caused by wind-borne debris have, in fact, been omitted from the published ProNet final report. Furthermore, the Insured finds it highly suspicious, disingenuous, and misrepresentative that ALL intentionally identified, specific, conclusively identifiable, and distinct instances of cut/gouges/scratches to the TPO roof membrane caused by wind-borne debris have, in fact, been omitted from scope of the published GCCS final estimate. The insured is left to presume that these glaring omissions are either independent of one another and miraculously coincidental, or they have been jointly executed in order to collude in the underpayment of this claim. This CRN provides the Insurer sixty (60) days to investigate and correct these objectively provable bad faith acts, omissions, and errors.
Lloyd’s has produced photographs from its engineer’s and adjuster’s inspections, and the photographs show TPO roof damage that was not estimated by Lloyd’s adjuster in the estimate produced to the Insured. Lloyd’s has either purposefully ignored these damages or has amended the adjuster’s estimate to not include these covered damages. Lloyd’s engineer’s report and adjuster’s estimate also fails to mention or include numerous damaged exterior fixtures and features such as security cameras, HVAC window unit cages, safety lighting, railing, windows, patio doors, entry doors, stucco, and paint. Additionally, Lloyd’s engineer’s report and adjuster’s estimate fail to mention or include the total wind displacement of the gazebo roof covering, roof framing, and associated fixtures. Importantly, Lloyd’s has not asserted any coverage position that denies or otherwise limits its liability to pay for these damages. Lloyd’s sent the Insured a letter dated May 23, 2023 in which Lloyd’s presented its below deductible estimate to the Insured in the amount of $89,157.14. As this estimated amount did not exceed the Insured’s deductible as calculated by Lloyd’s, the Insured did not receive any payment for the claim. In this letter, Lloyd’s asserts no coverage exclusions nor any declination of coverage, nor does Lloyd’s cite any policy language whatsoever upon which it bases its initial coverage determination and estimate valuation. The letter attempts to reserve Lloyd’s rights, but only as to “any policy provisions and/or conditions that may be revealed in the course of further investigation.”
626.9541(1)(i)(3)(a) Failing to adopt and implement standards for the proper investigation of claims.
626.9541(1)(i)(3)(c) Failing to acknowledge and act promptly upon communications with respect to claims.
Additionally, if Lloyd’s received an estimate and amended that estimate in any way, shape, or form to deny, exclude, or underpay its Insured based on such amendment, that amendment must be fully disclosed under Florida law. Lloyd’s violation of same is actionable under the following statute:
F.S. 626.9541(1)(i)(3)(j):
j. Altering or amending an insurance adjuster’s report without:
(I) Providing a detailed explanation as to why any change that has the effect of reducing the estimate of the loss was made.
(II) Including on the report or as an addendum to the report a detailed list of all changes made to the report and the identity of the person who ordered each change; or
(III) Retaining all versions of the report, and including within each version, for each change made within such version of the report, the identity of each person who made or ordered such change.
627.70131 Insurer’s duty to acknowledge communications regarding claims; investigation.— (6)(a) When providing a preliminary or partial estimate of damage regarding a claim, an insurer shall include with the estimate the following statement printed in at least 12-point bold, uppercase type: THIS ESTIMATE REPRESENTS OUR CURRENT EVALUATION OF THE COVERED DAMAGES TO YOUR INSURED PROPERTY AND MAY BE REVISED AS WE CONTINUE TO EVALUATE YOUR CLAIM. IF YOU HAVE QUESTIONS, CONCERNS, OR ADDITIONAL INFORMATION REGARDING YOUR CLAIM, WE ENCOURAGE YOU TO CONTACT US.
(b) When providing a payment on a claim which is not the full and final payment for the claim, an insurer shall include with the payment the following statement printed in at least 12-point bold, uppercase type: WE ARE CONTINUING TO EVALUATE YOUR CLAIM INVOLVING YOUR INSURED PROPERTY AND MAY ISSUE ADDITIONAL PAYMENTS. IF YOU HAVE QUESTIONS, CONCERNS, OR ADDITIONAL INFORMATION REGARDING YOUR CLAIM, WE ENCOURAGE YOU TO CONTACT US.
627.70131 Insurer’s duty to acknowledge communications regarding claims; investigation.—
(1)1(a) Upon an insurer’s receiving a communication with respect to a claim, the insurer shall, within 7 calendar days, review and acknowledge receipt of such communication unless payment is made within that period of time or unless the failure to acknowledge is caused by factors beyond the control of the insurer. If the acknowledgment is not in writing, a notification indicating acknowledgment shall be made in the insurer’s claim file and dated. A communication made to or by a representative of an insurer with respect to a claim shall constitute communication to or by the insurer.
(2) Such acknowledgment must be responsive to the communication. If the communication constitutes a notification of a claim, unless the acknowledgment reasonably advises the claimant that the claim appears not to be covered by the insurer, the acknowledgment must provide necessary claim forms, and instructions, including an appropriate telephone number.
Lloyd’s provided no policy language that purported to limit or exclude any coverage for the reported damage. There is no way for the Insured to know what policy language upon which Lloyd’s relied upon for the reason(s) for coverages extended, limited or denied.
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)(c) Failing to acknowledge and act promptly upon communications with respect to claims.
626.9541(1)(i)(3)(g) Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
As the claim has now been open for approximately two (2) years, and Lloyd’s has not made full payment of the Insured’s estimated loss, Lloyd’s shall owe statutory interest on any payments made, measured from the date of loss to the date of each payment.
Lloyd’s lack of explanation for its refusal to amend its estimate after being presented with objective evidence that the Insurer’s estimation and valuation is patently incorrect has been explained to be violative of the terms and conditions of the policy and Florida law as cited herein.
To cure this CRN, Lloyd’s must do the following within the next sixty (60) days:
1) Provide an explanation citing the policy language upon which Lloyd’s relies to deny, exclude or otherwise underpay each portion of the claim; and
2) Provide an explanation in writing for Lloyd’s refusal to re-inspect the property despite the Insured’s submission of relevant information and explanation of covered damages that were not properly evaluated by Lloyd’s; and
3) Provide an explanation citing policy language upon which Lloyd’s relies in refusing to amend its estimate after its receipt of information explaining that its estimate is clearly incorrect; and
4) Pay statutory interest measured by F.S. §55.02 for each payment made after day 90 of the claim, with interest on each payment calculated from the date of the claim’s opening, per the statute and terms and conditions of the policy of insurance; and
5) Notify the Insured of any information that Lloyd’s requires that is not already in Lloyd’s possession to adjust or pay any portion of the claim that is underpaid or has not yet been paid; and
6) Provide unredacted, unaltered copies of any and all estimates, photographs, reports, documents or other non-privileged information procured by Lloyd’s through its employees, contractors or agents and in relation to this claim, to include a written statement regarding any adjustments or amendments performed to those estimates which resulted in a lower payment to the Insured, with an explanation of the amendment and the policy language upon which coverage was denied, excluded or amended to be in accordance with the terms and conditions of the policy.
|
|
|
*
|
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
|