Civil Remedy Notice of Insurer Violations
Login

Filing Number:     785477
Filing Accepted:  10/2/2024
         Print Filing
Complainant
Last/Business Name *  
YOU RESTORATIONS LLC   First Name  
Street Address * 1420 CELEBRATIONS BLVD SUITE 200
City, State Zip * KISSIMMEE, FL 34747
Email Address * INFO@YOURESTORATIONS.COM
Complainant Type: * Third Party
Insured
Last/Business Name*   SANTOS, LEODIS   First Name  
Policy # * PFL434622-00 Claim #* CFL22581223
Attorney
Attorney is Applicable
Last Name* GONZALEZ ESQ. First Name * ROBERT F. Initial
Street Address* 8950 SW 74TH CT., STE 2267
City, State Zip* MIAMI , FLORIDA 33152
Email Address * INTAKE@FLINSLAW.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):* UNKNOWN
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Denial
Claim Delay
Unsatisfactory Settlement Offer
Unfair Trade Practice
* 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)(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.

Section 1 - Perlis Insured Against Section 1 - Property Coverages Loss Settlement Provision
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

Page 1 of 1On May 9, 2022, Santos, Leodis suffered a loss due to covered perils contemplated under thePolicy; and timely reported the damage to Defendant. Santos, Leodis contracted YOURestorations LLC in order to perform services to the Insureddirectly relating to the loss. Inexchange for YOU Restorations LLC's services Santos, Leodis executed an assignment ofbenefits. On or about May 24, 2022, YOU Restorations LLC provided People's Trust InsuranceCompany with notice of the Assignment of Benefits. Within the statutory period, YOURestorations LLC provide People's Trust Insurance Company with a copy of its invoice,assignment agreement, demand for payment of insurance benefits and supporting documentation.During the investigation of the claim, People's Trust Insurance Company sent an unqualifiedperson to make determinations of causation of damage in violations of 626.9541(1)(i)(3)(d).After completing its deficient investigation People's Trust Insurance Company should haveprovided coverage for the loss. People's Trust Insurance Company has unduly delayed fullpayment and coverage over the claim in violation of the insurance contract and has done so in amanner which violates multiple Florida Statutes. Furthermore, People's Trust InsuranceCompany failed to promptly provide a reasonable explanation in writing to the insured of thebasis in the insurance policy, in relation to the facts or applicable law, for denial of a claim or forthe offer of a compromise settlement.The failure to issue payment when there was no applicable exclusion for the type of service orclaim in relation to the covered claim is a violation of 624.155(1)(b)(1) and 624.155(1)(b)(3).People's Trust Insurance Company has been provided sufficient evidence to support coverage forthe subject claim and services. Despite making numerous payments in the past for these types ofservices which were performed in relation to valid insurance claims, People's Trust InsuranceCompany has subsequently made it a business practice to deny these services irrespective of thefacts for each claim in direct violation of 626.9541(1)(i)(3)(a) and 626.9541(1)(i)(3)(b).People's Trust Insurance Company has repeatedly and continuously acted in bad faith in thismatter and others like it. Despite the fact that these services are directly related to covered lossesand not excluded under the policy of insurance, People's Trust Insurance Company refuses to payinsurance benefits for same. In order to cure People's Trust Insurance Company’s continuousacts of bad faith, People's Trust Insurance Company must issue payment for the invoiced amountof $ 2,220.00 and which has a current balance of $ 2,220.00; as well as, statutory interest. Inaddition, People's Trust Insurance Company must cease its unfair trade practice of citing toirrelevant policy provisions in order to misrepresent the coverages afforded under its policies ofinsurance.PDC22-111174
Comments
User Id Date Added Comment
bfrankel@gmail.com 11-26-2024 The Legal Department, on behalf and for People’s Trust Insurance Company (“PTI”), hereby responds to this Civil Remedy Notice of Insurer Violation (“CRN”) filed on behalf of the above-referenced assignee, You Restorations LLC a/a/o Leodis Santos. PTI hereby denies all of the allegations contained in the CRN – particularly those falling within the rubric of “bad faith.” 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 influence pending coverage decisions or intimidate insurers during loss investigations, nor to demand legal fees, especially when none are due or owing. Florida Statute §624.155(3)(b) provides 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. In other words, a CRN is invalid as a matter of law if it makes allegations of supposed violations without detailed factual support, cites to the entire policy or whole sections of it as the “specific policy language” allegedly giving rise to supposed violations, relies on misrepresentations of fact or law, or demands legal fees or other claimed extra-contractual damages or remedies as the proposed cure. This CRN violates all of these requirements and prohibitions. In contravention of section 624.155(3)(b)2-4, the CRN did not state with specificity the facts and circumstances giving rise to a violation of section 624.155(1)(b)1, the CRN did not state with specificity the name of any individual involved in the violation of section 624.155(1)(b)1, and the CRN did not state with specificity the specific policy language that is relevant to the alleged violation of section 624.155(1)(b)1. In contravention of section 624.155(3)(b)2-4, the CRN did not state with specificity the facts and circumstances giving rise to a violation of section 624.155(1)(b)3, the CRN did not state with specificity the name of any individual involved in the violation of section 624.155(1)(b)3, and the CRN did not state with specificity the specific policy language that is relevant to the alleged violation of section 624.155(1)(b)3. In contravention of section 624.155(3)(b)2-4, the CRN did not state with specificity the facts and circumstances giving rise to a violation of section 626.9541(1)(i)3.a, and the CRN did not state with specificity the name of any individual involved in the violation of section 624.155(1)(i)3.a, and the CRN did not state with specificity the specific policy language that is relevant to the alleged violation of section 624.155(1)(i)3.a. In contravention of section 624.155(3)(b)2-4, the CRN did not state with specificity the facts and circumstances giving rise to a violation of section 626.9541(1)(i)3.b, the CRN did not state with specificity the name of any individual involved in the violation of section 626.9541(1)(i)3.b, and the CRN did not state with specificity the specific policy language that is relevant to the alleged violation of section 626.9541(1)(i)3.b. In contravention of section 624.155(3)(b)2-3, the CRN did not state with specificity the facts and circumstances giving rise to a violation of section 626.9541(1)(i)3.d, and the CRN did not state with specificity the name of any individual involved in the violation of section 624.155(1)(i)3.d. In relation to all of PTI’s alleged statutory violations asserted in the CRN, in contravention of section 624.155(3)(b)2 the CRN fails to state with specificity the type or cause of loss that the insureds suffered and the actual service(s) allegedly provided by Complainant in exchange for the alleged assignment of insurance benefits. In relation to PTI’s alleged violations of sections 624.155(1)(b)1, 3 and 626.9541(1)(i)3.b asserted in the CRN, in contravention of section 624.144(3)(b)4 the CRN fails to state with specificity the particular policy language which allegedly provided coverage for the underlying loss and for the specific service(s) that were provided by Complainant. Further, in relation to the alleged violation of 626.9541(1)(i)3.b, in contravention of section 624.144(3)(b)4 the CRN fails to state with specificity the pertinent facts or insurance policy provisions relating to the coverages at issue that PTI allegedly misrepresented. Despite lacking the required specifics, this CRN still includes false and misleading information about the circumstances of the subject claim, and policy rights and obligations of the parties. For example, among other misrepresentations this CRN falsely claims that PTI “sent an unqualified person to make determinations of causation of damage,” “failed to promptly provide a reasonable explanation in writing of the insured of thebasis [sic] in the insurance policy, in relation to the facts or applicable law, for denial of a claim or for the [sic] offer of a compromise settlement,” “made it its business practice to deny these services irrespective of thefacts [sic] of each claim,” and “has repeatedly and continuously acted in bad faith in thismatter [sic] and others like it.” Needless to say, this CRN contains many factually and legally inaccurate statements, and certainly does not reflect reality as documentary evidence would show. Beyond statutory requirements, any lawyer who submits a CRN must do so in accordance with the rules regulating members of the Florida Bar as established by the Florida Supreme Court. Specifically, that lawyer must act with due diligence and refrain from misrepresenting facts or law. Therefore, when a lawyer asserts facts or statements of law they know or should know are false, or submits a CRN without reasonably investigating whether any basis in law and in fact exists to support the violations alleged in it, they do so in violation of Florida Statute §624.155 and the rules and ethics governing legal practice in Florida. It logically follows that boilerplate CRNs should not be submitted as a business practice aimed at leveraging quicker or more lucrative settlements. Evidence of such practice may appear in the repetitive nature of certain allegations across a law firm’s entire book of submissions to the DFS (e.g., when a law firm routinely submits substantially similar CRNs hundreds of times against dozens of insurers on behalf of different policyholders who reported factually unique claims) and by reviewing the timeline of events that are not factually disputed and compare those undisputed facts to allegations in the CRN. If a good faith basis exists to justify submitting a CRN to the DFS, specificity of alleged violations and detailed factual support are needed, as required by law, to allow for a full and detailed response. Notwithstanding, to comply with statutory obligations, PTI provides the follow summary of facts in support of its categorical denial of every alleged statutory violation raised in this CRN. In short, PTI has implemented compliant standards for adjusting claims, which includes performing reasonable investigations, accurately representing 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 in writing detailed policy grounds supporting coverage decisions, paying undisputed damages if and when applicable, accepting or rejecting in whole or in part sworn proofs of loss within thirty days of receipt, and attempting in good faith to settle claims where appropriate without using coverage under one policy portion to influence settlements under another portion and without making any material misrepresentations. PTI has not only implemented those standards as a general practice, but fully adhered to them while adjusting the subject claim. On May 9, 2022, PTI first received notice of the subject loss that purportedly occurred on November 17, 2021 (the CRN falsely asserts that the alleged loss occurred on May 9, 2022 and that said alleged loss was “timely reported”). PTI quickly began investigating the loss under claim number CFL22581223 (the “Claim”) and mailed the Insured information concerning what to expect during the adjusting process. PTI sent a field adjuster to inspect and document the nature and scope of reported damages that were preserved and made available for inspection on May 18, 2022. The field adjuster observed and documented damages sink base cabinet in the kitchen and to the drywall behind the cabinet, but this damage was observed in the underwriting photos and was therefore preexisting. The field adjuster also found that the exterior stucco wall was damaged or improperly repaired as to allow the metal mesh and wall cavity exposed to the elements, but this condition was also documented in the underwriting photo report so was likewise preexisting. Of note, the insured Mr. Santos informed the field adjuster that he had noticed these damages after he had purchased the property, but that said damages had not been disclosed to during the purchase process. On May 23, 2022, PTI emailed the insured its coverage determination letter, which explained that there was no coverage for the claim based on the nature of the damages found, the facts provided to PTI, and the pertinent provisions and coverages of the insurance policy. The letter explained, “[s]pecifically, but without limitation, the damage to your property is due to faulty, inadequate or defective workmanship, maintenance and wear and tear,” and further that “the damages to the interior of the property are pre-existing to your policy inception and are specifically excluded covered under your policy.” The letter requested any additional information or documentation for PTI to review in relation to the claim that might require PTI to reassess the coverage determination. Further, after receiving a status request email from You Restorations on or about May 31, 2022, on June 6, 2022 PTI emailed You Restorations a letter explaining that coverage was not found for the subject claim and that PTI would not be tendering payment for the invoice sent by You Restorations as a consequence. Further, PTI notes that upon legal review, the subject assignment of insurance benefits is facially invalid and unenforceable pursuant to section 627.7152(2)(d), Florida Statutes (2022); among other deficiencies, the assignment fails to comply with subsections 627.7152(2)(a)3 627.7152(2)(a)4, and 627.7152(b)4. Accordingly, You Restorations LLC cannot enforce its invalid assignment agreement to claim payment against PTI or the insured. To be sure, binding case law provides that section 627.7152 precludes assignments in equity or quantum meruit in this context. Thus, neither Insureds nor PTI can be held liable for any payments to You Restorations LLC. 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. If you wish to discuss further, please do not hesitate to contact the undersigned. Thank you for your attention to this matter. Sincerely, Michael Greenberg Michael Greenberg, Esq. Litigation Counsel People's Trust Insurance Company
Acknowledgement
* The submitter hereby states that this notice is given in order to perfect the rights of the person(s) damaged to pursue civil remedies authorized by Section 624.155, Florida Statutes.

Before submitting a Notice using this system, please verify that all text has been entered correctly and completely. Once the Notice has been submitted, the text cannot be changed or deleted.




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