Civil Remedy Notice of Insurer Violations
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Filing Number:     785918
Filing Accepted:  10/6/2024
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Complainant
Last/Business Name *  
SANCHEZ   First Name   JONAH
Street Address * 2224 ARTERRA CT
City, State Zip * ROYAL PALM BEACH, FL 33411
Email Address * GEARXULTRA@GMAIL.COM
Complainant Type: * Insured
Insured
Last/Business Name*   SANCHEZ   First Name   JONAH
Policy # * SOIH4607580 Claim #* 61984
Attorney
Attorney is Applicable
Last Name* ALTMAN First Name * ALEXIS Initial
Street Address* 925 SOUTH FEDERAL HIGHWAY, 7TH FLOOR
City, State Zip* BOCA RATON , FL 33432
Email Address * AALTMAN@KPATTORNEY.COM
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   SOUTHERN OAK INSURANCE COMPANY
NAIC Company Code 12247
 
Name of individual responsible for violation (if any):* MIMI HIDALGO
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Denial
Unfair Trade Practice
Unsatisfactory Settlement Offer
* 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)(c) Failing to acknowledge and act promptly upon communications with respect to claims.
626.9541(1)(i)(3)(d) Denying claims without conducting reasonable investigations based upon available information.
626.9541(1)(i)(3)(e) Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed.
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

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.

This notice is given in order to perfect the right to pursue the civil remedy authorized by section 624.155, Florida Statutes. Johan S Sanchez (“insured”) purchased an all-risk policy of insurance with Southern Oak (“carrier”) to cover his home. The Insured made a claim after suffering damages from a windstorm. The loss was a direct result of a covered peril under the all-risk policy. Although it is clear that the damages are covered, the carrier has not attempted in good faith to settle the insured’s claim 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 their interests. Furthermore, the carrier is required to properly investigate and adjust claims and cannot place that burden upon the insured. This was made clear by the appellate court and the Florida Supreme Court in Allstate Indemnity Co. v. Ruiz, 899 So. 2d 1121 (Fla. 2005)(“The Legislature has clearly chosen to impose on the insurance companies a duty to use good faith and fair dealing in processing and litigating the claims of their insureds…”). The insured put the carrier on notice of the damages to his home after a storm caused leaking. Southern Oak sent an adjuster out to the property and sent a letter thereafter stating, “We have completed the investigation of your claim. We regret to inform you we will not be issuing payment for your claim for the reason(s) stated below. Our inspection found no damage to your roof and exterior caused by a peril insured against your policy.” The letter did not provide any report pursuant to Florida law showing the investigation that took place. It is clear that the carrier is determined to attribute the damages to everything but wind for financial incentive. Pursuant to Florida Statute §624.155(1)(b)(1), Southern Oak has failed to settle the claim in good faith when it could and should have done so. The damage to the Insured’ property was clearly caused by a covered peril under the Policy, but Southern Oak has intentionally and wrongfully denied the roof and interior damage, and callously delayed the claim process. Southern Oak has not shown a good faith intention to pay what was owed but rather has underpaid the claim for financial gain and profit. Pursuant to Florida Statute §626.9541(1)(i)(3)(a), Southern Oak has a duty to adopt and implement standards for the proper investigation of claims. The field adjuster sent out on behalf of Southern Oak displayed a lack of knowledge, improper training, and/or intent to misrepresent damages. Pursuant to Florida Statute §626.9541(1)(i)(3)(c), Southern Oak failed to acknowledge and act promptly upon communications with respect to claims as they ignored the request by Public Adjuster to provide a certified copy of Insured’s policy of insurance. Florida law mandates that insurers and adjusters do not mislead the Insured. Florida Insurance companies that fail to follow these Florida laws and regulations, designed to protect consumers, do not only breach their duties under the policy of insurance but do so in bad faith. In violation of Florida Statute §626.9541(1)(i)(3)(b), Southern Oak intentionally misrepresented the available coverage under the policy. Furthermore, the Insured believes Southern Oak repeatedly and as a standard business practice engages in this behavior to deprive its Insured of their rightful insurance proceeds when they experience a covered loss. Insured contends Southern Oak has implemented a claims program and business practices that are tailored to increase its profits at the expense of benefits that are owed to its customers and that other Insured have been refused insurance proceeds due and owing under the policy in the same or similar circumstances, and some have been provided inadequate insurance monies under the same or similar facts or circumstances. This is wrongful conduct and directly violates the purpose of insurance coverage. Southern Oak ’s wrongful conduct and omissions include, but are not limited to: claim delay, not conducting a full and prompt investigation, not treating the policyholder with good faith claims conduct, looking for ways to reduce recovery to Insured; looking for ways to delay full recovery to Insured; holding back and failing to pay portions of claim clearly owed; not adjusting the claim and evaluating the loss properly, promptly and fairly to provide full and prompt indemnity to the Insured; not training, supervising or managing adjusters properly so that prompt and full payments are made, but rather placing the company’s interests before the policyholder’s interests; establishing severity control initiatives and otherwise establishing a culture of not fully and promptly paying claims following losses; and failing to pay the full amount of the Insured’s damage despite knowing it must do so. Consequently, these actions have caused undo frustration and financial harm to the Insured. As a direct and proximate result of the poor handling of this Claim by Southern Oak the Insured sustained extracontractual damages. Due to the bad faith actions of Southern Oak , Insured was forced to engage the services of the Public Adjuster to attempt to recover the settlement to which they are rightfully entitled. All the aforementioned are part of what appears to be an ongoing pattern and practice of behavior of the carrier that it demonstrates a wanton and reckless regard for the insureds’ rights and a pattern and practice of bad faith claims practices to its insureds across the state of Florida. This notice is provided in order to perfect a right to pursue the civil remedy authorized by Florida Statute §624.155. Therefore, to cure the defects outlined in this Civil Remedy Notice, the carrier must: 1) Pay all amounts due and owing to the insured in the amount of $ $124,233.26 2) for indemnity benefits, minus any applicable deductible or prior payments; and 3) Pay the insured’s attorneys’ fees and costs as they have been forced to retain counsel to litigate the loss; and 4) Pay the statutory interest on the amount of unpaid damages from the date of loss to the date payment is finally made. Should you have any questions upon receipt please contact the undersigned at 561-892-9988. Sincerely, Alexis Altman
Comments
User Id Date Added Comment
rcovitz@falkwaas.com 12-04-2024 This is Southern Oak Insurance Company’s (SOIC) response to Civil Remedy Notice, Filing Number 785918 (the “CRN”) filed by, Johan Sanchez, Complainant, (“Complainant”, “Insured” or “policyholder”). Johan Sanchez contends that SOIC is in violation of: 624.155(1)(b)(1) Not attempting in good faith to settle 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; 624.9541(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; 624.9541(1)(i)(3)(d) Denying claims without conducting reasonable investigations based upon available information; and 626.9541(1)(i)(3)(e) Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed. At all times SOIC has acted in good faith, fairly and honestly toward its insured, with due regard for the insured’s interests. SOIC contends Complainants have failed to vest extracontractual rights under this CRN. First and foremost the CRN is invalid on its face as Complainant fails to even identify the date of the loss for which the benefits sought under the policy by SOIC’s insured. In reality, the Complainant through his Public Adjuster and representatives actually changed the date of the claimed loss midstream during the claim investigation process. The claim was initially reported by Mr. Sanchez’ spouse directly to SOIC on June 14, 2023 that they had a roof leak in the attic and master bedroom that first occurred the prior day, June 13, 2024. Thereafter, Mr. Sanchez retained Five Star Public Adjusters who also in their contract identified the date of loss to be June 13, 2024; then, after the inspection by Field Adjuster, Chad Hill, the public adjuster sent a change in date of loss request to SOIC now claiming the roof and interior damage occurred on September 28, 2022 or 21 months earlier than the date of loss first called in by the insureds themselves the next day after they noticed water leaking on June 13, 2024. As such, the failure of Complainant to even mention any date of loss or the circumstances of the above change in claim dates and facts associated with same renders the CRN a nullity and unenforceable. Although they list civil remedy statues as shown above, the insured fails to cite to any alleged violative conduct as to who did what or when that constituted a violation of any of the above statutes. Rather, the CRN cites to general propositions associated with claim review, inspection and investigation requirements and unilaterally accuses SOIC that it had no adequate basis to conclude the roof leak and claimed interior damage were not caused by a covered peril under the policy that created an opening in the roof that allowed rain water to enter the property and cause damage to the interior room of the home. At its core, the CRN merely generally states the policyholders disagree with SOIC claim decision. However, the CRN fails to have any facts as to who did what, when, why that was in violation of the above statutes and cites to no policy terms or provisions that set forth how SOIC allegedly acted in bad faith. SOIC has standards for the proper investigation of its claims and acted promptly on all communications related to its inspections, adjustment and claims decisions as explained above in this response. Its claim practices in this case were timely, thorough, informative and professional. SOIC first received notice of the Complainant’s roof leak on June 14, 2024 that occurred the prior day on June 13, 2024 with water seen in the attic and master bedroom. SOIC immediately opened a file, assigned their third party administrator to set up a claim and retain a qualified Field Adjuster to set up and inspection, provide cause and origin opinions if able to and document the damages being claimed. Contrary to the CRN’s allegations, SOIC performed a thorough investigation that included an inspection by an licensed and experienced Field Adjuster, Chad T. Hill who just five days after the claim was reported conducted a field inspection of the roof and interior of the home including the attic and all other areas of the property. Mr. Hill took 75 photographs documenting the roof, attic and all interior rooms of the house was able to determine condition of the roof where the leaking was reportedly seen was caused by commonly seen wear and tear and evidence of prior roof repairs which the insureds confirmed having had prior leaks without any indication of a weather related event associated with them. In addition, SOIC also offered the insureds who accepted their courtesy of recommending and engaging a reputable mitigation service company who placed a tarp on their roof and conducted related mitigation activities. On July 14, 2024, approximately one month after the claim was reported, SOIC had completed its investigation and advised their policyholders of their coverage decision and the reasons and policy language cited below for the lack of coverage. The policy provisions cited in this letter was as follows, HO 00 03 04 91 HOMEOWNER 3 SPECIAL FORM policy, as amended by the SPE HO SP 04 23 SPECIAL PROVISIONS – FLORIDA endorsement, which states in part under: SECTION I – PERILS INSURED AGAINST A. Coverage A – Dwelling and Coverage B – Other Structures We insure for sudden and accidental loss to property described in Coverages A and B only if that loss is a physical loss to covered property. We do not insure, however, for loss: 2. Caused by: e. Any of the following: (1) Wear and tear, marring, deterioration; (6) Settling, shrinking, bulging or expansion, including resultant cracking, of bulkheads, pavements, patios, footings, foundations, walls, floors, roofs or ceilings; g. Rain, snow, sleet, sand or dust to the interior of a building unless covered peril first damages the building causing an opening in a roof or wall and the rain, snow, sleet, sand or dust enters through this opening. Under items 1. and 2., any ensuing loss to property described in Coverages A and B not excluded or excepted in this policy is covered. SOIC claim decision was based on a full investigation of the facts of the claim, the weather conditions reported and that existed in Royal Palm Beach Florida on June 13, 2024 and also after the change in date of loss on September 28, 2022. Furthermore, upon receiving Complainant’s Notice of Intent to initiate litigation, SOIC went even further to assure their claim investigation results were based on the sound findings of the very well qualified Field Adjuster and opted to reinspect the roof and interior of the property including the attic on October 25, 2024 by Professional Engineer, S. Selim Cerci, P.E. who found no evidence of openings in the Sanchez roof created by severe weather on or around June 13, 2024, or on September 28, 2022. Rather, consistent with the Field Adjuster’s findings and cause and origin opinion as well as the insured’s own admission of prior unrelated to weather leaks that needed repairs, that the claimed water intrusion at their property was caused by age-related flashing leaks in the valley or roof-to-wall joint above the garage, a flashing leak at the vent penetration above the garage and a flashing leak or other leaks resulting from wear-and-tear above the master bathroom. Moreover there was no severe weather from Hurricane Ian or on June 13, 2024 in Royal Palm Beach, Florida that was sufficient to cause a peril created opening resulting in the claimed damages. Hurricane Ian made landfall on the west coast of Florida and did not have any significant effects based on wind speeds measured or reported in Palm Beach County based on the P.E.’s historical weather research data. Therefore the alleged civil remedy violations listed above and contained in the CRN are not meritorious or actionable. SOIC reserves all of its rights to assert all privileges including work product, claim file and attorney-client.
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