Civil Remedy Notice of Insurer Violations
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Filing Number:     786107
Filing Accepted:  10/8/2024
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Complainant
Last/Business Name *  
POULOS   First Name   CATHY
Street Address * 5200 MALABAR BOULEVARD
City, State Zip * MELBOURNE BEACH, FL 32951
Email Address * SEAISLAND84@YAHOO.COM
Complainant Type: * Insured
Insured
Last/Business Name*   POULOS   First Name   CATHY
Policy # * EDH5374365-01 Claim #* EDI962033
Attorney
Attorney is Applicable
Last Name* KRAPF First Name * GRANT Initial W.
Street Address* 2790 SUNSET POINT ROAD
City, State Zip* CLEARWATER , FLORIDA 33579
Email Address * ASSIST@KRAPFLEGAL.COM
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   EDISON INSURANCE COMPANY
NAIC Company Code 12482
 
Name of individual responsible for violation (if any):* JENNIFER JONES, JEFFERY DUPONT, DANETTE DOTSON, THERESA ELLIOTT, AND ANY OTHER INDIVIDUAL FROM, OR AGENT OF, EDISON INSURANCE COMPANY, WHO WAS INVOLVED IN THE CLAIM.
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Unfair Trade Practice
Claim Denial
Claim Delay
Other : Not treating the Insured with good faith claims conduct ?
Other : Looking for ways to deny full recovery to the Insured
Other : Looking for ways to delay 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
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 : Shifting the burden of insuring the loss to the Insured
Other : Failing to implement proper standards for the adjustment and investigation of claims ?
Other : Misrepresenting the terms of the insurance policy
* 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.
* 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.

Edison 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 the Insured; 3) looking for ways to deny benefit payments and otherwise “low ball” or “stone wall” claims; 4) not adjusting the claims promptly and fairly; 5) not attempting in good faith to settle claims; 6) conducting inadequate investigations; 7) failing to employ policies and procedures to conduct adequate investigations; 8) shifting the burden of investigating the loss onto the Insured; and 9) misrepresenting the terms of the insurance policy. On or about November 29, 2023, while the subject policy was in full force and effect, the Insured’s suffered a loss caused by a water leak. The areas impacted include but are not limited to the foyer, hallways, dining room, family room, media room, kitchen, pantry, office, fishing room, off set and balcony. The Insured timely submitted a claim on December 1, 2023, to the Insurer for water damage and the ensuing damage therefrom. Given the emergency nature of the damage, the Insured retained water mitigation service who prepared an estimate identifying $2,998.82 to perform initial remediation services. The foregoing estimate and photographs were sent to the Insurer who then assigned claim number EDI962033 to the loss and sent a field adjuster to inspect the property on December 5, 2023. Subsequently, in a coverage determination letter dated January 4, 2024, the Insurer notified the Insured that it was extending coverage for the loss. However, the Insurer wrongfully determined that it would only require $25,430.04 to restore the insured property to its pre-loss condition. The Insurer subtracted depreciation, resulting in $23,136.83 payment to the Insured for damage to the dwelling, and $2,998.82 issued to the Insured’s water mitigation services. The Insurer also allocated and issued $12.068.00 for additional coverage. Given the vastly underestimated cost of repairs and the scope and nature of the damage, the Insured retained a public adjuster. After assessing the damage and the true scope of repairs, the public adjuster prepared an estimate identifying $167,336.84 in covered damage to the dwelling. The foregoing estimate, photographs, and a letter of representation from the public adjuster were sent to the Insurer who then retained an engineer to reinspect the property. The Insurer, after having the property inspected by an engineer, issued a second coverage determination letter in which it notified the Insured that it was denying additional coverage for the loss. The Insurer misrepresented the loss and issued a wrongful partial denial. The Insurer based this denial on the rationale that the damage sustained was a result of “…wear and tear, marring, deterioration.” Although the Insurer and Insured are in dispute about how the dwelling 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. 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. 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. Despite the obvious water damage, the Insurer did not feel it was necessary to inspect the Insured’s home for mold. A mold inspection test can be purchased online from Amazon for around $46 before tax. This mold test only takes five minutes to assess whether or not the property has mold-particulates. However, the Insurer would much rather risk the health of the Insured in order to save some time and a money. In short, when it comes to mold, the Insurer accepts premiums but does not accept the responsibility of inspecting for mold. This is further evidence that the Insurer is placing its financial interest over the health and safety of the Insured. Additionally, Insurer shifted the burden and cost of investigating and insuring the loss onto the Insured. During their investigation, the insurer’s adjuster did not use a moisture meter, despite the presence of interior water damage. A moisture meter can be purchased online from Amazon for around $40 before tax. The Insurer could purchase a moisture meter and assess thousands of properties with one meter. Instead, the Insurer would rather place its financial interests over those of the Insured by failing to provide the adjuster with the necessary tools to correctly inspect the loss. As a result of the inadequate investigation and surrounding circumstances it is apparent that the Insurer significantly underestimated the scope of the loss to the Insured’s property. The Insurer and its adjuster have colluded to misrepresent the true scope of damages to the insured property and the true replacement costs of the damages. 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 determined that it would only require $25,430.04 to restore the insured property to its pre-loss condition. 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 delay 2. Not treating the Insured with good faith claims conduct 3. Looking for way to reduce recovery to the Insured 4. Looking for ways to deny recovery to the Insured 5. Not adjusting claims and evaluating loss properly, promptly and fairly to provide full and prompt indemnity to the Insured 6. 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 7. Placing the financial interest of the Insurer over that of the health and safety of the Insured 8. Shifting the burden of investigating onto the Insured 9. Conducting inadequate investigations 10. 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. 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: Edison Insurance Company P. O. Box 21957 Lehigh Valley, PA 18002 csclaims@edisoninsurance.com
Comments
User Id Date Added Comment
Blair@becklawpa.com 12-05-2024 Department of Financial Services Civil Remedy Section 200 East Gaines Street Tallahassee, FL 32399-0322 Re: Civil Remedy Notice of Insurer Violation Complainant : Cathy Poulos Insured(s) : Thanos P Poulos and Cathy G Poulos Policy Number : EDH5374365-01 Claim No. : EDI962033 DFS File Number : 786107 Acceptable Date : October 8, 2024 Insurer : Edison Insurance Company To Whom It May Concern: Please be advised that we represent Edison Insurance Company (“Edison”) in the above-referenced matter. Kindly consider this to be Edison’s report to the Department on the disposition of the alleged violations. Edison maintains that it has not been in any violation of the law, as alleged by the referenced Civil Remedy Notice (“CRN”) filed by Cathy Poulos (“the Insured”). Further, Edison maintains that the CRN is defective on its face and it fails to comply with the requirements outlined under Florida Statute 624.155. Edison hereby objects to the Departments acceptance of the above referenced CRN based on the deficiencies. By way of background, this matter involves alleged Water-Plumbing Leak damage that occurred on or about November 29, 2023. The alleged damage was not reported to Edison by the Insured until November 30, 2023. After the report of the alleged damage, Edison immediately inspected the property on or about December 5, 2023. As a result of that inspection, Edison determined that the amount of covered damages totaled $23,136.83 under Coverage A – Dwelling and $12,068.00 under coverage EDI HO ML 06 23, and further determined there was no coverage for the osmosis canister and would not be covered under this policy due to age related wear and tear. On or about January 5, 2024, Edison informed the Insured of the same. In addition, on or about May 9, 2024, Edison informed the insured that it conducted an additional investigation which revealed no visible water damage such as swelling, staining or distorted flooring as well as no staining observed at the cork backing at the areas of core samples. There was also no visible water damage observed to the front of the kitchen cabinet that indicated a leak escaped the cabinet. Based on the additional investigation(s) there was no damage to the wood flooring or cork subflooring and therefore there was no coverage for the wood flooring. The policy does not afford coverage for losses that are caused by wear and tear, marring, deterioration. On October 8, 2024, the Insured, through their legal counsel, filed a CRN against Edison, which is a pre-requisite to a bad faith lawsuit under Florida Statute 624.155. This CRN alleges that Edison engaged in “Unfair Trade Practice, Claim Delay, Not treating the Insured with good faith claims conduct, Looking for ways to deny full recovery to the Insured, Looking for ways to delay full recovery to the Insured, Failing to properly investigate the Insured’s loss, Failing to provide the Insured with the full benefits awarded under the contract of insurance in a, Not training, supervising, or managing adjusters properly so that prompt and full payments are made, Not adjusting claims and evaluating loss properly, Shifting the burden of insuring the loss to the Insured, Failing to implement proper standards for the adjustment and investigation of claims, and Misrepresenting the terms of the insurance policy.” Additionally, the CRN alleges that Edison has violated Florida Administrative Codes and Statutes, including 624.155, F.S.: 624.155(1)(b)(1); 624.155(1)(b)(3); 626.9541(1)(i)(2); and 626.9541(1)(i)(3)(a). The CRN requires the Complainant "pursuant to section 624.155, F.S. please indicate all statutory provisions alleged to have been violated." The CRN filed in this matter includes statutory provisions that could be claimed, regardless of whether they are relevant or applicable to the alleged facts contained in the CRN. Because the CRN fails to identify any specific statutes, without a shred of factual specificity to support them, Edison is unable to properly respond and it does not comply with F.S. § 624.155. The CRN further fails to set forth any specific policy language alleged to have been violated in accordance with Florida Statute §624.155(3)(b)(4). The copy of the CRN simply outlines the “Reference to specific policy language: The violations alleged are statutorily based and do not rely on any specific policy language” of the insurance policy. This failure is another reason why it does not comply with F.S. § 624.155. As already mentioned, Edison maintains this CRN filed by the Insured is defective on its face. Although Florida Statute 624.155 requires the Insured to include requisite factual specificity, this CRN merely contains boilerplate broad language, used routinely in a litany of other filings. In fact, the Insured’s counsel who filed this CRN has filed over 2,000 CRNs in approximately the past 3 years against over 30 different carriers. These CRNs largely include the same language, many uses the same sentences throughout, and include largely the same allegations. With regards to the CRN, it contains the same generic improper and legally insufficient allegations that are contained within every CRN filed by the Insured’s legal counsel. The purpose of a CRN is to place the carrier on notice of specific violations so that they can be corrected during the statutory “cure” period. This CRN fails to meet this requirement and as such, should not be able to proceed on such a defective and improper CRN that contains nothing but accusations and conclusions without any specificity. Further, the CRN goes on to allege that the carrier engaged in “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 the Insured; 3) looking for ways to deny benefit payments and otherwise “low ball” or “stone wall” claims; 4) not adjusting the claims promptly and fairly; 5) not attempting in good faith to settle claims; 6) conducting inadequate investigations; 7) failing to employ policies and procedures to conduct adequate investigations; 8) shifting the burden of investigating the loss onto the Insured; and 9) misrepresenting the terms of the insurance policy.” These allegations as stated are improper, factually incorrect, do not comply with the specificity requirements set forth in Florida Statute 624.155, and is unfairly vague to put the carrier on notice of any alleged violations. The CRN goes on to allege that the carrier “misrepresented the loss and issued a wrongful partial denial. The Insurer based this denial on the rationale that the damage sustained was a result of “…wear and tear, marring, deterioration” and “shifted the burden and cost of investigating and insuring the loss onto the Insured. During their investigation, the insurer’s adjuster did not use a moisture meter, despite the presence of interior water damage.” As stated, the facts of this matter clearly show that Edison acted fairly towards its Insured at all times with regards to this claim. Edison was notified of the claim on November 30, 2023. An adjuster was assigned to the claim immediately and promptly contacted the Insured to conduct an inspection of the residence on December 5, 2023. Based on the inspection, Edison determined that that the amount of covered damages totaled $23,136.83 under Coverage A – Dwelling and $12,068.00 under coverage EDI HO ML 06 23, and further determined there was no coverage for the osmosis canister and would not be covered under this policy due to age related wear and tear. On or about January 5, 2024, Edison informed the Insured of the same. Edison further informed the insured that it received documentation completed by Consolidated Environmental Engineering dated March 22, 2024 which the insured referred to as a flooring water damage assessment. As a result, Edison conducted an additional investigation which revealed no visible water damage such as swelling, staining or distorted flooring as well as no staining observed at the cork backing at the areas of core samples. There was also no visible water damage observed to the front of the kitchen cabinet that indicated a leak escaped the cabinet. Based on the additional investigation(s) there was no damage to the wood flooring or cork subflooring and therefore there was no coverage for the wood flooring. The policy does not afford coverage for losses that are caused by wear and tear, marring, deterioration. Therefore, the Insured’s claim that Edison violated Florida Statutes in this matter is misplaced as Edison acted fairly towards its Insured and in accordance the terms and conditions of the policy. For these foregoing reasons, Edison denies all allegations contained in the CRN filed by the Insured, and maintains that the CRN is defective on its face and should be dismissed. Further, the CRN indicates that only Cathy Poulos is the Insured. While Cathy Poulos is one of the Named Insureds under the policy, there is also a second Named Insured, specifically, Thanos P. Poulos. The CRN filed fails to identify, address or preserve Thanos P. Poulos interest as a Named Insured under the policy. On its face, the CRN is nothing more than a regurgitated recitation of alleged statutory violations, without providing any specificity as to the facts of the alleged claim, and thus, is statutorily deficient. The CRN alleges that in order to “cure” the Insured, Edison “must: (1). Admit full coverage for the Insured’s loss. (2). Tender full benefits owed to the Insured under the insurance contract.” Edison stands by its decision. Based on the information outlined above, Edison requests that the DFS re-consider its acceptance of the above-referenced CRN and further requests that the DFS provide Edison a list of the guidelines and requirements utilized by the DFS in determining to accept this defective CRN. As outlined above, Edison maintains that it has not been in violation of any law and that the CRN, as filed, is defective on its face as it fails to meet the specificity requirements of Florida Statute 624.155. Should the Department require additional information, please do not hesitate to contact us. Sincerely, JOSHUA S. BECK, ESQ.
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