Civil Remedy Notice of Insurer Violations
Login

Filing Number:     786427
Filing Accepted:  10/11/2024
         Print Filing
Complainant
Last/Business Name *  
ADAME   First Name   GREGORY
Street Address * 7833 BEGLEY HOLLOW COURT
City, State Zip * JACKSONVILLE, FL 32216
Email Address * NATMEDIC@PROTON.ME
Complainant Type: * Insured
Insured
Last/Business Name*   ADAME   First Name   GREGORY
Policy # * 1501-2002-0171 Claim #* FL24-0112676
Attorney
Attorney is Applicable
Last Name* KRAPF First Name * GRANT Initial W
Street Address* 2790 SUNSET POINT RD
City, State Zip* CLEARWATER , FL 33759
Email Address * GRANT@KRAPFLEGAL.COM
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   UNIVERSAL PROPERTY & CASUALTY INSURANCE COMPANY
NAIC Company Code 10861
 
Name of individual responsible for violation (if any):* BAILEY DARNER, LORI ROCCA, AND ANY OTHER INDIVIDUAL FROM, OR AGENT OF, UNIVERSAL PROPERTY & CASUALTY INSURANCE COMPANY, WHO WAS INVOLVED IN THE CLAIM.
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Delay
Unfair Trade Practice
Other : Misrepresenting the terms of the insurance policy
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 t
Other : Not training, supervising, or managing adjusters properly so that prompt and full payments are made
Other : Not adjusting claims and evaluating loss properly
Other : Shifting the burden of insuring the loss to the Insured
Other : Failing to implement proper standards for the adjustment and investigation of claims
* 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.
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

627.70131(7)(a) Within 60 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. The insurer shall provide a reasonable explanation in writing to the policyholder of the basis in the insurance policy, in relation to the facts or applicable law, for the payment, denial, or partial denial of a claim. If the insurer's claim payment is less than specified in any insurer's detailed estimate of the amount of the loss, the insurer must provide a reasonable explanation in writing of the difference to the policyholder. Any payment of an initial or supplemental claim or portion of such claim made 60 days after the insurer receives notice of the claim, or made after the expiration of any additional timeframe provided to pay or deny a claim or a portion of a claim made pursuant to an order of the office finding factors beyond the control of the insurer, 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 must 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. Reference to specific policy language: The violations alleged are statutorily based and do not rely on any specific policy language. "It is an accepted principle of law that when parties contract upon a matter which is the subject of statutory regulation, the parties are presumed to have entered into their agreement with reference to such statute, which becomes a part of the contract, unless the contract discloses a contrary intention." Westside EKG Assocs. v. Found. Health, 932 So. 2d 214, 216 (Fla. 4th DCA 2005), aff'd, 944 So. 2d 188 (Fla. 2006).
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

Universal Property & Casualty 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; 9) failing to render a claims determination within ninety (90) days; and 10) failing to pay interest on a claim that is older than ninety (90) days. On or about June 1, 2024, 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 bedrooms, bedroom closets, laundry room, bathrooms, hallways, game closet, linen closet, hall closet, HVAC closet, entry, living room, play area, kitchen, pantry, and contents. The Insured timely submitted a claim on June 1, 2024, to the Insurer for water damage and the ensuing damage therefrom. Thereafter, the Insurer assigned claim number FL24-0112676 to the loss and sent a field adjuster to inspect the property on June 3, 2024. Given the scope and nature of the damage, the Insured retained services including but not limited to water remediation, air quality assessors, and a public adjuster who performed initial repairs for which the Insured paid over $10,000.00 out-of-pocket. After assessing the damage and the true scope of repairs, the public adjuster prepared an estimate identifying $129,020.41 in covered damage to the dwelling. The foregoing estimates, invoices, photographs, a sworn statement in proof of loss, and a letter of representation from the public adjuster were sent to the Insurer. It was not until September 6, 2024, ninety-seven (97) days after the Insured reported their loss, that the Insurer finally issued its coverage determination in which it notified the Insured that it was extending coverage for the loss. However, the Insurer wrongfully determined it would only require $17,219.78 to restore the property to its pre-loss condition, which resulted in a net payment of only $13,562.70. The Insurer's lowball estimate is that of a classic under scope and under value of the claim. 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. The Insurer has placed obstacles to the Insured's ability to have the claim adjusted promptly to begin restoring the home by waiting more than sixty (60) days after receiving notice of the loss to make a claims determination. Under Fla. Stat. 627.70131(7)(a), "[w]ithin 60 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." There were and are currently no factors outside of the Insurer's control. As the Insurer has failed to make a timely determination, it has violated this code. As such, in addition to the below requirements to cure this CRN, any payment made to the Insured must contain interest for the damage as a result of the loss from the date the Insurer received first notice of the loss. The Insurer also failed to allocate and pay for overhead and profit, pursuant to Florida Statute 627.7011(3)(a). Where the Insureds are reasonably likely to need a general contractor for the repairs, Florida Statute 626.7011(3) does not permit an Insurer to withhold overhead and profit pending the actual repair, unless absent a showing by the Insureds that it was likely to need a general contractor for the repairs. Trinidad v. Fla. Peninsula ins. Co., 121 So. 3d 433, 435 (Fla. 2013). The Insurer has implemented policies and procedures that are designed to wrongfully withhold costs associated with restoring the insured property to its pre-loss condition. This is an underhanded attempt by the Insurer to place its financial interest above those of the Insured. 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 undervalued the amount required 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. Failing to render a written claims determination to the Insured within 60 days pursuant to Florida Statute 627.70131 11. Failing to pay interest on a claim that is older than sixty (60) days 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 CLAIMSPATH PORTAL Universal Property & Casualty Insurance Company 1110 W. Commercial Blvd. Fort Lauderdale, FL 33309
Comments
User Id Date Added Comment
jr0405@universalproperty.com 11-27-2024 November 27, 2024 VIA ELECTRONIC FILING Florida Department of Financial Services Bureau of Consumer Assistance Civil Remedy Section 200 East Gaines Street Tallahassee, FL 32399-0322 Re: DFS File No.: 786427 Filing Date: 10/11/2024 Complainant(s): Gregory Adame Insured(s): Gregory Adame Policy No.: 1501-2002-0171 Claim No.: FL24-0112676 Dear Sir/Madam: Please allow this to serve as Universal Property & Casualty Insurance Company’s (“Universal”) formal response to the above-referenced Civil Remedy Notice (“Notice”) filed by attorney, Grant W Krapf, on behalf of Complainant, Gregory Adame (also referenced as “Insured.”) The Notice alleges violations of Sections 624.155, 626.9541, 627.7011, and 627.70131, Florida Statutes. Universal specifically denies each allegation contained in the Notice. Additionally, Universal denies that it violated these or any statutes, Florida law, or policy provisions regarding the claim adjustment of this matter. With that said, Universal asserts that the Notice fails to comply with the specific notice and information requirements as set forth in Civil Remedy Notice of Insurer Violation document provisions, Section 624.155, Florida Statutes and Florida law. The Notice is deficient as a matter of law as it fails to comply with Section 624.155, Florida Statutes. See 316, Inc. v. Maryland Cas. Ins. Co., 625 F. Supp. 2d 1187 (N.D. Fla. 2008); Rousso v. Liberty Surplus Ins. Corp., 2010 WL 7367059, (S. D. Fla. 2010); Heritage Corp. of South Fla. v. Nat’l Union Fire Ins. Co. of Pittsburgh, P.A., 580 F. Supp. 2d 1294 (S.D. Fla. 2008); Talat Enterprises, Inc. v. Aetna Cas. & Surety Co., 753 So. 2d 1278 (Fla. 2000). Pursuant to Section 624.155(3)(b), Florida Statutes, the Notice “shall state with specificity” the following information: 1. The statutory provision, including the specific language, which the authorized insurer allegedly violated; 2. the facts and circumstances giving rise to the violation; 3. the name of any individual involved in the violation; 4. reference to specific policy language that is relevant to the violation, if any...; 5. a statement that the Notice is given in order to perfect the right to pursue the civil remedy authorized by this section. Moreover, the Department of Financial Services (“DFS”), created form DFS-10-363, which lays out 15 requirements that the Complainant must respond to with specificity. The Florida Supreme Court holds that Section 624.155, Florida Statutes “must be strictly construed.” Talat Enterprises, Inc. v. Aetna Cas. and Sur. Co., 753 So. 2d 1278, 1283 (Fla. 2000). Strict construction is appropriate as “this statute is in derogation of the common law.” Id. When interpreting a statute in derogation of the common law, “[a] court will presume that such a statute was not intended to alter the common law other than as clearly and plainly specified in the statute.” Time Ins. Co., Inc. v. Burger, 712 So. 2d 389, 393 (Fla. 1998). Such an interpretation would mean that statutory bad faith cases cannot proceed unless the Complainant has specifically complied with all statutory requirements. Pin-Pon Corp. v. Landmark American Ins. Co., 500 F. Supp. 3d 1336 (S.D. Fla. 2020); Julien v. United Property & Casualty Ins. Co., 311 So.3d 875 (Fla. 4th DCA 2021). The Notice fails to meet the requirement of Section 624.155, Fla. Stat., on several grounds. First, the Notice fails to satisfy the requirement to identify the person or persons representing the insurer most responsible for or knowledgeable of the facts giving rise to the allegations. In order to comply with the requirements of Section 624.155, Florida Statutes, the Complainant must name the individual(s) involved with specificity as it relates to the purported violation(s) to allow Universal to properly investigate the allegations. The Notice lacks the requisite specificity as required by Section 624.155, Florida Statutes. Here, the Notice states, “BAILEY DARNER, LORI ROCCA.” The Notice fails to include any specificity as to how the named individuals have knowledge of the facts giving rise to any purported allegation(s) and/or what, if anything, they did or failed to do as it relates to the claim at issue. Furthermore, the Complainant attempts a “catch-all” of “ANY OTHER INDIVIDUAL FROM, OR AGENT OF, UNIVERSAL PROPERTY & CASUALTY INSURANCE COMPANY, WHO WAS INVOLVED IN THE CLAIM,” which significantly prejudices Universal because the Complainant is failing to notify Universal of the individual(s) that purportedly committed statutory violations or the specific statutory violations any individual purportedly committed. Further, the statement clearly defeats the requirement in the DFS Form to provide specificity in order to put the carrier on notice and provide an opportunity to investigate any allegation with a specific individual. Specific identification of a person or persons with the most knowledge within Universal is of particular importance because the Complainant alleges that Universal “colluded to misrepresent the true scope of damages to the insured property…” The Notice fails to include the requisite specificity as to whom made any misrepresentations, what was misrepresented, when any of these misrepresentations occurred nor to whom any alleged misrepresentation was made to. Accordingly, Complainant’s Notice is insufficient as a matter of law. Second, the Notice fails to satisfy Fla. Statute § 624.155(3)(b)(4), in that it fails to reference specific policy language relevant to the alleged violation Instead, the Notice improperly cites Section 627.70131, Florida Statutes. However, this section is not contained within the Policy and the inclusion here is improper as it fails to put Universal on notice as to any alleged violation of the Policy. Moreover, the Notice states, “[r]eference to specific policy language: The violations alleged are statutorily based and do not rely on any specific policy language.” Thus, the Complainant admits that Universal in fact did not violate any specific policy language but fails to provide any specificity as to how any statutes were violated. As such, the Notice is deficient as a matter of law. See generally Julien v. United Property & Casualty Ins. Co., 311 So.3d 875 (Fla. 4th DCA 2021). Third, with respect to the requirement to set forth with specificity the “facts and circumstances giving rise to the violation,” the Notice fails to allege any specific conduct on the part of Universal that would violate any policy provision or statute. The Complainant provides twelve (12) reasons for filing the Notice, however, the Complainant’s allegations regarding these “Reasons for Notice” have no factual support anywhere in the Notice. The Notice asserts general allegations consisting largely of boilerplate, conclusory and inaccurate statements rather than specific allegations of facts regarding any alleged misconduct or statutory violations. As an example, the Notice states in part: “Universal Property & Casualty 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; 9) failing to render a claims determination within ninety (90) days; and 10) failing to pay interest on a claim that is older than ninety (90) days.” The Notice wholly fails to identify any specific facts or circumstances which support any of the above-listed conclusory and/or boilerplate allegations. Further, at no time has Universal placed the burden to investigate the claim on the Insured. The Notice also alleges “[i]t was not until September 6, 2024, ninety-seven (97) days after the Insured reported their loss, that the Insurer finally issued its coverage determination...” To the contrary, Universal issued its undisputed payment to the named Insureds on June 15, 2024, fourteen (14) days after Universal was first notified of the loss. Additionally, the Notice alleges “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.” The Notice, however, fails to include any facts regarding any misrepresentations made by Universal and does not identify the person or persons who made such misrepresentations and/or when any such misrepresentations were made. Additionally, the Notice states, “the Insurer is not acting with due regard for the Insured’s interests or safety… 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 Complainant fails to assert any specific facts to support these conclusory allegations. The Notice also alleges, “[t]here 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.” The Complainant is required to provide with specificity the facts and circumstances giving rise to the alleged violation strictly related to the allegations, not conjecture or speculation of what may be a business practice by the carrier or purported “further wrongful conduct.” Further, the Notice alleges “[t]he Insurer also failed to allocate and pay for overhead and profit, pursuant to Florida Statute 627.7011…” The Complainant has failed to specify any facts in its Notice to support the basis for owing overhead and profit in the adjustment of this claim. It is evident that the statement of facts in the Notice falls short of the specificity required by Section 624.155, Florida Statutes. As a result, the Complainant failed to comply with the requirements provided in Section 624.155(3)(b)(2), Florida Statutes. In summation, as outlined above, the Complainant failed to respond to each of the fields set forth on the DFS Form with the requisite specificity, including but not limited to, failing to identify all named policyholders, failing to satisfy the requirement to identify the person or persons representing the insurer most responsible for or knowledgeable of the facts giving rise to the allegations, failing to reference specific policy language relevant to the alleged violation, and failing to allege any specific conduct on the part of Universal that would violate any policy provision or statute. Therefore, the Notice is legally deficient and fails to satisfy the condition precedent to filing a bad faith action. Pin-Pon Corp. v. Landmark American Ins. Co., 500 F. Supp. 3d 1336 (S.D. Fla. 2020); Julien v. United Property & Casualty Ins. Co., 311 So.3d 875 (Fla. 4th DCA 2021). For the aforementioned reasons, the Notice is deficient as a matter of law. Nonetheless, and without waiving the above-referenced deficiencies, the following shall provide you with the facts and circumstances regarding this claim, which shall demonstrate that Universal has not violated any Policy terms or statutory provisions. On June 1, 2024, Universal was notified by Insured, Greg Adame, that the insured location was damaged that same day. Universal inspected the property and documented any visible damage. Universal, in accordance with the terms and conditions of the Policy, timely issued payment in the full amount of its estimate, less recoverable depreciation and applicable deductible. Under the terms of the Policy, Universal will initially pay at least the actual cash value of the insured loss, less any applicable deductible. It will then pay any remaining amounts necessary to perform such repairs as work is performed and expenses are incurred. Subsequently, Universal issued a supplemental payment to the named Insureds, pursuant to the terms of the Policy. To date, Universal has not received any documentation showing the amount necessary to perform such repairs or that expenses have been incurred in excess of the payments issued by Universal to the named Insureds. At no time has Universal breached any duty to its named Insureds. An Insurer has no obligation to pay whatever amount an insured demands. While an insurance carrier is required to settle claims that should be settled, it is not required to settle claims that are legitimately contested. As outlined above, the alleged statutory violations set forth in the Notice lack specific factual support and are without merit. Therefore, the Notice is legally deficient and fails to satisfy the condition precedent to filing a bad faith action. Universal has complied with all policy provisions and applicable Florida law regarding the adjustment of this claim. We trust that the foregoing is sufficient to advise you of Universal’s position regarding this matter and fully responds to the alleged violations in the Notice filed by the Complainant. Sincerely, /s/ Jonathan Rodriguez Jonathan Rodriguez, Esq. Associate General Counsel
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