Civil Remedy Notice of Insurer Violations
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Filing Number:     787731
Filing Accepted:  10/21/2024
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Complainant
Last/Business Name *  
GODAU   First Name   ROBERT
Street Address * 1167 TUSCANY BOULEVARD
City, State Zip * VENICE, FL 34292
Email Address * RLGODAU@GMAIL.COM
Complainant Type: * Insured
Insured
Last/Business Name*   GODAU   First Name   ROBERT
Policy # * EDH5414416-00 Claim #* EDI963268
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*   EDISON INSURANCE COMPANY
NAIC Company Code 12482
 
Name of individual responsible for violation (if any):* MATTHEW BEY, SUZANNE FOUCHE, LEROY MARTINEZ, 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 *
Claim Denial
Claim Delay
Unfair Trade Practice
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 : Intentionally misstating the terms, conditions, and benefits of the insurance policy 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.
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.
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)(i) Failing to pay personal injury protection insurance claims within the time periods required by s. 627.736(4)(b).
* 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) failing to act in due diligence and good faith to resolve claims; 2) placing the financial interest of Insurer before that of 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) misrepresenting the terms of the insurance policy; and 10) denying a claim which it knew or should have known the policy and Florida law provided coverage for. On or about September 28, 2022, while the subject policy was in full force and effect, the insured property suffered a loss caused by Hurricane Ian. The areas impacted include but are not limited to the roofing system, gutters, stucco, and exterior. The Insured timely submitted a claim on March 18, 2024, to the Insurer for damage caused by Hurricane Ian and the ensuing damage therefrom. Thereafter, the Insurer assigned claim number EDI963268 to the loss and sent a field adjuster to inspect the property. Then in a letter dated April 8, 2024, the Insurer notified the Insured that it was denying coverage for the loss. This coverage decision is incorrect. Denying coverage for the damage was wrongful as the damages are covered under the policy. Confusingly, the Insurer sent another letter dated April 15, 2024, advising it was unilaterally re-opening the claim based on additional information the Insurer had been made aware of related to the reporting of the loss. The letter fails to explain what additional information the Insurer received after denying the claim, but it certainly does not appear that this new information related to the cause of the loss the basis for which the Insurer denied coverage. This second letter demonstrates the Insurer performed a shoddy and faulty investigation in an effort to deny the claim. The Insurer had the ability to request an examination under oath as well as all the documents included in its April 15, 2024, prior to denying the claim. The Insurer then requested an Examination Under Oath of the Insured's public adjuster and the Insured's. However, the Insurer is acting in bad-faith by requesting documentation and examinations under oath after unequivocally denying coverage for the loss. Florida caselaw is clear that once an insurance carrier has denied a claim, a policyholder is no longer obligated to comply with any post-lost duties such as participating in an examination under other or providing documents. See Ifergane v. Citizens Prop. Ins. Corp., 232 So. 3d 1063, 1065 (Fla. 3rd DCA 2017)("[i]t is necessary to resolve this issue because should the factfinder determine that [carrier's] letter was a denial of coverage letter, then as a matter of law, [carrier] waived any right it had to enforce the insured's post-loss conditions including the right to take [the policyholder's] examination under oath; Wegener v. Int'l Bankers Ins. Co., 494 So. 2d 259, 259 (Fla. 3rd DCA 1986)(". . . the effect of the thus-found-to-be-improper repudiation of coverage was to waive any right to insist upon the insureds' necessarily-thus-futile compliance with the various conditions to recovery"); Castro v. Homeowners Choice Prop. & Cas. Ins. Co., 228 So. 3d 596, 599 (Fla. 2nd DCA 2017)("[w]hen an insurance carrier investigates a claim of loss and denies coverage because it concludes that a covered loss has not occurred, the insurance carrier cannot assert the insured's failure to comply with the policy's conditions precedent to filing suit as a basis for summary judgment") Indian River State Bank v. Hartford Fire Ins. Co., 35 So. 228, 246 (1903)("[a] simple allegation of the denial of all liability on the policy by the company through its agent was sufficient to give to the plaintiff any advantage to be derived from the waiver of proofs of loss following as a legal consequence upon a denial of liability"); Hartford Acc. & Indem. Co. v. Phelps, 294 So. 2d 362, 365 (Fla. 1st DCA1974)("an insurer, by unconditionally denying any liability upon its policy, waives proof of loss required by the policy.") Given the denial, the Insured's disagreement with the coverage decision, and the scope and nature of the damage resulting from Hurricane Ian, the Insured retained a public adjuster. After assessing the damage and the true scope of repairs, the public adjuster produced an estimate identifying $172,928.42 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 subsequently requested a reinspection. The Insurer then issued a second coverage determination letter, dated August 29, 2024, in which it notified the Insured that it was maintaining its wrongful denial. 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. However, when the Insurer conducted its inspection of the insured property, the Insurer's adjuster failed to conduct a thorough and adequate investigation, or the adjuster intentionally ignored the damage observed and failed to make truthful and unbiased reports of the facts after investigating. As a result, the Insurer breached the policy by failing to fully indemnify the Insured for the covered loss. The Insurer misrepresented the loss and wrongfully denied coverage for the damage sustained to the Insured's property. According to the claims determination letter, the Insurer's field adjuster observed sudden and direct damage to the insured property, but attributed the cause of this damage to deterioration, wear and tear, and flood. 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. The Insurer intentionally ignored covered damage to deny the reported loss and wrongfully fail to pay the Insured. This is an underhanded attempt to place the financial interests of the Insurer over those of the Insured and to delay and frustrate the Insured's ability to have his claim adjusted promptly to begin restoring his property. The conduct outlined above is done within the Insurer's routine course of the business. 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. 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 denied coverage for the loss. 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. Claim denial 3. Not treating the Insured with good faith claims conduct 4. Looking for way to reduce recovery to the Insured 5. Looking for ways to deny recovery to the Insured 6. Not adjusting claims and evaluating loss properly, promptly and fairly to provide full and prompt indemnity to the Insured 7. 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 8. Placing the financial interest of the Insurer over that of the health and safety of the Insured 9. Shifting the burden of investigating onto the Insured 10. Conducting inadequate investigations 11. 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 18002-1957 csclaims@edisoninsurance.com
Comments
User Id Date Added Comment
tsalehi@salehiboyer.com 11-08-2024 VIA ELECTRONIC SUBMISSION: civilremedy@myfloridacfo.com Florida Department of Insurance Civil Remedy Section 200 East Gaines Street Tallahassee, Florida 32399 Re: Complainant: Robert Godau Policyholder: Robert Godau Filer: Grant W. Krapf Claim #: EDI963268 Policy #: EDH5414416-00 CRN filing No.: 787731 CRN filing date: October 21, 2024 To Whom It May Concern at The Department of Financial Services: With this correspondence, Edison Insurance Company (“EDISON”) responds to the Civil Remedy Notice of Insurer Violations (“CRN”) filed by Grant W. Krapf, Esq. on behalf of Robert Godau (the “Complainant” or “Claimant”). After reviewing the CRN, EDISON conducted a thorough review of its handling of the Complainant’s claim. EDISON denies that it has violated any of the statutes referenced in the CRN. At all times, EDISON has acted in good faith, fairly and honestly toward the Complainant and with due regard for their interests. EDISON also argues that the CRN fails to actually describe the alleged violations and fails to provide any information such as facts and circumstances which would allow EDISON to correct the alleged violations. The Complainant alleges multiple violations of various statutory provisions in the CRN. Specifically, the Complainant alleges violations of: 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. EDISON denies the allegation that it violated the above referenced statute. 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. EDISON denies the allegation that it violated the above referenced statute. 626.9541(1)(i)(3)(a): Failing to adopt and implement standards for the proper investigation of claims. EDISON denies this allegation that it violated the above referenced statute. 626.9541(1)(i)(3)(b): Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue. EDISON denies the allegation that it violated the above referenced statute. 626.9541(1)(i)(3)(c) Failing to acknowledge and act promptly upon communications with respect to claims. EDISON denies the allegation that it violated the above referenced statute. 626.9541(1)(i)(3)(d): Denying claims without conducting reasonable investigation based upon available information. EDISON denies the allegation that it violated the above referenced statute. 626.9541(1)(i)(3)(i): Failing to pay personal injury protection insurance claims within the time periods required by. EDISON denies the allegation that it violated the above referenced statute; moreover, this statute has no nexus to the subject claim or the facts at hand. EDISON specifically denies each and every one of the Complainant’s allegations that EDISON violated the above referenced statutes. In addition to the statutory provisions, EDISON denies all allegations that it violated any provision under the subject policy. In addition to the allegations specifically denied above, EDISON generally denies all allegations presented in this Civil Remedy Notice as EDISON has not violated any statute or rule. CRN MUST BE DISMISSED The CRN must be dismissed first and foremost because the Complainant failed to allege specific, actual facts in support of any of their statutory allegations. Next, the CRN requires that 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 numerous statutory provisions that could be claimed against an insurance company, regardless of whether they are relevant or applicable to the allegations contained in the Notice. Because the Civil Remedy Notice fails to allege any adequate facts and/or circumstances in support of its allegations, EDISON is unable to properly respond; as such, the CRN should be rejected and returned. The CRN is completely devoid of any factual allegations relating to the monetary amount of any claims. See Rousso v. Liberty Surplus Ins. Corp., No. 10-cv-20554, 2010 WL 7367059, at *4 (S.D. Fla. Aug. 13, 2010) (“In this case, the Plaintiffs do not explain how or identify which claims or suits the Defendant responded to in a manner that was contrary to good faith, unfair, or dishonest.”). This glaring deficiency fails to apprise EDISON of the nature of any purported violation and cannot satisfy the statutory standard of “pleading the facts and circumstances” giving rise to the violation with specificity. The CRN first addresses Section 624.155(1)(b)(1), Florida Statutes, which addresses an insurer’s refusal to attempt to settle in good faith. The CRN, however, does not specify when any settlement opportunity or proposal existed, the details of the settlement proposal, the nature of the underlying claim(s), or the circumstances supporting the conclusion that the unspecified refusal to settle was not in good faith. To the extent the CRN suggests that EDISON should tender payment due on the claim, the CRN fails to provide any description of the facts and circumstances supporting this contention. As to Section 626.9541(1)(i)(2), Florida Statutes, the Purported Notice fails to describe any "misrepresentation" made to the Insured or any other person having an interest. The Purported Notice's failure to describe the facts or circumstances of the claim precludes Edison from evaluating what error, if any, allegedly occurred during the claim process. The Purported Notice provides no description of the applicable policy provisions, the facts or circumstances of Edisons’ investigation, the disposition of the claim, or the facts and circumstances indicating Edisons’ investigation was in some way defective. Regarding the alleged violation of Section 626.9541(1)(i)(3)(a), Florida Statutes, the CRN’s failure to describe any of the facts or circumstances of the claim precludes EDISON from evaluating what error, if any, allegedly occurred during the investigation of the claim. Complainant cannot possibly support the position that EDISON failed to adopt and implements standards for the proper investigation of the claim because the CRN provides little to no description of the facts or circumstances of EDISON’s investigation, the disposition of the claim, or the facts and circumstances indicating EDISON’s investigation was in some way defective. As to Section 626.9541(1)(i)(3)(b), Florida Statutes, the CRN provides only conclusory and unsupported allegations of EDISON’s “misrepresentation” or false statements relating to the facts of the claim or coverage at issue. Because the CRN fails to describe the facts or circumstances of the claim with any particularity, EDISON is precluded from evaluating what error, if any, allegedly occurred during the claim process. As to Section 626.9541(1)(i)(3)(c), Florida Statutes, the CRN does not describe any standards applicable to the purported “claim” advanced by the Complainant, much less the facts and circumstances giving rise to the contention that EDISON failed to acknowledge and act promptly upon communications with respect to claim. Regarding the alleged violation of Section 626.9541(1)(i)(3)(d), Florida Statutes, the CRN does not describe any standards applicable to denying claims without conducting reasonable investigations based upon available information, much less the facts and circumstances giving rise to the contention that EDISON denied the subject claim without first conducting a reasonable investigation. Finally, as to Section 626.9541(1)(i)(3)(i), Florida Statutes, the CRN does not describe any standards applicable to the purported “claim” advanced by the Complainant. More specifically, this Section is not applicable as it is related to a failure to pay personal injury protection insurance claims within the time periods required by s. 627.736(4)(b). The claim at issue is not personal injury related. Furthermore, contrary to the requirement to “describe the facts and circumstances giving rise to the insurer’s violation as you understand them at this time,” the purpose of which is “to enable the insurer to investigate and resolve [the] claim,” the CRN itself only provides unsupported, conclusory, and incorrect allegations with no basis in fact or circumstance. Aside from the fact that the allegations are devoid of adequate specific facts, the tenor and inferences of the allegations are wholly without merit and EDISON denies each and every one. The allegations set forth in the CRN are denied as they are mere conclusory allegations unsupported by facts, devoid of logic and clearly intended solely to tarnish EDISON’s name and reputation. EDISON, at all times, acted fairly, honestly and in good faith in its dealings with the Complainant. EDISON at no time misrepresented any pertinent facts or insurance policy provisions. EDISON conducted a reasonable and prudent investigation of the claim and acted upon all communications from the Complainant. Finally, EDISON promptly and appropriately communicated with the Complainant and provided explanations for the actions and decisions that were made. EDISON retained a field adjuster and conducted an inspection of the subject property to investigate the Complainant’s claim. As it relates to the facts of the claim, EDISON received notice of the subject loss from the Complainant on March 18, 2024, alleged to have occurred September 28, 2022. Specifically, it was alleged that the dwelling sustained damage as a result of Hurricane Ian. Promptly thereafter, on March 26, 2024, an adjuster went to the subject property to conduct an inspection on behalf of EDISON. After analysis of the subject policy of insurance, and based on the above factual investigation, EDISON issued a coverage determination letter on April 8, 2024, denying coverage based on the information that it had available. The correspondence was in writing and was promptly sent to the Complainant with policy excerpts and Information on Mediation and Claims Handling. Thereafter, since providing the letter dated April 8, 2024, EDISON had been made aware of additional information relating to the loss as reported which requires clarification regarding the details leading up to the reporting of the claim. For this reason, EDISON re-opened the claim and requested Examinations Under Oath pursuant to the applicable terms of the policy to continue with its investigation and ensure that EDISON is in possession of all the relevant information related to the claim, the subject property, and the policy. As part of its investigation, EDISON requested from the Claimant and his Public Adjuster to submit to an Examination Under Oath and to provide supporting documents that would assist in EDISON’s investigation, including photographs of any claimed damages and any estimates from contractors for repairs to damaged materials. The Examination Under Oath of Robert Godau was taken on May 31, 2024. The Examination Under Oath of the Public Adjuster took place on August 13, 2024, which revealed the existence of new documents. After analysis of the subject policy of insurance, and based on the above factual investigation, EDISON issued a coverage determination on August 29, 2024, reaffirming its denial of coverage and providing its basis for same. The correspondence was in writing and was promptly sent to the Complainants with pertinent policy excerpts. The above demonstrates quite clearly that EDISON acted in good faith, acted fairly and honestly, acknowledged and acted promptly upon receipt of the claim, attempted to determine coverage for the claim pursuant to the terms of the policy, took reasonable steps to investigate the claim, communicated reasonably with the Complainant about the claim, and provided the Complainant a reasonable explanation for each of its actions. Additionally, the CRN contains “cures” for the alleged defects; however, the listed “cures” are improper pursuant to Florida case law, specifically the case of Talat Enterprises, Inc., v. Aetna Casualty and Surety Co., 753 So.2d 1278, 1281 (Fla. 2000). The Talat case provides that the scope of what can be "cured" is limited to the alleged non-payment of the contractual amount due to the insureds. Talat also commented that, “[i]t naturally follows that for there to be a ‘cure,’ what had to be ‘cured’ is the non-payment of the contractual amount due the insured. In the context of a first-party insurance claim, the contractual amount due the insured is the amount owed pursuant to the express terms and conditions of the policy after all of the conditions precedent of the insurance policy in respect to payment are fulfilled....” As a result, only a demanded “cure” relating to the specific amount needed to repair covered damages is proper and legal – any remaining “cures” are improper remedies and contrary to Florida law. In closing, EDISON first believes that the CRN should be rejected and returned by the Department of Financial Services due to its failure to comply with Florida Statute § 624.155, Florida Statute § 626.9541, and Florida case law, and regardless of the rejection, EDISON denies all allegations contained in the CRN and submits that there are no violations. While this response is meant to be comprehensive, EDISON based the above-mentioned statements upon the limited information provided in the CRN and the information EDISON has been provided to date. If the Complainant feels that EDISON is not in possession of all the facts, please provide such additional information as soon as possible. Please note that EDISON’s response is not necessarily exhaustive and does not preclude the assertion of other valid reasons for seeking rejection and return of the CRN. Also, nothing in this letter, or any act or failure to act on the part of EDISON or any agent or representative of EDISON should be construed as a waiver of any rights or defenses available to it by contract or at law as all such rights and defenses are hereby specifically reserved. We trust that this response addresses the allegations of insurer violation alleged in the CRN. Should you have any questions regarding this matter or need anything further, please do not hesitate to contact the undersigned. Regards, Oscar Lombana on Behalf of Edison 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.

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