Filing Number: 789336
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| Filing Accepted: 10/30/2024 |
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CARPENTER
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First Name |
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JOHN AND ZELDA |
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| Street Address
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9410 JAYHAWK LN. |
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JACKSONVILLE,
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32221
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| Email Address
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MARIANENG@HOTMAIL.COM |
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Insured |
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| Last/Business Name* |
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CARPENTER |
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First Name |
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JOHN AND ZELDA |
| Policy # * |
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FLA306902 |
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Claim #* |
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1300035-241001 |
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Attorney is Applicable
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| Last Name* |
O'NEIL
First Name *
JONATHAN
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| Street Address* |
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203 FORT WADE ROAD, SUITE 260 |
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PONTE VEDRA
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FLORIDA
32081
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| Email Address * |
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JONATHAN@WOOLSEYMORCOM.COM |
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| Insurer Type
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 Authorized Insurer
 Unauthorized Insurer
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| Insurer Name |
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| Insurer Name* |
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AMERICAN STRATEGIC INSURANCE CORP.
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| Insurer Name* |
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NAIC Company Code 10872 |
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| Name of individual responsible for violation (if any):*
GABRIELLE BROCCONE (FLA. ADJ. LIC. #W394998)
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| Type of Insurance
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Residential Property & Casualty
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| Reason for Notice
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Claim Delay
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Other
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Wrongful claim denial
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Unfair Trade Practice
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Other
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Unfair claim settlement practices
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Other
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Unreasonable investigation
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Other
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Failure to act on claim
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Other
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Failure to conduct a reasonable investigation based on available information
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Other
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Failure to maintain proper complaint handling procedures
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Other
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Misrepresenting the insurance policy provisions to the insured
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Other
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Misrepresenting Florida statutory provisions to the insured
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Other
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Misrepresenting facts to the insured
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Other
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Failure to acknowledge and act promptly upon communications with respect to claims
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Other
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Denying claims without conducting reasonable investigations based upon available information
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Statutory provision(s) which the insurer allegedly violated.
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| 624.155(1)(b)(1) |
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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.
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| 624.155(1)(b)(3) |
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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.
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| 626.9541(1)(i)(2) |
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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.
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| 626.9541(1)(i)(3)(a) |
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Failing to adopt and implement standards for the proper investigation of claims.
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| 626.9541(1)(i)(3)(b) |
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Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.
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| 626.9541(1)(i)(3)(c) |
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Failing to acknowledge and act promptly upon communications with respect to claims.
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| 626.9541(1)(i)(3)(d) |
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Denying claims without conducting reasonable investigations based upon available information.
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| 626.9541(1)(i)(3)(e) |
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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.
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| 626.9541(1)(i)(3)(f) |
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Failing to promptly provide a reasonable explanation in writing to the insured of the basis in the insurance policy, in relation to the facts or applicable law, for denial of a claim or for the offer of a compromise settlement.
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| 626.9541(1)(i)(3)(g) |
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Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
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| 626.9541(1)(i)(3)(h) |
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Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
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| 626.9541(1)(i)(4) |
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Failing to pay undisputed amounts of partial or full benefits owed under first-party property insurance policies within 60 days after an insurer receives notice of a residential property insurance claim, determines the amounts of partial or full benefits, and agrees to coverage, unless payment of the undisputed benefits is prevented by factors beyond the control of the insurer as defined in s. 627.70131(5).
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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
Coverage A – Dwelling and Coverage B – Other Structures:
We insure against risk of direct physical loss to property described in Coverages A and B only if that loss is a physical loss to property.
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[A]ny ensuing loss to property described in Coverages A and B not excluded or excepted in this policy is covered.
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Coverage C – Personal Property:
We insure for direct physical loss to the property described in Coverage C caused by a peril listed below unless the loss is excluded in the SECTION – I Exclusions . . . 2. Windstorm or hail.
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OTHER COVERAGES
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1. Debris Removal. We will pay your reasonable expense for the removal of: a. debris of covered property if a Peril Insured Against causes the loss; or b. ash, dust or particles from a volcanic eruption that has caused direct loss to a building or property contained in a building. Debris removal expense is included in the limit of liability applying to the damaged property.
2. Reasonable Repairs. We will pay the reasonable cost you incur for necessary repairs made solely to protect covered property from further damage, if the peril causing the loss and related damages are covered.
3. Trees, Shrubs and Other Plants. We cover trees, shrubs, plants or lawns, on the Described Location for loss caused by the following Perils Insured Against: Fire or lightning, Explosion, Riot or civil commotion, Aircraft, Vehicles not owned or operated by you or a resident of the Described Location or Vandalism or malicious mischief, including damage during a burglary or attempted burglary, but not theft of property. The limit of liability for this coverage will not be more than 5% of the Coverage A limit of liability, or more than $500 for any one tree, shrub or plant. We do not cover property grown for commercial purposes. This coverage is additional insurance.
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11. “Fungi”, Mold, Wet Or Dry Rot, Or Bacteria a. We will pay up to the amount stated in the Declarations for Limit of Liability for “Fungi” Coverage for: (1) The total of all loss payable under Section I – Property Coverages caused by or resulting directly or indirectly from “fungi”, mold, wet or dry rot, or bacteria; (2) The cost to remove “fungi”, mold, wet or dry rot, or bacteria from property covered under Section I - Property Coverages. (3) The cost to tear out and replace any part of the building or other covered property as needed to gain access to the “fungi”, mold, wet or dry rot, or bacteria; and (4) The cost of testing of air or property to confirm the absence, presence or level of “fungi”, mold, wet or dry rot, or bacteria whether performed prior to, during or after removal, repair, restoration or replacement. The cost of such testing will be provided only to the extent that there is a reason to believe that there is the presence of “fungi”, mold, wet or dry rot, or bacteria.
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Also refer to:
Coverage A provision, coverage B provision, coverage C provision, coverage D provision, all additional coverages provisions, all coverages provided by endorsement or rider, the declarations page, loss payment or settlement provision, duties in event of loss policy provision, all terms and conditions of section I of the insurance policy, the insurance policy definitions section, the insurance policy‘s exclusion of coverage provisions, all insurance policy provisions that provide coverage to the insured property, and all policy provisions.
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Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
624.155(1)(a)(1) – violating 626.9541(1)(i)
626.9541(1)(a)(1) -- misrepresenting the terms of an insurance policy.
626.9541(1)(i) -- unfair claim settlement practices.
Facts of the case:
American Strategic Insurance Corp. (“AMERICAN STRATEGIC”) has committed the following in handling the insured’s claim: 1) failure to pay benefits owed; 2) failure to act in due diligence and good faith to resolve claims; 3) placing the financial interest of the insurer before that of the policy holder and claimant; 4) failure to properly train, evaluate, and manage adjusters retained to represent the policies and procedures of AMERICAN STRATEGIC; 5) looking for ways to delay benefit payments and otherwise “low ball” or “stone wall” claims; 6) looking for ways to deny the insured’s claim; 7) looking for ways to reduce recovery to the insured; 8) failure to perform a reasonable investigation; 9) misrepresenting Florida statutory provisions to its insured; 10) misrepresenting insurance policy provisions to the insured; 11) AMERICAN STRATEGIC has failed and refused to acknowledge coverage and promptly pay the benefits due and owed to the insured; 12) the reasons for this may be attributed to improper training, supervision, and/or motivation of outside adjusters and claims supervisors to promptly and fairly adjust and pay full benefits available to the insured. The insurer may have failed to adopt proper standards of investigation and adjustment of losses or is otherwise not implementing those standards because a proper investigation and full and prompt payment for the loss is not occurring.
In Florida, the work of adjusting insurance claims engages the public trust. AMERICAN STRATEGIC has breached this duty by its adjustment of the insured’s claim of loss. AMERICAN STRATEGIC has failed to create and implement adequate guidelines for proper investigation to evaluate claims handling and for training and supervision of employees resulting in violations as set forth above. AMERICAN STRATEGIC has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the insured’s insurance claim for damages. Despite the insured’s timely notification to AMERICAN STRATEGIC of their insurance claim, AMERICAN STRATEGIC has failed and refused to acknowledge the covered loss and pay all amounts due and owing to the insured under the policy of insurance. AMERICAN STRATEGIC has failed to promptly settle the insured’s insurance claim, when the obligation to settle the claim had become reasonably clear, under one portion of the insurance, in order to influence settlements under other portions of the insurance policy coverage. Despite the insured’s pleas otherwise, AMERICAN STRATEGIC has failed and refused to acknowledge its obligation to tender all insurance proceed monies due and owing the insured or assist the insured in mitigation of the damages.
In exchange for a premium paid by the insured, AMERICAN STRATEGIC issued the subject insurance policy which provided coverage for the insured property from October 12, 2023 through October 12, 2024 for “risk of direct physical loss to property described in Coverages A and B only if that loss is a physical loss to property.” As such, the subject all-risk Policy contains coverage for all direct physical losses to the insured property unless the loss is specifically and unambiguously excluded from coverage by the Policy. On or about December 17, 2023, the insured property suffered a windstorm loss and the insured immediately submitted a claim to AMERICAN STRATEGIC for property damage, i.e., storm and wind damages throughout the insured property. Hence, the insured suffered a substantial loss regarding the real property and continue to suffer such loss. Having suffered such substantial damage, the insured promptly notified AMERICAN STRATEGIC of the loss in an effort to mitigate the current damage and prevent the exacerbation of any additional losses. The desired result did not follow. AMERICAN STRATEGIC since being presented the Insured’s claim has misrepresented policy provisions to avoid paying the insured what they are owed under the policy. Ultimately, AMERICAN STRATEGIC has failed and refused to properly settle the insured’s claim in good faith. The insured have requested that AMERICAN STRATEGIC conduct an investigation, admit coverage, and pay damages; AMERICAN STRATEGIC has failed and refused to do so. In short, AMERICAN STRATEGIC has failed to handle its insured’s claim in good faith in violation of Fla. Stat. 624.155(1)(b)(1), 624.155(1)(b)(3), and 626.9541(1)(i).
Based upon AMERICAN STRATEGIC’s investigation and property inspection, which confirmed windstorm damages, AMERICAN STRATEGIC nevertheless sent correspondence to the insured dated January 23, 2024, (signed by AMERICAN STRATEGIC’s adjuster, Gabrielle Broccone (Fla. Adj. Lic. #W394998)) and communicated its unequivocal denial of the claim. In regard to insurance contracts, a specific refusal to pay a claim is the breach which triggers the cause of action. Allstate Ins. Co. v. Kaklamanos, 843 So. 2d 885, 892 (Fla. 2003); Donovan v. AMERICAN STRATEGIC Fire and Cas. Co., 574 So. 2d 285, 286 (Fla. 2nd DCA 1991) (finding that a breach of contract takes place at the moment the insurance company refuses to pay a claim). Therefore, AMERICAN STRATEGIC breached the Policy. Moreover, AMERICAN STRATEGIC’s argued exclusions and/or limitations to coverage are devoid of anti-concurrent causation language. Thus, “coverage may exist where an insured risk constitutes a concurrent cause of the loss even when it is not the prime or efficient cause.” Sebo v. Am. Home Assurance Co., Inc., 208 So. 3d 694, 699 (Fla. 2016). In addition, under the Policy, any ensuing loss to property not excluded or excepted in this policy is covered. Hence, there are a myriad of coverages under the Policy that would provide coverage for the loss. Nevertheless, AMERICAN STRATEGIC failed and refused to acknowledge the covered loss and pay all amounts due and owing for the loss. Therefore, AMERICAN STRATEGIC breached the Policy.
Questioning the propriety of AMERICAN STRATEGIC’s coverage decision, and given the extensive nature of the physical damage, the insured a loss consultant, Property Pros Consulting (“PPC”) to perform an investigation and damage evaluation in accordance with industry standards and Florida law. Based on its investigation, PPC determined that a windstorm on or about December 17, 2023, including wind, caused damage throughout the exterior of the insured property (particularly the roof warranting replacement). Moreover, PPC determined that at least $75,062.78 worth of repairs would be required to return the property to its pre-loss condition as a result of the windstorm loss. Nevertheless, AMERICAN STRATEGIC failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, AMERICAN STRATEGIC breached the Policy.
Thereafter, the insured sent correspondence to AMERICAN STRATEGIC enclosing the supporting PPC report outlining the cause, scope, and cost of the loss along with other supporting documents and requested AMERICAN STRATEGIC to reconsider its coverage denial. Nevertheless, AMERICAN STRATEGIC failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, AMERICAN STRATEGIC breached the Policy.
Questioning the propriety of AMERICAN STRATEGIC’s continued coverage denial, and given the extensive nature of the physical damage, the insured a consulting licensed contractor, Tom Gannon, with LSC Construction Consultants, LLC (“LSC”), to perform an investigation and damage evaluation in accordance with industry standards and Florida law. Based on his investigation, Mr. Gannon likewise concluded that a windstorm on or about December 17, 2023, including wind, caused damage throughout the exterior of the insured property (particularly the roof warranting replacement). Moreover, Mr. Gannon determined that at least $43,121.18 worth of repairs would be required to return the property to its pre-loss condition as a result of the windstorm loss. Nevertheless, AMERICAN STRATEGIC failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, AMERICAN STRATEGIC breached the Policy.
On October 30, 2024, the insured sent correspondence to AMERICAN STRATEGIC enclosing their Sworn Statement in Proof of Loss, the supporting PPC report and LSC report outlining the cause, scope, and cost of the loss along with other supporting documents, the Notice of Intent to Initiate Litigation, and requested AMERICAN STRATEGIC to reconsider its coverage denial. To date, AMERICAN STRATEGIC has failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, AMERICAN STRATEGIC breached the Policy.
As such, AMERICAN STRATEGIC’S coverage denial is a blatant misrepresentation of the available coverages under the Policy in direct violation of Fla. Stats. 626.9541(1)(a)(1), 626.9541(1)(i)(3)(b), 626.9541(1)(a)(1), and 626.9541(1)(i)(2) and is nothing more than a mere pretext to wrongfully deny and delay this claim. As a result, AMERICAN STRATEGIC has materially misrepresented the coverages under the subject policy to the insured for the purpose and with the intent of effecting settlement of the insured’s claim on less favorable terms than those provided in, and contemplated by, the subject policy in direct violation of Fla. Stat. § 626.9541(1)(i)(2). Further, AMERICAN STRATEGIC is in violation of Florida statutes §§ 626.9541(1)(a)(1), 626.9541(1)(i)(3)(b), and 626.9541(1)(a)(1) by misrepresenting pertinent facts and insurance policy provisions relating to coverages at issue; and also in violation of Fla. Stat. 626.9541(1)(i)(3)(d) by denying the insured’s claim without conducting a reasonable investigation based upon available information.
In summary, the insured’s loss is clearly covered by the terms of the policy of insurance with AMERICAN STRATEGIC. However, AMERICAN STRATEGIC chose to deny coverage for the insured’s loss. Despite clear evidence that the damages were covered and caused by a covered peril, the claim was denied. To date, AMERICAN STRATEGIC continues to deny the insured and its insured full indemnity for the claim. While AMERICAN STRATEGIC refuses to honor this claim, a jury in Duval County will likely do what AMERICAN STRATEGIC has refused; exercise the benefit of doubt in favor of the insured in finding full coverage for this loss. Indeed, the insured will undoubtedly meet the burden of proof at trial, under the AMERICAN STRATEGIC all-risk policy, to show that, while AMERICAN STRATEGIC provided insurance coverage, damage occurred to the insured property. See Jones v. Federated Nat'l Ins. Co., 235 So. 3d 936, 942 (Fla. 4th DCA 2018). With the data presented within AMERICAN STRATEGIC’s investigation, PPC’s investigation, and LSC’s investigation, AMERICAN STRATEGIC’s burden to demonstrate by the greater weight of the evidence that all the physical damage to the insured property was caused solely by excluded perils under the policy and not in combination with a covered peril has not and cannot be met. See Sebo v. Am. Home Assurance Co., Inc., 208 So. 3d 694 (Fla. 2016). Despite clear indicators of covered damage, AMERICAN STRATEGIC nevertheless inexplicably denied the insured’s claim.
As of today, AMERICAN STRATEGIC has failed and refused to inform the insured of his rights under the policy of insurance and Florida statutes, has improperly delayed the insured’s claim, has wrongfully denied the insured’s claim, and has failed and refused to adequately indemnify the insured for the loss and defiantly continues to do so. Indeed, from the time of receiving the claim, AMERICAN STRATEGIC has purposely and maliciously delayed in adjusting the subject claim in an effort to either avoid paying the claim altogether or, at the very least, avoid paying the full extent of the loss. Notably, under Florida law, “[t]he filing of a lawsuit does not extinguish the insurer’s obligations under the policy to adjust and pay the claim.” Tristar Lodging, Inc. V. Arch Specialty Ins. Co., 434 F. Supp. 2d 1286, 1289 (M.D. Fla. 2006).
To date, the insured has made a good faith effort to comply with all of the requirements under the subject policy of insurance, and it is only fair that AMERICAN STRATEGIC do the same. Yet, that is not the case. The insured feels that the insured property is a valuable asset, and, by continuously delaying the proper handling of this claim, AMERICAN STRATEGIC is putting the insured property at risk. As a responsible property owner, the insured purchased insurance to protect the property, paid all of the premiums, and has kept up to date with the responsibilities under the policy. Yet, when the insured needed to rely on the insurance because of this unforeseen loss, AMERICAN STRATEGIC turned its back and delayed and wrongfully denied coverage that the insured is rightfully owed.
Ultimately, AMERICAN STRATEGIC has failed and refused to properly investigate the loss. The insured has requested that AMERICAN STRATEGIC admit coverage and pay damages, AMERICAN STRATEGIC has failed and refused to do so, and continues to refuse to fully indemnify the insured for the loss and pay the amounts necessary to properly repair the insured’s property, despite knowing it is required to do so. In short, AMERICAN STRATEGIC has failed to handle its insured’s claim in good faith.
In Florida, the work of adjusting insurance claims engages the public trust; AMERICAN STRATEGIC has breached this duty by its insufficient adjustment of the insured’s claim. AMERICAN STRATEGIC has failed to create and implement adequate guidelines for proper investigation to evaluate claims handling and for training and supervision of employees resulting in statutory violations set forth above. AMERICAN STRATEGIC has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the insured’s insurance claim for damages.
Florida statute § 624.02 defines insurance as a contract whereby one undertakes to indemnify another or pay or allow a specified amount or a determinable benefit upon determinable contingencies. Inherent is the fact that payment must be made timely and promptly so that the insured may mitigate their damages to put them back into the position they were prior to loss as quickly as possible. AMERICAN STRATEGIC breached this duty.
The actions taken by AMERICAN STRATEGIC in the handling / adjustment of the insured’s claim were willful, wanton, and with complete disregard for the rights of its insured and occur with such a frequency as to indicate a general business practice and are in violation of Fla. Stat. 624.155 and 626.9541.
AMERICAN STRATEGIC’S actions amount to but are not limited to the following:
1. Claim delay
2. Wrongful claim denial
3. Unfair trade practice
4. Unfair claim settlement practices
5. Unreasonable investigation
6. Failure to act on claim
7. Failure to conduct a reasonable investigation based on available information
8. Failure to maintain proper complaint handling procedures
9. Misrepresenting the insurance policy provisions to the insured
10. Misrepresenting Florida statutory provisions to the insured
11. Misrepresenting facts to the insured
12. Failure to acknowledge and act promptly upon communications with respect to claims
13. Denying claims without conducting reasonable investigations based upon available information
14. 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.
15. Failing to promptly provide a reasonable explanation in writing to the insured of the basis in the insurance policy, in relation to the facts or applicable law, for denial of a claim or for the offer of a compromise settlement.
16. Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
17. Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
18. Failing to pay undisputed amounts of partial or full benefits owed under first-party property insurance policies within 90 days after an insurer receives notice of a residential property insurance claim, determines the amounts of partial or full benefits, and agrees to coverage, unless payment of the undisputed benefits is prevented by an act of God, prevented by the impossibility of performance, or due to actions by the insured or claimant that constitute fraud, lack of cooperation, or intentional misrepresentation regarding the claim for which benefits are owed.
Therefore, to cure the defects outlined in this civil remedy notice, AMERICAN STRATEGIC must:
(1): Admit full coverage for the insured’s loss; and
(2): Tender all insurance monies due and owing to the insured for the loss under the subject Policy.
A copy of this form submitted to the FDFS has been emailed and/or uploaded and also printed out and mailed to the following parties providing them notice of the filing of this civil remedy notice:
American Strategic Insurance Corp.
Progressive Home Claims
P.O. Box 5009
Antioch, TN 37011-5009
claims@asicorp.org
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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.
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DFS-10-363
Rev. 10/14/2008
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