Civil Remedy Filing

Civil Remedy Notice of Insurer Violations

Filing Number: 790615

Filing Accepted: 11/6/2024

Print Filing

Complainant

Last/Business Name *

PEDRAZA

First Name

LEYANIS

Street Address *

700 NE 16TH TERRACE

City, State Zip *

CAPE CORAL, FL 33909

Email Address *

LSTEPHAN@MINEOLAW.COM

Complainant Type: *

Insured

Last/Business Name*		PEDRAZA		First Name		LEYANIS
Policy # *		EDH5370177-00		Claim #*		EDI950945

Attorney

Attorney is Applicable

Last Name*	STEPHAN First Name * LANCE Initial
Street Address*		5600 DAVIE ROAD
City, State Zip*		DAVIE , FLORIDA 33314
Email Address *		LSTEPHAN@MINEOLAW.COM

Violation

Insurer Type *		Authorized Insurer Unauthorized Insurer

Insurer Name
Insurer Name*		EDISON INSURANCE COMPANY
Insurer Name*
Street Address*
City, State Zip*		,
NAIC Company Code 12482

Name of individual responsible for violation (if any):* ALL ADJUSTERS, SUPERVISORS, MANAGERS, ATTORNEYS, AND INDIVIDUALS ASSOCIATED WITH AND/OR RETAINED BY EDISON INSURANCE COMPANY CONCERNING THE CLAIM AT ISSUE; JOAN ROSE; TONYA CALDWELL; JERRI OAKES; LATASHIA CRAFT HARRIS; ELISARDO CUETO (BSA CLAIMS SERV
Type of Insurance * Residential Property & Casualty

Reason for Notice *

	Cancellation
	Non-renewal
	Claim Denial
	Claim Delay
	Unsatisfactory Settlement Offer
	Unfair Trade Practice
	Other : VIOLATION OF CODE OF ETHICS

* 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)(2)		Making claims payments to insureds or beneficiaries not accompanied by a statement setting forth the coverage under which payments are being made.
	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)(1)		Attempting to settle claims on the basis of an application, when serving as a binder or intended to become a part of the policy, or any other material document which was altered without notice to, or knowledge or consent of, the insured.
	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)(e)		Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed.
	626.9541(1)(i)(3)(f)		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.
	626.9541(1)(i)(3)(g)		Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
	626.9541(1)(i)(3)(h)		Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
	626.9541(1)(i)(4)		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).

* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

In addition to the breach of the above statutory duties, see: Section I – Property Coverages, Coverage A – Dwelling, Coverage B – Other Structures, Coverage C – Personal Property; Section I - Perils Insured Against, Coverage A - Dwelling And Coverage B – Other Structures, Coverage C – Personal Property; Section I Conditions, 3. Loss Settlement, and 10. Loss Payment; Section I Property Coverages – ADDITIONAL COVERAGES: 1. Debris Removal, 2. “Emergency Mitigation Services,” 11. “Fungi,” Wet or Dry Rot, Yeast or Bacteria. In addition, see Emergency Order in case 300997-22-EO issued by the Florida Office of Insurance Regulation.

* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

STATUTORY VIOLATIONS (CONTINUED): 624.155(1)(a)1 Any person may bring a civil action against an insurer when such person is damaged: (a) by violation of any of the following provisions by the insurer: (1) Section 626.9541(1)(i), (o), or (x). 69B-220.201(3)(b) An adjuster shall treat all claimants equally. 69B-220.201(3)(b)(1) An adjuster shall not provide favored treatment to any claimant. 69B-220.201(3)(b)(2) An adjuster shall adjust all claims strictly in accordance with the insurance contract. 69B-220.201(3)(c) An adjuster shall not approach investigations, adjustments, and settlements in a manner prejudicial to the insured. 69B-220.201(3)(d) An adjuster shall make truthful and unbiased reports of the facts after making a complete investigation. 69B-220.201(3)(e) An adjuster shall handle every adjustment and settlement with honesty and integrity, and allow a fair adjustment or settlement to all parties without any compensation or remuneration to himself or herself except that to which he or she is legally entitled. 69B-220.201(3)(f) An adjuster, upon undertaking the handling of a claim, shall act with dispatch and due diligence in achieving a proper disposition of the claim. 69B-220.201(3)(j) An adjuster shall not knowingly fail to advise a claimant of the claimant’s claim options in accordance with the terms and conditions of the insurance contract. 69B-220.201(3)(k) An adjuster shall not undertake the adjustment of any claim concerning which the adjuster is not currently competent and knowledgeable as to the terms and conditions of the insurance coverage, or which otherwise exceeds the adjuster’s current expertise. 626.877 Every adjuster shall adjust or investigate every claim, damage, or loss made or occurring under an insurance contract, in accordance with the terms and conditions of the contract and of the applicable laws of this state. 626.878 An adjuster shall subscribe to the code of ethics specified in the rules of the department. The rules shall implement the provisions of this part and specify the terms and conditions of contracts, including a right to cancel, and require practices necessary to ensure fair dealing, prohibit conflicts of interest, and ensure preservation of the rights of the claimant to participate in the adjustment of claims. 627.70131(1)(a) Upon an insurer’s receiving a communication with respect to a claim, the insurer shall, within 14 calendar days, review and acknowledge receipt of such communication unless payment is made within that period of time or unless the failure to acknowledge is caused by factors beyond the control of the insurer which reasonably prevent such acknowledgment. If the acknowledgment is not in writing, a notification indicating acknowledgment shall be made in the insurer’s claim file and dated. A communication made to or by an agent of an insurer with respect to a claim shall constitute communication to or by the insurer. 627.70131(5)(a) Within 90 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. Any payment of an initial or supplemental claim or portion of such claim made 90 days after the insurer receives notice of the claim, or made more than 15 days after there are no longer factors beyond the control of the insurer which reasonably prevented such payment, 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 shall 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. FACTS AND CIRCUMSTANCES GIVING RISE TO THE VIOLATION: Edison Insurance Company (the “Insurance Company”) issued a homeowners’ insurance policy to its insured, Leyanis Pedraza (the “Insured”), for the insured property located at 700 NE 16th Terrace, Cape Coral, FL 33909. The subject Policy afforded various types of coverages including coverage for damage to dwelling, other structures, personal property, and for loss of use. On or about September 28, 2022, while the subject Policy was in full force and effect, the Insured’s home was damaged as a result of the Hurricane Ian storm event. The Insured subsequently notified the Insurance Company of the loss. Thereafter, the Insurance Company acknowledged the loss and assigned claim number EDI950945 to the loss. The Insured complied with all policy conditions and cooperated with the Insurance Company’s investigation efforts. The Insurance Company performed a cursory inspection, failing to retain the experts necessary to adequately inspect the property to restore the property to its pre-loss condition and issued a “low-ball” payment to the Insured totaling $41,369.65 for repairs. The Insured and Insured’s representative provided the Insurance Company with all claim-related documents including an estimate to repair covered damages in the amount of $263,578.21, and other supporting documentation and/or information. The Insurance Company continues to completely ignore the Insured’s claim and request for supplemental payment. As a direct result of the loss, many of the Insured’s contents / personal property were damaged / ruined. The Insured estimate that the value of the damaged contents is approximately $7,344.99. The Insured provided the Insurance Company with a personal property inventory form in the amount of $7,344.99, identifying the damaged contents / personal property. To date, the Insurance Company has failed to provide coverage / indemnify / issue payment to the Insured for the damaged contents / personal property. The Insurance Company’s actions are in violation of the subject policy and Florida law. The Insurance Company did not issue full payment for the subject claim (including all applicable coverages) within sixty (60) days of receiving notice of the loss. The Insurance Company’s actions are in direct violation of section, 627.70131(7)(a), Florida Statutes, which provides that “[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.” Accordingly, the Insurance Company has misrepresented facts and policy language related to the coverages provided under the policy, and has accordingly collected a premium for insurance that has not been provided in full. The obligation to pay the full value of Insured’s claim has been made clear based on the facts and evidence available, yet the Insurance Company has failed to pay the full value of the Insured’s claim. This is caused in part by the Insurance Company’s failure to adopt and implement standards for the proper investigation of claims. Here, the Insurance Company has failed to pay the full amounts owed to the Insured’s under the policy, despite being provided with an estimate for the correct amount of damages. This has made repairs to the insured property extremely difficult. Additionally, despite knowing there is a dispute over the amount of damages and that repairs have not yet been completed, on or about August 20, 2024 (i.e., after Hurricane Ian made landfall in Florida and damaged the insured home), the Insurance Company issued a notice of non-renewal of the insurance policy effective December 27, 2024. This is in direct violation of the Emergency Order in case 300997-22-EO issued by the Office of Insurance Regulation, which states that the policy cannot be non-renewed at this time (and until at least ninety days after repairs have been completed following Hurricane Ian). Additionally section 627.4133 states: “With respect to any personal lines or commercial residential property insurance policy, including, but not limited to, any homeowner, mobile home owner, farmowner, condominium association, condominium unit owner, apartment building, or other policy covering a residential structure or its contents… (d)1. Upon a declaration of an emergency pursuant to s. 252.36 and the filing of an order by the Commissioner of Insurance Regulation, an insurer may not cancel or nonrenew a personal residential or commercial residential property insurance policy covering a dwelling or residential property located in this state which has been damaged as a result of a hurricane or wind loss that is the subject of the declaration of emergency for a period of 90 days after the dwelling or residential property has been repaired. A structure is deemed to be repaired when substantially completed and restored to the extent that it is insurable by another authorized insurer that is writing policies in this state.” Here, the Insurance Company failed to issue full payment for the Insured as it relates to the subject Hurricane Ian claim. Due to the Insurance Company’s actions, the Insured has been unable to make all of the requisite repairs at the subject property. In spite of this fact, the Insurance Company has sent the Insured a notice of non-renewal of the subject property, which is effective December 27, 2024 at 12:01 a.m. Consequently, the Insurance Company has issued a non-renewal of the Insured’s policy in violation of Florida law. What is more troubling, is the that Insured will likely be unable to obtain homeowners’ insurance with another insurance company as she has not been able to fully repair the home following the subject Hurricane Ian (due to the Insurance Company’s failure to make full payment of the claim). Thus, the Insurance Company must rescind the non-renewal of the subject property. Accordingly, the Insurance Company has misrepresented facts and policy language related to the coverages provided under the policy, and has accordingly collected a premium for insurance that has not been provided in full. The obligation to pay the full value of Insured’s claim has been made clear based on the facts and evidence available, yet the Insurance Company has failed to pay the full value of the Insured’s claim. This is caused in part by the Insurance Company’s failure to adopt and implement standards for the proper investigation of claims. The Insured provided the Insurance Company with documentation evaluating the loss, and rather than issuing the proper payment or attempting to reach an agreement with its Insured, the Insurance Company is delaying and denying the claim. Upon information and belief, the Insurance Company performs the subject actions as a business practice, including delaying the claim and/or denying the claim in an attempt to dissuade its insureds from pursuing the claim to the detriment of its insureds to increase financial profits. The Insurance Company has failed to issue proper payment for the claim and has failed to issue sufficient payment to include damages and repairs covered by the policy and Florida law. The Insured provided the Insurance Company with documentation evaluating the loss, and rather than issuing the proper payment or attempting to reach an agreement with its Insured, the Insurance Company is delaying and denying the claim. Upon information and belief, the Insurance Company performs the subject actions as a business practice, including delaying the claim and/or issuing "low ball" payments in an attempt to dissuade its insureds from pursuing the claim to the detriment of its insureds to increase financial profits. The concept of insurance is that insurance is the insurer's granting of timely and prompt indemnity or security against a contingent loss. Florida Statute §624.02 defines insurance as a contract whereby one undertakes to indemnify another or pay or allow specified amount or a determinable benefit upon determinable contingencies. Inherent is the fact that payment must be made timely and promptly so that insureds may mitigate their damages and be put back into the position they were in prior to the loss as quickly as possible. The Insurance Company has breached this duty. The Insurance Company has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the Insured’s insurance claim for damages. The Insurance Company has refused and/or failed to tender insurance proceeds to the Insured upon demand as required by the policy and law. Refusal and/or failure to settle the Insured’s claim when under all the circumstances it could have and should have done so had it acted fairly and honestly towards the Insured is wrong. The actions taken by the Insurance Company in the handling/adjustment of the Insured’s claim were willful, wanton, and in disregard for the rights of its Insured and occur with such a frequency as to indicate a general business practice, and further, are in violation of Florida Statutes §624.155 and §626.9541. In Florida, the work of adjusting insurance claims engages the public trust. The Insurance Company has breached this duty by its adjustment of the Insured’s claim of loss. Based on the foregoing actions and omissions, the Insurance Company has engaged in the following conduct: 1. Improper claim delay. 2. Improper claim denial. 3. Not conducting a full and fair investigation of the Insured’s claim. 4. Looking for ways to deny recovery to the Insured. 5. Looking for ways to delay recovery to the Insured. 6. Not adjusting the claim and evaluating the loss properly, promptly, and fairly so as to provide full and prompt indemnity to its Insured. 7. Failing to implement proper standards for the adjustment and investigation of insurance claims. 8. Not training, supervising or managing adjusters and independent contractors properly so that prompt and full payments are made, but rather placing the company’s interests before the policyholder’s interests by attempting to deny or minimize payments. 9. Establishing severity control initiatives and otherwise establishing a culture of not fully and promptly paying claims following losses. In order to remedy the above defects, the Insurance Company must do the following: 1. Immediately admit coverage and pay the Insured the full value of the claim: i.e., $263,578.21, for dwelling repairs (less the applicable deductible and prior payment); and $7,344.99 for damages to personal property / contents. 2. Pay statutory interest on the amount of unpaid damages from the date of loss. 3. Act fairly and honestly toward its Insured with due regard for her interests in attempting to resolve the claim. 4. Cease and desist all present and future bad faith actions with regard to this claim. 5. Implement standards for the property investigation of claims. 6. Stipulate to the Insured’s entitlement to attorney’s fees and court costs pursuant to section 627.428 and/or 627.70152, Florida Statutes, and pay the amount of fees and costs incurred. 7. Rescind the August 20, 2024 policy non-renewal pursuant to the Emergency Order in case 300997-22-EO issued by the Office of Insurance Regulation.

Comments

User Id		Date Added		Comment
rhollingsworth@conroysimberg.com		11-24-2024		Any and all matters by and between the parties have been amicably resolved.

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