Civil Remedy Notice of Insurer Violations
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Filing Number:     790833
Filing Accepted:  11/7/2024
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Complainant
Last/Business Name *  
DAVILA   First Name   CARMEN
Street Address * 8880 SUNRISE LAKES BLVD
City, State Zip * SUNRISE, FL 33322
Email Address * WITHHELD
Complainant Type: * Insured
Insured
Last/Business Name*   DAVILA   First Name   CARMEN
Policy # * 79B4G1593 Claim #* 59-70R2-24K
Attorney
Attorney is Applicable
Last Name* DANIELS First Name * MONICA Initial E
Street Address* 560 VILLAGE BOULEVARD, SUITE 110
City, State Zip* WEST PALM BEACH , FLORIDA 33409
Email Address * MDANIELS@THEDANIELS-LAWGROUP.COM
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   STATE FARM FLORIDA INSURANCE COMPANY
NAIC Company Code 10739
 
Name of individual responsible for violation (if any):* GADIEL PENA, AND ANY AND ALL OTHER ADJUSTERS, MANAGERS, SUPERVISORS, AND INDIVIDUALS ASSOCIATED WITH THE CLAIM.
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Unfair Trade Practice
Claim Denial
Claim Delay
* 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.
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)(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.
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

SECTION I – PROPERTY COVERAGES COVERAGE A – DWELLING 1. Dwelling. We cover the dwelling and materials and supplies located on or adjacent to the residence premises for use in the construction, alteration, or repair of the dwelling or other structures on the residence premises. SECTION I – ADDITIONAL COVERAGES 2. Temporary Repairs. If damage is caused by a loss insured, we will pay the reasonable and necessary cost you incur for temporary repairs to covered property to protect the property from further immediate damage or loss. This coverage does not increase the limit applying to the property being repaired. 14. Tear Out. If a loss insured to Coverage A property is caused by water, steam, or sewage escaping from a system or appliance, we will also pay the reasonable cost you incur to tear out and replace only that particular part of the building structure necessary to gain access to the specific point of that system or appliance from which the water, steam, or sewage escaped. We will not pay for the cost of repairing or replacing the system or appliance itself. This coverage does not increase the limit applying to Coverage A property. SECTION I – LOSSES INSURED COVERAGE A – DWELLING We will pay for accidental direct physical loss to the property described in Coverage A, unless the loss is excluded or limited in SECTION I – LOSSES NOT INSURED or otherwise excluded or limited in this policy. However, loss does not include and we will not pay for, any diminution in value. SECTION I – LOSS SETTLEMENT COVERAGE A – DWELLING 1. A1 – Replacement Cost Loss Settlement – Similar Construction. a. We will pay the cost to repair or replace with similar construction and for the same use on the premises shown in the Declarations, the damaged part of the property covered under SECTION I – PROPERTY COVERAGES, COVERAGE A – DWELLING, except for wood fences, subject to the following: SECTION I – CONDITIONS 8. Loss Payment. We will adjust all losses with you.
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

Carmen Davila (the “Insured”) purchased an insurance policy from State Farm Florida Insurance Company (the “Insurer”), subscribing to policy number 79B4G1593 (the “Policy”), to cover property located at 8880 Sunrise Lakes Blvd, Sunrise, FL 33322 (the “Property”). On or about July 3, 2024, the Insured’s property suffered damages as the result of a sudden and accidental plumbing loss, to wit, a ruptured pipe, which caused extensive water damage to the Property, which necessitates repairs in the following areas to bring the Property back to its pre-loss condition: primary bedroom with primary closet, primary bath with primary linen closet, guest bathroom, guest bedroom with guest closet, hallway, living room, kitchen, and linen closet #2. The Insured and her association immediately mitigated the damages by opening up the drywall and repairing the plumbing issue, then the Insured promptly contacted the insurance company, and complied with all applicable post-loss obligations. The Insurer acknowledged the loss and assigned claim number 59-70R2-24K (the “Claim”) and assigned claims adjuster Gadiel Pena to adjust the Claim. The Insured promptly provided the Insurer a true and accurate estimate of the damages, photographs relating to the Claim, an executed Sworn Proof of Loss, and complied with all of the Insurer’s requests for information and documentation. It is clear that the Insured has done everything in her power to comply with the Insurer’s requests and all applicable post-loss obligations. Despite all the above and the Insured promptly filing this claim and mitigating all damages in compliance with the Policy, the Insurer unreasonably took roughly three weeks to inspect the Property, and subsequently denied the Claim asserting that the damage was the result of rot and long term seepage. If the carrier had properly and promptly investigated this matter, it would have been abundantly clear that this was a sudden and accidental loss. The Insured understandably became extremely frustrated by the Insurer’s clear delay tactics, failure to properly indemnify her for this Claim in a timely fashion, and failure to adjust the Claim in good-faith. To combat any further attempts by the Insurer to delay the Claim and its failure to make the Insured whole, the Insured had no choice but to retain legal counsel to assist with the Claim. Without sufficient funds to repair the Property, the Insured may continue to suffer additional damages. Despite providing all necessary documentation to the Insurer to make good on its duty to restore the Property to its pre-loss condition, Insurer grossly undervalued the Claim and ultimately denied a clearly covered loss. The Insurer’s refusal to properly investigate, adjust and fully compensate the Insured for this Claim undoubtedly evidences the Insurer’s violation of Section 626.9541(1)(i)(3)(a), Florida Statutes, which requires the Insurer to “adopt and implement standards for the proper investigation of claims.” All available information leads to one conclusion – the Property was damaged by a covered cause of loss for which the Insured is entitled to full and complete compensation. The Insurer’s obligation to promptly settle the Insured’s Claim is undeniable, and therefore, the Insurer has also violated Fla. Stat. Section 624.155(1)(b)(1) and 624.155(1)(b)(3). The Insurer’s conduct continues to be egregious because the Insurer retained biased and inexperienced individuals who approached the loss with an eye towards denial. The actions taken by the Insurer in the handling and adjustment of the Claim are willful, wanton, and in disregard for the rights of the Insured, and have occurred with such frequency as to indicate a general business practice in violation of the law. This practice includes the Insurer hiring biased and inexperienced adjusters and experts and failing to properly and timely pay for obvious damages owed to its Insured. The Insurer’s actions amount to, but are not limited to: A. “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 the insured and with due regard for her or his interests;” B. “Except as to liability coverages, failing to promptly settle claims, when the obligation to settle a claim has become reasonably clear;” C. “Failing to adopt and implement standards for the proper investigation of claims;” D. Claim Delay; E. Unsatisfactory Settlement Offers; and F. Unfair Trade Practices In addition to the above statutory violations, the Insurer’s adjuster violated the following ethical requirements of the Florida Administrative Code 69B-220.201: (3) Code of Ethics . . . An adjuster shall put the duty for fair and honest treatment of the claimant above the adjuster’s own interests in every instance. The following are standards of conduct that define ethical behavior, and shall constitute a code of ethics that shall be binding on all adjusters: (b) An adjuster shall treat all claimants equally. 2. An adjuster shall adjust all claims strictly in accordance with the insurance contract. (c) An adjuster shall not approach investigations, adjustments, and settlements in a manner prejudicial to the insured. (d) An adjuster shall make truthful and unbiased reports of the facts after making a complete investigation. (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 remuneration to himself except that to which he is legally entitled. (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. (o) 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. The Insured is a dutiful customer who made it a priority to pay insurance premiums to ensure that in such an event as the one here, the Property would be covered. The Insured timely filed the Claim and fulfilled all post-loss obligations. The Insurer acknowledged the loss, assigned a claim number, inspected the property, and then ultimately unjustifiably denied the Claim. It is abundantly clear that the Insurer has failed to provide the Insured with qualified representatives to ensure the Claim was initially adjusted, evaluated, and paid properly. To deny the Insured the benefit of the bargain after she has satisfied all her obligations is morally and ethically reprehensible, and reeks of Unfair Trade Practice. Insurer is putting its profits ahead of its contractual and statutory obligations. In Florida the work of adjusting insurance claims engages the public trust. The Insurer has failed to create and implement adequate guidelines for the proper investigation to evaluate claims handling, and for training and supervision of employees. The Insurer has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the Insured’s insurance Claim and damages. Therefore, the Insurer breached its statutory and ethical duties, and has put profits ahead of the duties it owed to its Insured when she most needed the insurance coverage she paid for. Florida Statute § 624.02 defines “insurance” as a contract where one undertakes to indemnify another or pay or allow specified amounts, or determinable benefit, upon determinable contingencies. Inherent is the fact that payment must be made timely and promptly. This timely and prompt payment allows the insured to mitigate their damages and place them back to the position they were in prior to the loss, as quickly as possible. The Insurer breached this duty. The Insurer has refused and failed to tender all insurance proceeds to the Insureds upon demand. The Insurer’s refusal and/or failure to settle the insurance Claim when it, under all circumstances, should have done so, is wrongful conduct. The Insurer is failing to timely settle the Insured’s claim as it is required to do so by contract and Florida law. To cure the defects outlined in this civil remedy notice, the Insurer must (1) immediately, and under no circumstances no later than sixty days from the date of this civil remedy notice, tender all insurance monies due and owing to the Insured, specifically $54,941.93 under Coverage A, which is the amount of the Insured’s estimate less deductible; (2) immediately, and under no circumstances no later than sixty days from the date of this civil remedy notice, tender all insurance monies due and owing for any mitigation services rendered in connection with this claim; (3) ensure that payment made would be adequate to place the Insured back in her pre-loss condition; and (4) reimburse the Insured’s attorneys’ fees and costs, since the Insured was forced to hire legal counsel in order to receive adequate payment. Should the Insurer fail to comply with the demands set forth in this civil remedy notice, the Insurer must prepare to pay the full cost of its failure to rightfully indemnify the Insureds, including all future damages and legal expenses that come about as a result of the Insurer’s failure to comply with the demands set forth in this civil remedy notice. This Notice is giving in order to perfect the right to pursue the civil remedy authorized by section 624.155(3)(b), Florida Statutes.
Comments
User Id Date Added Comment
admin@bernstein-chackman.com 12-27-2024 Dear Carmen Davila: This letter is to advise you that my firm represents State Farm Florida Insurance Company (hereinafter “State Farm”) in the matter referenced above. This shall serve as State Farm’s response to civil remedy notice number 790833, which was submitted to the Department of Financial Services on behalf of Carmen Davila, on November 7, 2024. The civil remedy notice states that State Farm violated §624.155 and §626.9541 by doing the following: not attempting in good faith to settle claims; failing to promptly settle claims; failing to adopt standards for proper claim investigation; and other alleged wrongdoings. State Farm denies all allegations of wrongdoing or violation of Florida Law. State Farm has acted in accordance with Florida law and the subject policy in its handling of this claim. Additionally, the civil remedy notice fails to comply with the requirements of Florida Statute §624.155. State Farm does not waive any deficiencies in the civil remedy notice with the filing of this response. The notice neglects to include facts which demonstrate that State Farm violated Florida law, fails to identify the specific policy language that was allegedly violated, or include a reasonable cure for the alleged violations. The purpose of the civil remedy notice is to grant the insurer an opportunity to cure the alleged violations of Florida law. Therefore, complainants must identify the specific policy provisions and statutory language that were violated. In addition, complainants must identify what actions the insurer did that violated such provisions and identify what actions must be taken to cure the violations. As such, Florida Statute §624.155(3)(b) states: The notice shall be on a form provided by the department and shall state with specificity the following information, and such other information as the department may require: 1. The statutory provision, including the specific language of the statute, 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. If the person bringing the civil action is a third party claimant, she or he shall not be required to reference the specific policy language if the authorized insurer has not provided a copy of the policy to the third party claimant pursuant to written request. 5. A statement that the notice is given in order to perfect the right to pursue the civil remedy authorized by this section. In this instance, civil remedy notice 790833 does not include specific facts and circumstances that demonstrate a violation as required by §624.155(3)(b)(2). The notice contains conclusory allegations that State Farm improperly and insufficiently adjusted the claim. As such, the notice fails to comply with §624.155(3)(b)(4). See Talat Enters. v. Aetna Cas. & Sur. Co., 753 So. 2d 1278 (Fla. 2000) & Julien v. United Prop. & Cas. Ins. Co., 311 So. 3d 875 (Fla. 4th DCA 2021). The insured procured policy no.: 79-B4-G159-3 for her home located at 8880 Sunrise Lakes Blvd, Apt 102, Sunrise, FL., 33322. The policy carries a $10,000 water damage limit. The policy was in effect from June 21, 2024, through June 21, 2025. This claim was reported to State Farm on July 12, 2024, with an alleged date of loss of July 3, 2024. During the quality first contact the public adjuster advised that there is a water leak in the condo. He contacted the HOA and they checked out the leak - made holes in the walls to locate the source. The HOA is not responsible for the interior. The public adjuster advised there was water damage in the bathroom and two bedrooms, as well as contents. No emergency mitigation services or dry out services were utilized following the alleged loss. There is no evidence of any plumbing invoices, or invoices that show that any alleged leak was fixed. The public adjuster submitted an estimate in the amount of $13,273.57. The estimate includes costs for repairs to the primary bedroom, primary bathroom, primary closet, guest bathroom and the guest closet. Gadiel Pena inspected the property on September 12, 2024. Gadiel stated the origin of loss as the HOA’s supply lines. Gadiel observed that the leak appears to have been slowly trickling from some time, there are signs of continuous and repeated seepage or leakage, including dark stains and mold in affected areas. This claim was denied by letter dated October 1, 2024. The denial letter states: “Thank you for the opportunity to handle your claim. State Farm Insurance completed an interior inspection of the home. Based on the results of our inspection and investigation, we are unable to provide coverage for this loss. Our investigation and observations of the damage showed and signs of rot, corrosion and deterioration that were consistent with slow, trickling, gradual and repeated leakage of water from the supply lines. The supply lines displayed no sudden or accidental physical loss, but rather appeared to have failed due to wear, tear and deterioration. These are all damages that are specifically excluded under the policy. While we did observe fungus (including mold) during our investigation, there is no coverage for the remediation, testing, or any cost incurred associated with fungus (including mold) as the cause of the damages are not the result of a covered loss. In addition, the HOA is responsible for drywall repairs. We are therefore unable to provide coverage for this loss.” This civil remedy notice was submitted to the department on November 7, 2024. However, at this time, nothing has been presented to State Farm that would change its coverage determination. In this Civil Remedy Notice the claimant alleges that State Farm violated §624.155(1)(b)(1) and §624.155(1)(b)(3) by 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 his interests and failing to promptly settle claims. However, this claim was properly denied. There is no coverage under this policy for the claim made. The claimant alleges that State Farm violated §626.9541(1)(i)(3)(c) by failing to acknowledge and act promptly upon communications. In this claim, State Farm timely acknowledged the claim and acted promptly after the reporting of the claim. The claim was then properly denied. The claimant alleges that State Farm violated §626.9541(1)(i)(3)(a) by failing to adopt and implement standards for the proper investigation of the claim. In this claim, based on State Farm’s inspection and evaluation of the claim, it was determined that there was no coverage for the damage being claimed. The claimant alleges that State Farm violated §626.9541(1)(i)(3)(d) by denying claims without conducting reasonable investigations. However, State Farm did conduct a reasonable investigation. Gadiel Pena performed an in-person inspection, based on that it was determined that there is no coverage under the policy for this claim. The claimant alleges that State Farm violated §626.9541(1)(i)(3)(f) by 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 and §626.9541(1)(i)(3)(g) by failing to promptly notify the insured of any additional information necessary for the processing of a claim. In this case, no additional information was necessary. State Farm also provided a detailed claim determination letter, which set forth the facts and policy provisions as to why there is no coverage under the policy for this claim. State Farm denies all allegations of non-compliance with Florida law or the subject policy. Furthermore, the civil remedy notice is deficient in that it does not comply with the requirements of Florida Statute §624.155(3)(b). State Farm does not waive any such deficiencies in the filing of this response. Regardless, the accusations raised within the notice are devoid of merit. Thank you for your attention to the above. Very truly yours, /s/ Brian A. Chackman Brian A. Chackman
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