Civil Remedy Notice of Insurer Violations
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Filing Number:     792831
Filing Accepted:  11/18/2024
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Complainant
Last/Business Name *  
STAFFORD   First Name   ALISA
Street Address * 461 CLARK STREET
City, State Zip * ORANGE CITY, FL 32763
Email Address * ALISAJ54@YAHOO.COM
Complainant Type: * Insured
Insured
Last/Business Name*   STAFFORD   First Name   ALISA
Policy # * PFL384641-05 Claim #* CFL24602383
Attorney
Attorney is Applicable
Last Name* TEMPLETON First Name * LOGAN Initial C
Street Address* 1000 LEGION PLACE, STE. 1200
City, State Zip* ORLANDO , FLORIDA 32801
Email Address * LOGANT@SOUTHMILHAUSEN.COM
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   PEOPLE'S TRUST INSURANCE COMPANY
NAIC Company Code 13125
 
Name of individual responsible for violation (if any):* JENNIFER MOSCOSO
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Denial
Claim Delay
Unfair Trade Practice
* 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)(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)(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)(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.

Section I – Property Coverages, Coverage A – Dwelling (entire section) Section I – Property Coverages, Additional Coverages, Reasonable Repairs (entire section) Section I – Property Coverages, Additional Coverages, Reasonable Emergency Measures (entire section) Section I – Property Coverages, Additional Coverages, “Fungi”, Wet or Dry Rot, or Bacteria (entire section) Section I – Property Coverages, Additional Coverages, Ordinance or Law (entire section) Section I – Perils Insured Against, Coverage A – Dwelling and Coverage B – Other Structures (entire section) Section I – Conditions, Loss Settlement (entire section) Section I – Conditions, Loss Payment (entire section)
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

The Carrier has not attempted in good faith to settle the Insured’s Claim 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 interests. The Carrier has delayed full payment of the Claim due and owing under the Policy, putting its interests over those of the Insured. Furthermore, the Carrier is required to properly investigate and adjust claims and cannot place that burden upon the Insured. This was made clear by the Florida Supreme Court in Allstate Indemnity Co. v. Ruiz, 899 So. 2d 1121 (Fla. 2005)(“The Legislature has clearly chosen to impose on the insurance companies a duty to use good faith and fair dealing in processing and litigating the claims of their insureds…”). The property located at 461 Clark St., Orange City, FL 32763 (the “Insured Property”) suffered a covered loss due to water resulting from a failure of the shower system. More specifically, on or about May 16, 2024, the Insured woke up to find the floors in her master bedroom, master bathroom and hallway bathroom floors wet. This was the first time the Insured Property experienced a leak from a failure of the shower system. The Insured called her home warranty company, American Home Shield, which sent out a plumber. The plumber determined that there was a leak. She then reached out to a mitigation company, Back 2 Basics (“B2B”) which came out to fix the leak and dry out the Insured Property. B2B removed the shower pan and the shower has not been used since. B2B subsequently completed mold remediation services as well. No further repairs have been made. The Insured then filed the Claim with the Carrier. The Carrier sent out a field adjuster to conduct an inspection to determine the cause and extent of the damage and the necessary repairs to bring the Insured Property back to its pre-loss condition. In addition to the field adjuster’s inspection, B2B also submitted all photos, invoices and documents supporting this sudden and accidental water loss. After completing its inspection, including review of the documents and information submitted by B2B, the Carrier denied the Claim. The Carrier’s August 13, 2024 Denial Letter states: “Looking at the facts of your claim and reading the language of cited above, your policy does not provide coverage for your particular loss. Specifically, but without limitation, your policy does not provide coverage for long term seepage/leakage causing fungi growth. The policy also excludes damages arising out of workmanship. As a result, PTI must respectfully deny coverage for your claim.” It is unclear how the Carrier came to this conclusion when all the evidence supports the damage resulting from a sudden and accidental loss. A review of the evidence clearly shows that the Carrier misrepresented the cause of the sudden and accidental damage to the Insured. Further, the Carrier failed to provide any explanation based on the language in the Policy and the presented evidence as to how the damage also resulted from faulty workmanship. This practice by the Carrier of refusing to provide coverage for the full benefits available under the Policy is for the purpose of avoiding having to pay the total amount due and owing for the Claim. The Carrier engages in this practice with such regularity and frequency as to indicate that it is a general business practice of this Carrier, in reckless disregard for the rights of the Insured. It is clear that the Carrier has not acted in good faith toward the Insured; failed to pay the amounts clearly owed; did not adjust and evaluate the loss properly, promptly and fairly to provide full and timely indemnity to the Insured; placed its interests before the Insured’s interests; and looked for ways to delay full recovery to the Insureds, when a reasonable carrier in a similar position would have tendered full payment in accordance with both the Policy and statutory requirements. The Carrier’s actions are in violation of Florida Statutes §§ 624.155(1)(b)(1), 626.9541(1)(i)(3)(a) ,626.9541(1)(i)(3)(b), 626.9541(1)(i)(3)(d), 626.9541(1)(i)(3)(f), and 626.9541(1)(i)(3)(i). All the aforementioned are part of what appears to be an ongoing pattern and practice of behavior by the Carrier that demonstrates a wanton and reckless disregard for the Insured’s rights and a pattern and practice of bad faith claims practices to its insureds across the State of Florida. Therefore, to cure the defects outlined in this Civil Remedy Notice, the Carrier must: 1) pay the Insured the remaining amount of insurance benefits available under the Policy including the mitigation invoice and mold invoice submitted by B2B as well as the reconstruction costs to return the Insured Property to its pre-loss condition; and 2) pay the statutory interest on the amount of unpaid insurance benefits from the date of loss to the date payment is finally made. A copy of this letter and filed form submitted to the Florida Department of Financial Services has been printed out and mailed.
Comments
User Id Date Added Comment
bfrankel@gmail.com 12-30-2024 The Legal Department has been requested by People’s Trust Insurance Company (“PTI”) to assist it in responding to a Civil Remedy Notice of Insurer Violation (“CRN”) filed on behalf of its Insured, Alisa Stafford (“Insured”). In direct response to the CRN filing, PTI maintains that it has not been in any violation of the law and that the CRN is defective on its face and fails to comply with the specificity requirements under Florida Statute 624.155. As such, PTI objects to the Department’s acceptance of the above-referenced CRN. To be more specific, the CRN requirements set forth by Section 624.155 are that the notice be filed on a form provided by the department stating with specificity the following information, and such other information 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 light of the instant CRN, PTI will provide a simple review of the facts and claims handling in support of its position there was no “bad faith” in the handling of this claim and detail how and why PTI acted property and within the letter of the law while handling the subject insurance claim. Following the claims summary, PTI will then address each respective statutory violation alleged in the Insureds’ CRN and respond accordingly in order to highlight why the CRN fails to perfect the Claimant’s right to pursue civil remedies under Florida Statutes. ? 1) On 5/24/2024, the Insured and a representative named “Austin” from Back-to-Basics Reconstruction LLC (“B2B”0 reported water damage in the hall bathroom from a broken shower pan. Per the Insured’s representative, there was water damage to the hall bathroom floors, wall and vanity, as well as damages to the adjacent walls in the master bathroom, master closet, baseboards and flooring. The representative further advised that the company was performing mitigation services and that upon removing the wall in the hall bathroom mold had been observed. Therefore, the company was performing mold pre-testing and writing a protocol. At the time of reporting, there was no content damage alleged. Following the reporting of the loss PTI sent the Homeowner’s Bill of Rights, as well as a What to Expect Form detailing the claims investigation process about to commence. 2) On 5/28/2024, PTI received the service agreement between B2B and the Insured via an email in which the company indicated they would be handling the water mitigation, mold remediation, as well as the rebuild. Worth noting, the service agreement was executed a week prior to the reporting of the loss. In response thereto, PTI issued correspondence informing B2B of the policy at issue; specifically, the Preferred Contractor Endorsement and monetary limits in place for mitigation services and/or necessary repairs to protect the property from further damage. 3) Thereafter, on 5/31/2024, PTI’s Field Adjuster inspected the home in order to determine the cause of loss and scope of damages. At the time of the inspection, the Insured’s sister, Florence Vandom, was present and confirmed the loss was reported as a shower pan leak in the hallway bathroom. PTI’s Field Adjuster was unable to observe the alleged damages as B2B had already removed the lower half of the shower, the vanity, the mirror, drywall in the master closet, and master bathroom, and some tiles in the master shower. Due to the inability to observe the damaged property, PTI reached out to the Insured and requested any leak detection reports or any documentation depicting the damaged property prior to the removal of the items. A formal Request for Information letter was sent on 6/11/2024, and after not receiving any documentation, PTI issued a Reservation of Rights letter on 6/21/2024. 4) While B2B submitted an estimate for water mitigation, mold remediation, and build back repairs, along with photographs, there was no documentation provided to confirm a shower pan leak occurred and therefore PTI was prejudiced in its investigation. 5) As a result of the investigation and inspection, PTI issued its coverage determination letter on 7/3/2024 advising that the loss is not covered by the policy. The letter explained that at the time of the inspection by PTI’s Field Adjuster repairs had already started and/or been completed, which prevented PTI the ability to inspect the damage and determine whether the loss is covered. On 8/2/2024 the coverage position was re-iterated after receiving mold testing and protocol invoices. Subsequently, PTI received photographs prior to the removal of the walls and shower pan showing that the shower drain was installed partially into the wall cavity. After reviewing the documentation, a revised denial letter was sent on 8/13/2024 stating that the policy does not provide coverage for long term seepage/leakage causing fungi growth, or damages arising out of workmanship. As shown, PTI has not acted in bad faith but has observed the terms and conditions of the Policy and Florida law. PTI further maintains that its practices and/or guidelines for response to claims are adequate to provide for the proper investigation and resolution of all claims. While the CRN references “claim denial, claim delay, and unfair trade practice” as reasons for the notice, it fails to mention specific policy language or factual support in support of said allegations. To the contrary, the above-referenced timeline of events shows that PTI acted timely in its adjustment of the claim and communications with the Insured and/or Insured representatives, and thoroughly investigated the claim by way of an initial inspection in order to confirm there was no coverage under the subject policy that would warrant a payment and/or settlement offer. As it relates to unfair trade practice, the CRN does not provide any information in support of this and therefore PTI denies said allegations. As for “claim denial” alleged as a reason for notice, PTI maintains that the denial was issued in accordance with its findings during the investigation of the claim and pursuant to the terms of the policy at issue. Turning to the statutory sections alleged to be violated, PTI responds as follows: GENERAL DENIAL PTI denies of all the statutory violations alleged in the Insured’s CRN. 1) ALLEGED VIOLATION §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: RESPONSE PTI denies this alleged statutory violation, and advises that Claimants have not provided any facts to sustain such an allegation. As stated above, the investigation of the claim failed to reveal any damages to trigger coverage under the policy at issue. 2) ALLEGED VIOLATION §626.9541(1)(i)(3)(a) – Failing to adopt and implement standards for the proper investigation of claims. RESPONSE PTI denies this alleged statutory violation, and advises that Claimants have not provided any facts to sustain such an allegation. PTI advises that this allegation requires specific facts regarding the method of the investigation; the reasons the investigation was improper or otherwise inadequate; the reasons why this alleged inadequacy is due to the failure to adopt and implement standards for the proper investigation of claims, and the facts supporting these conclusions. To allege an inadequate investigation, the Notice must include specific facts regarding the method, rather than merely the results. Valenti v. Unum Life Ins. Co. of America, 2006 WL 1627276 (M.D. Fla. 2006) As the Insureds have not advised PTI as to how it failed to investigate the claim and/or what standards were not adopted or implemented, this alleged violation is emphatically denied. 3) ALLEGED VIOLATION §626.9541(1)(i)(3)(b) – Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue. RESPONSE The Insured does not indicate what facts and/or policy provisions were misrepresented. Hence, PTI denies this alleged statutory violation. 4) ALLEGED VIOLATION §626.9541(1)(i)(3)(d) – Denying claims without conducting reasonable investigations based upon available information. RESPONSE PTI denies this alleged statutory violation, and advises that Claimants have not provided any facts to sustain such an allegation. As mentioned above, the Insureds have not advised PTI as to how it failed to investigate the claim and/or what standards were not adopted or implemented. 5) ALLEGED VIOLATION §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. RESPONSE PTI denies this alleged statutory allegation in its entirety. As indicated in the numbered paragraphs above, PTI issued a denial of coverage letter following its inspection by the Field Adjuster at the outset of the claim. Within the letter, the findings of the Field Adjuster were communicated, as well as the relevant policy provisions upon which PTI was relying on. 6) ALLEGED VIOALTION §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). RESPONSE The subject claim and instant CRN involves a homeowner’s insurance policy and dispute and does not involve any allegations and/or facts related to personal injury. For that reason, PTI advises this alleged violation is irrelevant and hereby denied. CONCLUSION /SUMMATION As outlined above, PTI maintains that it has not been in violation of any law and that payment is not due or owing pursuant to the investigation findings, as well as the terms of the policy at issue. The CRN alleges that in order to “cure” the alleged violation, PTI must pay the Insured the remaining amount of insurance benefits available under the policy. However, PTI stands by its claim decision, has at all times acted in good faith with regard to the claim, and has not breached any duty owed. PTI further maintains that the CRN, as filed, is defective on its face as it fails to meet the specificity requirements of Florida Statute 624.155. Should the Department require additional information, please do not hesitate to contact us. Very truly yours, /S/ Cosima Ortiz Cosima Ortiz, Esq. Corporate Counsel People’s Trust Insurance Company Cc: Logan C. Templeton, Esq. 1000 Legion Place, Ste. 1200 Orlando, Fl 32801 E-mail: logant@southmilhausen.com
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