Civil Remedy Filing

Civil Remedy Notice of Insurer Violations

Filing Number: 792857

Filing Accepted: 11/18/2024

Print Filing

Complainant

Last/Business Name *

MARTINEZ

First Name

JULIO

Street Address *

770 PONCE DE LEON BLVD, STE 101

City, State Zip *

CORAL GABLES, FL 33134

Email Address *

JULIO@MSPGLAWGROUP.COM

Complainant Type: *

Other

Insured

Last/Business Name*		CABALLERO		First Name		AGNES
Policy # *		W013032711		Claim #*		3300478900

Attorney

Attorney is Applicable

Last Name*	MARTINEZ First Name * JULIO Initial
Street Address*		770 PONCE DE LEON BLVD, STE 101
City, State Zip*		CORAL GABLES , FL 33186
Email Address *		JULIO@MSPGLAWGROUP.COM

Violation

Insurer Type *		Authorized Insurer Unauthorized Insurer

Insurer Name
Insurer Name*		TOWER HILL INSURANCE EXCHANGE
Insurer Name*
Street Address*
City, State Zip*		,
NAIC Company Code 17179

Name of individual responsible for violation (if any):* UNKNOWN
Type of Insurance * Residential Property & Casualty

Reason for Notice *

Unsatisfactory Settlement Offer

* Statutory provision(s) which the insurer allegedly violated.

	624.155(1)(b)(1)		Not attempting in good faith to settle claims when, under all the circumstances, it could and should have done so, had it acted fairly and honestly toward its insured and with due regard for her or his interests.
	626.9541(1)(i)(2)		A material misrepresentation made to an insured or any other person having an interest in the proceeds payable under such contract or policy, for the purpose and with the intent of effecting settlement of such claims, loss, or damage under such contract or policy on less favorable terms than those provided in, and contemplated by, such contract or policy.
	626.9541(1)(i)(3)(a)		Failing to adopt and implement standards for the proper investigation of claims.
	626.9541(1)(i)(3)(b)		Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.
	626.9541(1)(i)(3)(d)		Denying claims without conducting reasonable investigations based upon available information.

* 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 – PERILS INSURED AGAINST A. COVERAGE A – DWELLING AND COVERAGE B – OTHER STRUCTURES 1. We insure against direct physical loss to the property described in Coverage A and B . . . Narrative:

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

On or about November 15, 2023, while the Policy was in full force and effect, the Property sustained damages due to Wind (hereinafter referred to as “Loss”). The Insurer assigned claim number 3300478900. However, after conducting an investigation on the subject claim, Insurer has failed to honor Insureds’ claim and, instead, denied said claim in full. As such, Insurer has failed to fully, or even 2 partially, indemnify the Insureds as it was contractually obligated to do pursuant to the subject Policy. After a lawsuit commenced, the insurer sent the policyholder a notice of nonrenewal, presumably because there is an open claim. Insurer violated numerous Florida Statutes in its handling of Insureds’ claim. Insurer did not attempt in good faith to settle claims when, under all circumstances, it could and should have done so, made a material misrepresentation for the purpose and with the intent of effecting settlement of such claims, loss or damage on less favorable terms than those provided in the policy, and misrepresented pertinent facts or insurance policy provisions relating to Coverages at issue. [626.9541(1)(i)(2)] [626.9541(1)(i)(3)(b)] [624.155(1)(b)1] Further, by ignoring obvious damage resulting from the claim, Insurer failed to adopt and implement standards for the proper investigation of claims, and effectively denied the remained of Insureds’ claim without conducting reasonable investigations based on available information. [626.9541(1)(i)(3)(d)] [626.9541(1)(i)(3)(a)] Insurer can cure this breach by paying insurance monies due and owed to the Insureds that would reasonably place them back to their pre-loss condition, as well as compensating the Insureds for incurred Additional Living Expenses, as well as any and all reasonable attorney’s fees and costs incurred to them to date in connection with this claim and stemming from the aforementioned violations by the Insurer. This notice is given in order to perfect the right to pursue the Civil Remedy Authorized by this section. Further, by closing this claim out, per the terms and conditions of the policy as alleged by the insured, they will be able to obtain insurance on their property. Insurer did not attempt in good faith to settle claims when, under all 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, specifically when it refused to renew the policy of insurance with the insured. [624.155(1)(b)1]

Comments

User Id		Date Added		Comment
sseale@wallenkelley.com		01-17-2025		January 17, 2025 Florida Department of Financial Services Consumer Assistance/Civil Remedy Section Larson Bldg., 200 E. Gaines Street Tallahassee, Florida 32399-0322 Re: Complainant: Julio Martinez, Esq. Address: 770 Ponce de Leon Blvd., Suite 101, Coral Gables, Florida 33134 Email: julio@mspglawgroup.com Insured: Agnes Caballero Insured Address: 7852 W 14th Avenue, Hialeah, Florida 33014 Policy #: W013032711 Claim #: 3300478900 Attorney: Julio Martinez, Esq. Address: 770 Ponce de Leon Blvd., Suite 101, Coral Gables, Florida 33134 DOI File #: 792857 Date of Acceptance: November 18, 2024 To Whom It May Concern: Please accept this as the response of Tower Hill Insurance Exchange (“Tower Hill”) to the Civil Remedy Notice filed by the Complainant. (It should be noted from the onset that the Complainant is NOT an insured.) As the Complainant is not an Insured the instant Civil Remedy Notice is fatally deficient. Notwithstanding the aforementioned deficiency, Tower Hill’s response is specifically in regard to Claim 3300478900. The Insured’s property located at 7852 W 14th Avenue, Hialeah, Florida 33014 was insured by Tower Hill under policy W013032711 with the effective dates of that Policy being August 6, 2023 through August 6, 2024 and was in effect on the alleged date of loss, November 15, 2023. Statement of Facts This matter arises from an alleged windstorm claim which purportedly resulted in damage to the Insured’s Hialeah property. For the convenience of the reader, I have broken down the Statement of Facts that will detail Tower Hill’s handling of the file. I. Claim 3300478900 The instant claim was reported to Tower Hill on November 28, 2023, (13 days after the alleged date of loss) as a result of an alleged windstorm. After receipt of the claim, Tower Hill immediately assigned a claim number, 3300478900, and assigned a Claims Examiner to the file. Tower Hill also sent the Insured a Claim Acknowledgement Letter which informed her of her Right to Mediation and included a Homeowner Claims Bill of Rights. Thereafter, Tower Hill assigned Glory Rivera of Bluegrass Insurance Management, LLC, a licensed field adjuster, the task of inspecting the Insured’s property. On November 29, 2023, the Insured’s Public Adjuster, The Public Adjusters Advantage Corp. (“PA”) sent Tower Hill its Contract. The following day, Tower Hill sent a letter to the Insured and her PA to advise them that it was rejecting the PA’s contract because it did not comply with Florida Law. The letter clearly stated that “Please be advised we are in receipt of your Public Adjuster’s contract dated (11/15/2023). Unfortunately, the contract is not valid as per Florida Statute 626.8796 and 626.854 as it is deficient in the following ways: 1. The Letter of Representation was submitted on 11/29/2023, it was signed on 11/15/2023. Due to the Florida State Statute it must submitted to the Insurance company within 7 days of execution. This letter was not submitted until 14 days after execution. 2. The contract does not the title of “Public Adjuster Contract” prominently as well as the Florida Fraud Warning Statement in minimum 18-point bold type before the reserves space for signatures, and the remainder of the contract is in 12-point type. We would ask that a valid contract be submitted as soon as possible if your intent is to be represented by a licensed Public Adjuster. Therefore, until a valid contract is received by us, we can only discuss the adjustment of your claim with you, or other Insureds as so defined by the policy.” Thereafter, on December 1, 2023, the Insured’s PA sent Tower Hill its Letter of Representation, Contract, and W-9. On December 5, 2023, the Insured’s PA sent Tower Hill its Amended Contract. That same day, Tower Hill emailed the Insured’s PA and informed them that their Amended Contract was still non-compliant with Florida Law and that a compliant contract needed to be submitted. On December 8, 2023, Ms. Rivera inspected the Insured’s property. During that inspection, Ms. Rivera took photographs of the property and prepared a report which contained her findings. Later that day, the Insured’s PA sent Tower Hill its Letter of Representation, 2nd Amended Contract, and W-9. After reviewing the materials from Ms. Rivera, Tower Hill retained an engineering firm, ProNet Group, Inc., to determine the cause and origin of the claimed damage. On December 13, 2023, Tower Hill sent a Reservation of Rights Letter that informed the Insured and her PA that an engineer was being retained to re-inspect the property. The letter clearly stated that “You have submitted a claim to Tower Hill Insurance Exchange Company, hereinafter referred to as Tower Hill, for loss or damage to your property resulting from Windstorm. Tower Hill is conducting a claim investigation to ascertain the cause of the loss, evaluate the extent of the loss, and determine its obligations under the policy for your claim. We have received and reviewed the Field Adjuster’s report and after reviewing the report we are not able to make a determination at this time. We are making a referral for an expert to inspect the reported damage to assist with our investigation. At this time we are pending a recorded statement. Please schedule with me a day a time for a recorded statement. Tower Hill will be retaining the services of qualified engineer to inspect the property and make certain determinations regarding the cause & origin of the loss and extent of the loss. Please note that on average it can take 2-3 weeks post the date of inspection for the report to be submitted. Tower Hill will undertake an investigation into the above referenced loss before making any decision with regard to applicable coverages under the policy… We are here to assist you with understanding the repair and claims process. If you are ever in need of information or would like to share information pertaining to any aspect of your claim, please contact me and I would be happy to address any questions or concerns you may have. We appreciate your business and we look forward to working with you to conclude your claim.” That same day, the Insured’s PA sent Tower Hill a copy of its estimate. On December 26, 2023, Estuardo Terraza, P.E. of ProNet Group, Inc. inspected the Insured’s property. During the inspection, Mr. Terraza took photographs of the property and prepared a report which contained his findings. After reviewing the materials from Mr. Terraza, Tower Hill sent a denial letter to the Insured and her PA via email on January 19, 2024, which specifically informed them that coverage was not being afforded for the loss. The letter clearly stated that “After a complete and thorough investigation, it has been determined that the claim you have presented to Tower Hill Insurance Exchange Company for damage does not qualify for payment. As part of our investigation, we engaged the services of an engineer from ProNet Group to inspect the reported damage at the property. Per their inspection they found no evidence of any wind and or any storm related damage to the home. The reported damage to the roof tiles was from normal age-related wear, tear and deterioration. Along with foot traffic, expansion/contraction of the tiles. The water damaged ceiling drywall in the living room was consistent with rainwater entering the home because of the condition of the roof. The stains on the ceiling of the South side of the family room was from long term water exposure from rainwater of the roof covering. The stained and cracked ceiling drywall is from condensation buildup on the A/C register which has been going on for many years and is from long term water exposure. Unfortunately, the damages and causes of the damages all fall under categories that are not covered by the policy. For water intrusion to be covered the damages must have been caused by a covered peril under the policy. In this situation that did not happen for this claim, and we will have to deny the damages for this claim. We regret that we are unable to be of greater assistance to you in this instance. However, if you have any information that you believe would alter our current understanding, please feel free to contact us to discuss this matter further…” In the email, Tower Hill also informed the Insured and her PA of the next steps that they could take if they did not agree with the coverage decision. The email clearly stated that “I am aware you may not be in agreement with these findings. Mediation is available for you to have your claim reviewed by a third party representative. I have attached the brochure for that process as well. Please feel free to contact me with questions after you have reviewed the denial letter.” That same day, A1 Mold Assessors (“A1”) sent Tower Hill its Invoice, Certificate of Mold Analysis, Mold Report, W-9, Contract, and Photo Report. On January 22, 2024, Tower Hill emailed A1 and informed them that no payment would be forthcoming because the claim had been denied. Thereafter, on February 28, 2024, the Insured’s PA emailed Tower Hill and requested a certified copy of the Policy. The next day, Tower Hill sent the Insured’s PA a copy of the Policy. On March 14, 2024, the Insured’s counsel, M.S.P.G. Law Group, P.A., filed a Notice of Intent to Initiate Litigation. Provided with the Insured’s Notice of Intent to Initiate Litigation was the Insured’s counsel’s Letter of Representation and a copy of the PA’s estimate. On March 15, 2024, Tower Hill sent its response to the Insured’s Notice of Intent to Initiate Litigation to the Insured and her counsel. In its response, Tower Hill stated that “As you are aware, Tower Hill Insurance Group issued an insurance policy to you with effective dates of coverage from 08/06/2023 through 08/06/2024. This policy was issued subject to the terms, conditions, limitations, exclusions, and endorsements contained within the policy. On 11/28/2023, you reported to Tower Hill a claim for damage to the insured property. After investigation and careful consideration, Tower Hill concluded that the claim was not covered by the policy. You were made aware of these conclusions in correspondence dated 01/19/2024. Tower Hill received a Notice of Intent to Litigate filed by a law firm acting on your behalf. As part of its review of the Notice of Intent to Initiate Litigation, Tower Hill has again considered the circumstances of your claim and is confident in the determinations made regarding the claim… If you have any information that you believe would alter our current understanding, please feel free to contact us to discuss this matter further using the contact information supplied below.” Thereafter, on May 9, 2024, the Insured’s counsel withdrew the Insured’s Notice of Intent to Initiate Litigation and filed a second Notice of Intent to Initiate Litigation. Provided with the Insured’s second Notice of Intent to Initiate Litigation was a Letter of Representation from the Insured’s counsel and a copy of the PA’s estimate. On May 10, 2024, Tower Hill sent its response to the Insured’s second Notice of Intent to Initiate Litigation to the Insured and her counsel. In its response, Tower Hill stated that “As you are aware, Tower Hill Insurance Group issued an insurance policy to you with effective dates of coverage from 08/06/2023 through 08/06/2024. This policy was issued subject to the terms, conditions, limitations, exclusions, and endorsements contained within the policy. On 11/28/2023, you reported to Tower Hill a claim for damage to the insured property. After investigation and careful consideration, Tower Hill concluded that the claim was not covered by the policy. You were made aware of these conclusions in correspondence dated 01/19/2024. Tower Hill received a Notice of Intent to Litigate Notice Number 188658 filed by a law firm acting on your behalf. As part of its review of the Notice of Intent to Initiate Litigation, Tower Hill has again considered the circumstances of your claim and is confident in the determinations made regarding the claim… If you have any information that you believe would alter our current understanding, please feel free to contact us to discuss this matter further using the contact information supplied below.” Soon thereafter, on June 25, 2024, Tower Hill was served with a lawsuit. Throughout the entire claims process, Tower Hill was in constant communication with the Insured and her PA regarding the status of the claim. Tower Hill would also like to note that the Insured never provided a recorded statement. II. Nature of the Complainant’s Civil Remedy Complaint In the Civil Remedy Notice, the Complainant alleges Tower Hill: (1) made an unsatisfactory settlement offer, (2) failed to attempt in good faith to settle the claim, (3) made a material misrepresentation to the insured, (4) failed to adopt and implement standards for the proper investigation of the claim, (5) misrepresented pertinent facts or insurance policy provisions relating to coverage for the claim, and (6) denied the claim without conducting a reasonable investigation based upon the available information. These boilerplate accusations are misleading, inaccurate, and unfair given the nature of the facts and damages surrounding this claim. Here, the claim was thoroughly processed, the Insured’s property was inspected multiple times, and a coverage letter which outlined the pertinent facts and included the reasoning behind the coverage decision was sent to the Insured and her Public Adjuster. Moreover, the Complainant has not included a specific cure for their Civil Remedy Notice. Instead, they merely state: “Insurer can cure this breach by paying insurance monies due and owed to the Insureds that would reasonably place them back to their pre-loss condition, as well as compensating the Insureds for incurred Additional Living Expenses, as well as any and all reasonable attorney’s fees and costs incurred to them to date in connection with this claim and stemming from the aforementioned violations by the Insurer.” In response, Tower Hill would state that the Complainant has failed to provide a proper “final cure” request in that they failed to list the FINAL amount for all damages, and thus, the insurer would be unable to cure the alleged violation. It should also be noted that the Complainant’s Civil Remedy Notice is deficient in the following aspects: • Failed to list a specific policy provision that was violated by Tower Hill. • Failed to list a specific individual that committed acts of bad faith. • Section 624.155(3)(b)(2), Florida Statutes, requires that the Civil Remedy Notice state with specificity the facts and circumstances giving rise to the violation. The Purported Notice does not supply facts or circumstances that explain the allegations. Rather, it includes false allegations, incorrect facts, and fails to explain how the purported facts constitute violations of Florida law. Thus, the Purported Notice is invalid for noncompliance with Section 624.155(3)(b)(2), Florida Statutes. • The Purported Notice improperly demands that Tower Hill pay attorney’s fees and costs. In Talat Enter., Inc. v. Aetna Cas. and Sur. Co., 753 So. 2d 1278, 1283 (Fla. 2000), the Florida Supreme Court adopted the following analysis by United States Magistrate Judge Glazebrook: The Court rejects as unsupported Talat’s contention that the insurer must not only pay the claim within the sixty-day window, but must also pay all compensatory damages that flow from any delay in settling the claim. Section 624.155 does not impose on an insurer the obligation to pay whatever the insured demands. The sixty-day window is designed to be a cure period that will encourage payment of the underlying claim, and avoid unnecessary bad faith litigation. Surely an insurer need not immediately pay 100% of the damages claimed to flow from bad faith conduct in order to avoid the chance that the insured will succeed on a bad faith cause of action. If the insurer may avoid a bad faith action only by paying in advance every penny of the damages that it faces if it loses at trial, the insurer would have no reason to pay. Furthermore, few insureds would restrict their demands to compensatory damages. There is no reason why insureds would not demand also the advance payment of punitive damages and attorney’s fees. Section 624.155(2)(d) would have no effect or purpose under such an interpretation. The law does not support such an expansive and illogical reading of Fla. Stat. Ann. § 624.155(2)(d). See Talat, 753 So. 2d 1278, at 1282 (emphasis added). III. Conclusion As can be seen from the above, Tower Hill has credible evidence to support its belief that the claim was properly adjusted. The claim has been thoroughly processed, the Insured’s property was inspected multiple times, and a coverage letter which outlined the pertinent facts and included the reasoning behind the coverage decision was sent to the Insured and her Public Adjuster. Furthermore, Tower Hill believes that the Complainant’s position is untenable due to the facts surrounding the claim. Tower Hill has spent considerable time and resources in the investigation of this matter and believes that its efforts were made in good faith and based on the information available at the time of the claim. In turn, this Civil Remedy Notice unfairly characterizes the facts of the Insured’s claim and unfairly paints Tower Hill in a negative light. Finally, the Civil Remedy Notice is deficient in that it fails to specifically identify a number of highly relevant details concerning this claim, as well as failing to meet the requirements under 624.155. Sincerely, Sheldon A. Seale, Esq. On Behalf of Tower Hill Insurance Exchange

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