Civil Remedy Notice of Insurer Violations
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Filing Number:     794313
Filing Accepted:  11/26/2024
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Complainant
Last/Business Name *  
SUBRAHMANIAN   First Name   JAYRAM AND RAJALAKSHMI
Street Address * 11851 NW 10TH PL
City, State Zip * CORAL SPRINGS, FL 33071
Email Address * SDC@WEKLAW.COM
Complainant Type: * Insured
Insured
Last/Business Name*   SUBRAHMANIAN   First Name   JAYRAM AND RAJALAKSHMI
Policy # * EDH5339178-01 Claim #* EDI962271
Attorney
Attorney is Applicable
Last Name* CHOKSHI First Name * SAURIN Initial
Street Address* 800 EAST BROWARD BOULEVARD, SUITE 510
City, State Zip* FORT LAUDERDALE , FLORIDA 33301
Email Address * SDC@WEKLAW.COM
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   EDISON INSURANCE COMPANY
NAIC Company Code 12482
 
Name of individual responsible for violation (if any):* MARK TISHMAN
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Denial
Claim Delay
Unsatisfactory Settlement Offer
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.
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)(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.
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

The Loss Payment/Loss Settlement provision found in the homeowner's policy authorizes payment in the event of a covered loss to insured property.
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

At all times material hereto, Edison Insurance Company (“Edison”) insured Jayram and Rajalakshmi Subrahmanian’s (the “Insureds”) home under a policy of insurance. The subject policy provides coverage for sudden and accidental losses and damages arising from water claims/windstorms/hurricanes. The loss payment provision and governing law provides that the insurer has a fiduciary duty to in good faith promptly investigate, adjust, and issue payment of the undisputed amount of the loss and damages. See Doe v. Allstate Ins. Co., 653 So. 2d 371, 374 (Fla. 1995) (stating that the obligation of insurance company toward insured is a "fiduciary duty requiring the exercise of good faith"). Edison failed to pay the insureds’ claim under the homeowners’ insurance policy when, under all of the circumstances, it could and should have done so, had it acted fairly and honestly and with due regard for the interests of insured. Edison failed to act with diligence and thoroughness in investigating the facts specifically pertinent to coverage. Edison failed to attempt to settle the liability claim in the face of the coverage dispute. Edison failed to assess the substance of the coverage dispute or the weight of legal authority on the coverage issue. Edison has a regular business practice of failing to adequately evaluate its policyholder’s claims and undervalues the claims to save itself money. It is clear that the insurer’s general business practice of willful, wanton, immoral, deceptive and bad faith claim handling policies, procedures, adjusting, investigating has caused the insured to suffer further harm and extra-contractual damages which have accrued, and will continue to accrue. That said, and even though Edison knows that it has a fiduciary duty to promptly adjust insurance claims, it failed to institute the necessary policies, procedures, guidelines and protocols to adjust insurance claims promptly and pursuant to the policy’s Loss Payment Provision. By way of cited legal authorities and considerations, Edison knew that it had an obligation to treat all insureds equally and honestly. However, and for their own financial interest, they will only start to fully consider their obligations as stated herein if the insured retains legal representation and pursues a legal action which exposes them to liabilities and costs. Even then, they will withhold monies owed in an unjust effort to limit/delay their liabilities in relation to the statutory considerations and otherwise. To cure the above stated immoral, deceptive, unlawful and generally described bad faith conduct which is part of a general business practice that is knowingly being utilized by Edison for self-gain, Edison must: (1) accept coverage for the subject claim; (2) promptly make payment pursuant to the policy’s Loss Payment/Loss Settlement Provision for covered damages in the amount of $334,004.00 (3) tender interest on any overdue payments; and (4) acknowledging liability for taxable cost and reasonable attorneys in the pending lawsuit. Comments
Comments
User Id Date Added Comment
hgoldman@klaubergoldman.com 01-16-2025 This firm represents Edison Insurance Company (Edison). This letter is their response to the Civil Remedy Notice filed with the Department of Financial Services on behalf of Jayram Subrahmanian and Rajalakshmi Subrahmanian (the “Insured”) under filing number 794313 (the “CRN”). THE CRN IS DEFICIENT AS A MATTER OF LAW This CRN is misapplied using general statements and it does not meet the statutory requirements or the case law that interprets those requirements. There are five pieces of information which must be included in a CRN along with fifteen requirements noted on the Department of Financial Services form that must be stated with specificity. You have not provided the requisite information or met those specificity requirements. The statutes governing the Civil Remedy Notice require fair notice to the carrier and an opportunity to cure legitimate issues in the handling of a claim. The sixty-day window following notice to the carrier is designed to be a cure period during which a carrier can identify the specific claims raised in the Civil Remedy Notice and correct the circumstances giving rise to a legitimate violation. Because the statutes are in derogation of the common law, the requirements, including the one for specificity, are strictly construed. You only provide conclusions that mirror the statutory language, but no specific details supporting any of those conclusions. The strict construction of §624.155 demands a specificity level of compliance with the requisite provision of information to the Department of Financial Services and Edison. This is not new information, and you can confirm by reading Julien v. United Property & Casualty Insurance Company, 311 So.3d 875 (Fla 4th DCA 2021) and Demase v. State Farm Florida Insurance Company, 351 So.3d 136 (Fla 5th DCA 2022). Your CRN lacks specificity and has the same fatal flaws described in those cases. With no specificity, you cannot meet the requirements of Florida law to produce a valid Civil Remedy Notice. You should read Justice Sasso’s specially concurring opinion in Damase, which was decided shortly before she was appointed to the Florida Supreme Court. She discusses the “kitchen sink” approach to a Civil Remedy Notice, why it does not satisfy the specificity requirements of section 624.155, and why the design of the statute would crumble if a Civil remedy Notice like this one was permitted to meet the requirements for a claim of bad faith. You’ll learn why the plain language of section 624.155(3)(b) and (d) demonstrate that the required information is for the purpose of providing notice and an opportunity for the carrier to cure after it receives that notice. For those provisions to have meaningful operative effect, the substance of a Civil Remedy Notice must be stated in a way that enables the insurer to ascertain directly from the notice both the alleged violation and the steps it must take to cure the violation. Your CRN has no substance. There is not one claim-specific fact mentioned—it only cites statutory provisions and offers no specific policy language, which fails to meet the legal requirements of the statutes. You have cited to ten separate statutory violations and four different reasons for the CRN but have not articulated any facts that support any of them. You reference the results of Edison’s coverage determination, but you don’t explain why you think that decision was wrong. Instead, you skip to conclusions about how and why that decision was reached. For instance, there is no explanation supporting the assertion that the carrier failed to “promptly notify the Insured of any additional information necessary” to process the claim or how it failed to “clearly explain the nature of the requested information.” Similarly, you do not explain how Edison failed to “promptly provide a reasonable explanation in writing to the Insured” regarding the claim denial or how the carrier denied the claim “without conducting reasonable investigations based upon available information.” If you could articulate how you arrived at those conclusions, then we would be able to address any legitimate concerns. You didn’t mention anything about how those alleged violations supposedly occurred or what evidence you relied on to draw those conclusions. The law also requires that you provide specific policy language relevant to the alleged violations. Instead, you cite to “Loss Settlement provision found in the homeowner’s policy authoriz[ing] payment in the event of a covered loss to insured property.” Your reference is not specific at all and there is no way for Edison to decipher that and address a legitimate issue. Considering that Florida statutes §624.1551 requires a policyholder to establish that the carrier breached the insurance contract as a prerequisite to a bad faith claim, you can’t have an effective Civil Remedy Notice without, at minimum, providing the specific language you believe was breached and the facts you relied on to reach that conclusion. You made no effort to do that, and the proper inference is that you didn’t do it because you can’t. Some other examples of the lack of specificity are: (1) you claim that there was a violation of §624.155(1)(b)(1), but you offer nothing explaining what was allegedly dishonest or unfair about Edison’s estimate, (2) you claim that there was a violation of §624.155(1)(b)(3), but don’t explain why you allege that Edison failed to settle a claim under one portion of the policy in order to influence a settlement under another portion of the policy, and (3) you allege a violation of §626.9541(1)(i)(3)(b), but you don’t explain which facts or policy provisions were misrepresented. I point out those examples, but there are others. The only thing I can tell from your CRN is that you don’t agree with Edison’s decision, and you can’t explain why—either by reference to the law, the facts, or the language of the policy. Failure to satisfy the requirement that the insured identify the specific statute and specific policy provision relevant to the alleged violation as well as facts and circumstances that you believe led to those violations, renders this CRN legally insufficient as a matter of law. Regardless, we provide the remainder of this response to demonstrate how this claim was properly handled. GENERAL RESPONSE TO CRN Edison performed all of its obligations under the insurance policy promptly, diligently and with due regard for the interest of the Insured. The CRN includes a list of alleged violations by Edison with respect to the handling of claim number EDI962271. None of those alleged violations have occurred and Edison denies that there was a violation of any of the Insured’s rights. For the reasons explained below, the CRN is deficient and not supported by the facts and circumstances surrounding the handling of the claim. When there is a proper basis for someone to file a Civil Remedy Notice, the law requires that you provide specific allegations supported by facts and references to specific policy provisions so that the carrier can investigate legitimate issues and have a fair opportunity to correct them. This claim was evaluated based on the results of a prompt and thorough investigation, which revealed no water damage caused by a storm-related opening or covered peril. Despite this finding, you decided not to address it and tell Edison why you think that determination was wrong or give it something to consider. Instead, without explanation, you claim that Edison, as a general business practice, “undervalues the claims to save itself money,” and you suggest that Edison should have paid $334,004.00 based on a public adjuster’s unsupported and biased opinion. If your position is that Edison intentionally violated Florida law or lacks standards for adjusting claims, you must also acknowledge the possibility that a public adjuster’s estimate could be inflated, designed to secure a windfall for themselves and attorney’s fees for you. With no specific facts, no specific policy language and no claim-specific articulation of your issues, you give Edison nothing to consider, and your CRN fails as a matter of law. Regardless of the lack of required specificity and other deficiencies, and without prejudice to raise those issues as defenses in any litigation and the basis for an award of attorney’s fees, we provide this response on behalf of Edison to demonstrate, with facts, how and why this claim was properly handled. FACTS SUPPORTING THE PROPER HANDLING OF THE CLAIM This claim was reported to Edison by the Insured’s public adjuster from Five Star Claims Adjusting on December 21, 2023 as an alleged loss from hurricane Ian, 450 days earlier on September 28, 2022. An independent field adjuster was assigned to the loss, met with the Insured, and performed an inspection of the property on January 6, 2024. The inspection revealed no storm-related damage to any surface of the roof, and the pool screen enclosure was intact. There was also no visible damage to the interior of the property, and nothing else anywhere on the property indicative of any storm-related damage. If you have seen the property or any pictures of it, you know that you can’t refute those findings. While a few cracked tiles were observed, there was no indication that the roof was destroyed or even affected by Hurricane Ian. Those findings are wholly consistent with the fact that the alleged cause of the damages occurred 450 days prior to the date the claim was reported. In the living room, there was a ½ square foot hole cut in the ceiling with no signs of water damage, along with a broken floor tile near the entryway, consistent with normal wear and tear. The field adjuster also identified 12 square feet of water stains on the textured ceiling of the office, caused by water intrusion from the left slope of the roof, which was undergoing repairs at the time of inspection. In bedroom #4, there was damaged wood flooring, and seven feet of baseboard removed, attributed to water intrusion from around the bedroom window. On January 15, 2024, Family First Mold and Water submitted invoices for its emergency mitigation services (EMS). A coverage determination letter dated January 22, 2024 was sent to the Insured. The letter explained that there was no coverage for this claim because there were no signs of water damage caused by a storm-related opening and there was evidence of prior and ongoing repairs to the tile roof. There was also no evidence of wind-related damage to any of the roof slopes. The letter also explained that there was no covered loss to the water stains observed on the ceiling because it was pre-existing and unrelated to Ian in any way. The water intrusion from the left slope of the roof was caused by either wear and tear, prior repair, or ongoing repairs. The letter included policy language clarifying the decisions. On January 24, 2024, a coverage determination letter was sent to Family First Mold and Water reaffirming its coverage decision. There is not one fact in your CRN explaining why you think the determination made by Edison was not correct, nor is there anything probative of bad faith. You disagree with something about that investigation and analysis, but your CRN does not explain why. It seems that you are suggesting that Edison is in bad faith because they did not pay the amount suggested by the public adjuster, who gets paid a percentage of the recovery and who came along almost a year and a half after Hurricane Ian and decided, with no evidence, that something occurred on that specific day. You appear to be relying completely on the opinion of, and estimate from, the public adjuster. The opinion is completely unsupported, and the estimate is a sham. Maybe you didn’t notice the issues with the estimate, but if you look at it carefully, you’ll agree that it is inflated and unsupported by the facts of the claim. The public adjuster claims that the cost to replace a 53.84 square foot roof is $193,018.87. That equates to about $3,585.05 per square for a tile roof. You can’t ethically argue that anyone would pay that much for a tile roof in South Florida. Nor would any legitimate contractor offer that price on an estimate that was not made to support an insurance claim. This is one major reason why the law recently changed in Florida—to eliminate claims like this. You don’t offer any explanation for your disagreement with Edison’s decision, but it appears to be based entirely on the public adjuster’s unsupported conclusion that the roof has to be replaced, and that Edison should pay an overinflated amount just because a public adjuster used Xactimate to create it. If you have seen the roof or any pictures of it, you know that the estimate is not legitimate, nor is the need for a roof replacement. But your opinion is that Edison should have ignored the field adjuster’s findings, replaced the roof even though there was no evidence of storm damage, and relied completely on the public adjuster, who gets compensated based on the amount paid by the carrier, in order to demonstrate good faith. That is not a tenable position. Edison did not violate any statutes and handled this claim diligently, fairly and pursuant to the terms of the insurance policy. CONCLUSION This response to the CRN clearly shows that Edison met its obligations to the Insureds in a fair and honest manner with due regard for their interest. Nothing in this letter, nor any action taken by this firm or by Edison, including by way of example and not limitation, investigations, defense, settlement or adjustment, will be construed as a waiver of Edison’s right to deny coverage, and is subject to a full reservation of rights We trust that this response adequately addresses any concerns that the Insured may have concerning this matter and the issues raised in the CRN. Please contact me if you need any additional information. Thank you for your attention to this matter.
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