Filing Number: 794984
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| Filing Accepted: 12/3/2024 |
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| Street Address
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4107 SOUTHWEST 11TH AVENUE |
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CAPE CORAL,
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33914
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| Email Address
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DENAMANNERS@ROGERS.COM |
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Insured |
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| Last/Business Name* |
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MANNERS |
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First Name |
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DENA |
| Policy # * |
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AGH0466550 |
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Claim #* |
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CHO-00153479 |
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Attorney is Applicable
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| Last Name* |
KRAPF
First Name *
GRANT
Initial
W
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| Street Address* |
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2790 SUNSET POINT RD |
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CLEARWATER
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FL
33759
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GRANT@KRAPFLEGAL.COM |
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| Insurer Type
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 Authorized Insurer
 Unauthorized Insurer
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| Insurer Name |
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| Insurer Name* |
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AMERICAN INTEGRITY INSURANCE COMPANY OF FLORIDA
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| Insurer Name* |
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NAIC Company Code 12841 |
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| Name of individual responsible for violation (if any):*
JOHN PALMER, RICK SCARBROUGH, AND ANY OTHER INDIVIDUAL FROM, OR AGENT OF, AMERICAN INTEGRITY INSURANCE COMPANY OF FLORIDA WHO WAS INVOLVED IN THE CLAIM.
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| Type of Insurance
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Residential Property & Casualty
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| Reason for Notice
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Claim Denial
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Claim Delay
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Unfair Trade Practice
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Other
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Not treating the Insured with good faith claims conduct
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Other
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Looking for ways to deny full recovery to the Insured
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Other
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Looking for ways to delay full recovery to the Insured
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Other
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Failing to properly investigate the Insured's loss
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Other
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Failing to provide the Insured with the full benefits awarded under the contract of insurance in a t
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Other
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Not training, supervising, or managing adjusters properly so that prompt and full payments are made
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Other
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Not adjusting claims and evaluating loss properly
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Other
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Shifting the burden of insuring the loss to the Insured
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Other
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Intentionally misstating the terms, conditions, and benefits of the insurance policy to the insured
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Other
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Failing to implement proper standards for the adjustment and investigation of claims
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Other
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Making material misrepresentations
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Statutory provision(s) which the insurer allegedly violated.
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| 624.155(1)(b)(1) |
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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.
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| 626.9541(1)(i)(2) |
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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.
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| 626.9541(1)(i)(3)(a) |
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Failing to adopt and implement standards for the proper investigation of claims.
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| 626.9541(1)(i)(3)(b) |
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Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.
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| 626.9541(1)(i)(3)(d) |
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Denying claims without conducting reasonable investigations based upon available information.
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| 626.9541(1)(i)(3)(i) |
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Failing to pay personal injury protection insurance claims within the time periods required by s. 627.736(4)(b).
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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
627.70131(7)(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. The insurer shall provide a reasonable explanation in writing to the policyholder of the basis in the insurance policy, in relation to the facts or applicable law, for the payment, denial, or partial denial of a claim. If the insurer's claim payment is less than specified in any insurer's detailed estimate of the amount of the loss, the insurer must provide a reasonable explanation in writing of the difference to the policyholder. 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 must 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. However, failure to comply with this subsection does not form the sole basis for a private cause of action.
Reference to specific policy language: The violations alleged are statutorily based and do not rely on any specific policy language. "It is an accepted principle of law that when parties contract upon a matter which is the subject of statutory regulation, the parties are presumed to have entered into their agreement with reference to such statute, which becomes a part of the contract, unless the contract discloses a contrary intention." Westside EKG Assocs. v. Found. Health, 932 So. 2d 214, 216 (Fla. 4th DCA 2005), aff'd, 944 So. 2d 188 (Fla. 2006).
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Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
American Integrity Insurance Company of Florida (the "Insurer") has committed the following in handling the Insured's claim: 1) failing to act in due diligence and good faith to resolve claims; 2) placing the financial interest of Insurer before that of the Insured; 3) looking for ways to deny benefit payments and otherwise "low ball" or "stone wall" claims; 4) not adjusting the claims promptly and fairly; 5) not attempting in good faith to settle claims; 6) conducting inadequate investigations; 7) failing to employ policies and procedures to conduct adequate investigations; 8) denying a claim which it knew or should have known the policy and Florida law provided coverage for; 9) failing to provide an estimate that complies with the Florida Building Codes; 10) making material misrepresentations; and 11) failing to render a claims determination within ninety (90) days.
On or about September 28, 2022, while the subject policy was in full force and effect, the Insured's property was severely damaged by Hurricane Ian. The areas impacted include but are not limited to the roofing system, exterior, pool area, kitchen, master bedroom, master bathroom, garage, and bedroom. The Insured timely submitted a claim on October 17, 2022, to the Insurer for hurricane damage and the ensuing damage therefrom. Thereafter, the Insurer assigned claim number CHO-00153479 to the loss and sent a field adjuster to inspect the property on November 1, 2022. Then in a letter dated February 11, 2023, the Insurer notified the Insured that it was extending partial coverage for the loss. However, the Insurer wrongfully determined that it would only require $4,128.31 to restore the insured property to its pre-loss condition, which failed to exceed the policy deductible. The Insurer's lowball estimate is that of a classic under scope and under value of the claim. The Insurer erroneously denied coverage for some of the Insured's roof damage as well as the Insured's interior damage.
Given the partial denial, the Insured's disagreement with the coverage decision, and the scope and nature of the damage resulting from Hurricane Ian, the Insured retained a general contractor. After assessing the damage and the true scope of repairs, the general contractor produced an estimate identifying $144,753.94in covered damage to the dwelling.
Upon receiving notice of the loss, the Insurer had the duty to provide the full benefits under the policy. This includes providing the Insured with a proper investigation and the funds necessary to return the home to its pre-loss condition. However, when the Insurer conducted its inspection of the insured property, the Insurer's adjuster failed to conduct a thorough and adequate investigation, or the adjuster intentionally ignored the damage observed and failed to make truthful and unbiased reports of the facts after investigating. As a result, the Insurer breached the policy by failing to fully indemnify the Insured for the covered loss.
The Insurer misrepresented the loss and wrongfully denied coverage for the damage sustained to the Insured's property. According to the claims determination letter, the Insurer's engineer observed damage to the roof and interior, but attributed the cause of this damage causes excluded under the policy. However, the Insurer knows or should know that when independent perils converge and no single cause can be considered the sole or proximate cause, it is appropriate to apply the concurring cause doctrine. Sebo v. Am. Home Assurance Co., 208 So. 3d 694, 697 (Fla. 2016). The concurring cause doctrine states that coverage may exist where an insured risk constitutes a concurrent cause of the loss even when it is not the prime or efficient cause. Id. at 698. A covered peril that meets with an uncovered peril may still provide for coverage under a policy when the covered peril triggered the events that eventually led to the loss. Id. at 697. The Insurer intentionally ignored covered damage to deny the reported loss and wrongfully fail to pay the Insured. This is an underhanded attempt to place the financial interests of the Insurer over those of the Insured and to delay and frustrate the Insured's ability to have his claim adjusted promptly to begin restoring his property.
Furthermore, the Insurer observed damaged to the roof but concluded no storm created openings were observed. The term "opening" is not defined by the policy. Cambridge English dictionary defines opening as "a hole or space that something or someone can pass through." https://dictionary.cambridge.org/us/dictionary/english/opening. Here, subsequent water damage was observed to the interior of the property, including the ceiling, of the Insured's home. As a result, the very simple question arises of "where did the water come from?" Utilizing the definition cited, the roof was damaged in a way that allowed something, here the water, to pass through the roofing structure and subsequently damaging the interior of the Insured's property. However, the Insurer is instead interpreting the ambiguous term "opening" in a method most against the Insured's interest, often utilizing it as a provision that requires a visible opening or even to the extent of a hole in which one can see through. When faced with this ambiguity in the policy the Insurer should err on the side of the Insured and not its bottom-line as is apparent in this matter and other claims like it. This duty is further emphasized by the Supreme Court of Florida who re-iterated in Berkshire Life Ins. Co. v. Adelberg, 698 So. 2d 828, 830 (Fla. 1997), that ""[i]t has long been a tenet of Florida insurance law that an insurer, as the writer of an insurance policy, is bound by the language of the policy, which is to be construed liberally in favor of the insured and strictly against the insurer. Citing Firemans Fund Ins. Co. v. Boyd, 45 So.2d 499, 501 (Fla.1950)." The Insurer is undoubtedly aware of this precedent and is handling the claims in abrogation of said case law.
Rather than the Insurer pay for a roof replacement consistent with all laws and ordinances, the Insurer contends the roof is repairable which is not true. All repairs to the roofing system must be done in accordance with applicable Florida Building Codes which require all repairs be done consistent with the manufacturer's specifications and warranties which this Insurer clearly did not account for.
The Insurer has placed obstacles to its Insured's ability to have the claim adjusted promptly to begin restoring the home by waiting more than ninety (90) days after receiving notice of the Insured's claim to make a claims determination. The Insured reported the loss on October 17, 2022, but the Insurer did not render a claims determination until February 11, 2023. Under Fla. Stat. 627.70131(5)(a), "[w]ithin 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." There were no factors outside of the Insurer's control. As the Insurer has failed to make a timely determination, it has violated this code. As such, in addition to the below requirements to cure this CRN, any payment made to the Insured must contain interest for the damage as a result of the loss from the date the Insurer received first notice of the loss.
The conduct outlined above is done within the Insurer's routine course of the business.
There may be further wrongful conduct which has not been made known to the Insured at this moment. Certain conduct or actions may be discovered throughout discovery or cannot be verified without a review of the Insurer's claim file and standards and procedures for the adjustment and investigation of claims.
In short, the Insurer is not acting with due regard for the Insured's interests or safety. In Florida the work of adjusting insurance claims engages the public trust. The Insurer has breached this trust and its duty to the Insured. The Insurer and its agents conducted cursory and inadequate investigations and wrongfully determined that it would only require $4,128.31 to restore the insured property to its pre-loss condition.
Moreover, the Insurer has engaged in bad faith practices designed to delay claims and prevent the Insured from recovering what is rightfully owed under the subject policy of insurance. The Insurer's actions and inactions have continued to frustrate and delay the resolution of the Insured claim.
The Insurer's actions amount to but are not limited to the following:
1. Claim denial
2. Claim delay
3. Not treating the Insured with good faith claims conduct
4. Looking for way to reduce recovery to the Insured
5. Looking for ways to deny recovery to the Insured
6. Not adjusting claims and evaluating loss properly, promptly and fairly to provide full and prompt indemnity to the Insured
7. Not training, supervising or managing adjusters properly so that prompt and full payments are made, but rather placing the company's interests before the Insured's' interests
8. Placing the financial interest of the Insurer over that of the health and safety of the Insured
9. Failing to provide an estimate that complies with the Florida Building Codes
10. Shifting the burden of investigating onto the Insured
11. Conducting inadequate investigations
12. Failing to render a written claims determination to the Insured within 90 days pursuant to Florida Statute 627.70131
13. Making material misrepresentations
Therefore, to cure the defects outlined in this civil remedy notice, the Insurer must:
(1). Admit full coverage for the Insured's loss.
(2). Tender full benefits owed to the Insured under the insurance contract.
A copy of this form submitted to the FDFS has been sent via e-mail to the following parties providing them notice of the filing of the civil remedy notice. Please e-mail any response to this civil remedy notice to badfaith@krapflegal.com.
Via E-mail:
American Integrity Insurance Company of Florida
5426 Bay Center Drive, Suite 650
Tampa, FL 33609
claimsmail@aiicfl.com
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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.
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DFS-10-363
Rev. 10/14/2008
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