Filing Number: 795332
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| Filing Accepted: 12/4/2024 |
| Last/Business Name
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METZGER
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First Name |
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CAMERON |
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| Street Address
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2171 LAKEVIEW DRIVE |
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SEBRING,
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33870
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| Email Address
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CKAIGHN7@GMAIL.COM |
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Insured |
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| Last/Business Name* |
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METZGER |
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First Name |
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CAMERON |
| Policy # * |
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TMASDW318714 |
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Claim #* |
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4385783 |
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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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| Email Address * |
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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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UNDERWRITERS AT LLOYD'S, LONDON
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| Insurer Name* |
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NAIC Company Code |
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| Name of individual responsible for violation (if any):*
ANGELA MATTINGLY, DAVID WILLETTE, BRENDAN KIRKPATRICK, AND ANY OTHER INDIVIDUAL FROM, OR AGENT OF, CERTAIN UNDERWRITERS AT LLOYDS, LONDON SUBSCRIBING TO POLICY NO. TMASDW318714, OR CRAWFORD & COMPANY, U.S. PROPERTY & CASUALTY WHO WAS INVOLVED IN THE
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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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Misrepresenting the terms of the insurance policy
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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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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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| 624.155(1)(b)(3) |
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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.
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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)(c) |
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Failing to acknowledge and act promptly upon communications with respect to claims.
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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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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 60 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. 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 60 days after the insurer receives notice of the claim, or made after the expiration of any additional timeframe provided to pay or deny a claim or a portion of a claim made pursuant to an order of the office finding factors beyond the control of the insurer, 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.
627.444(2)(a) Notwithstanding any other law, an insurer shall provide to an insured within 15 calendar days after an individual or entity designated by the insurer receives the insured's written request, either: A loss run statement;
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.
Certain Underwriters at Lloyds, London Subscribing to Policy No. TMASDW318714 (the "Insurer") has committed the following in handling the Insured's claim: 1) failure to act in due diligence and good faith to resolve claims; 2) placing the financial interest of Insurer before that of the policyholder and 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) shifting the burden of investigating the loss onto the Insured; 10) failing to render a claims determination within sixty (60) days; 11) failing to provide a loss run statement; and 12) misrepresenting the terms of the insurance policy.
On or about April 24, 2023, while the subject policy was in full force and effect, the Insured's suffered a loss caused by wind. The areas impacted include but are not limited to the roofing system, exterior surfaces, upstairs den, back porch, front porch, foyer, guest bedrooms, hallways, windows, and doors. The Insured timely submitted a claim on February 13, 2024, to the Insurer for wind damage and the ensuing damage therefrom. Given the scope and nature of the damage, the Insured retained a public adjuster. After assessing the damage and the true scope of repairs, the public adjuster prepared an estimate identifying $111,657.82 in covered damage to the dwelling. The foregoing estimate, photographs, and a letter of representation from the public adjuster were sent to the Insurer who thereafter assigned claim number 4385783 to the loss and sent a field adjuster to inspect the property on March 14, 2024.
It was not until June 24, 2024, one-hundred thirty-two (132) days after the insured reported their loss, that the Insurer issued a coverage determination letter in which it notified the Insured that it was denying coverage for the loss. The Insurer misrepresented the loss and issued a wrongful denial. The Insurer based this denial on the rationale that the damage sustained was a result of " wear and tear, deterioration and prior deficiencies." As the discovery process will uncover, the Insurer's adjuster intentionally ignored the damage observed and has failed to make truthful and unbiased reports of the facts following the investigation. Although the Insurer and Insured are in dispute about how the dwelling was damaged, 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 observed damage 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 Insurer'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 Insurer'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 their 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.
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. 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.
The Insurer has placed obstacles to the Insured's ability to have the claim adjusted promptly to begin restoring the home by waiting more than sixty (60) days after receiving notice of the loss to make a claims determination. Under Fla. Stat. 627.70131(7)(a), "[w]ithin 60 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 and are currently 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.
Furthermore, the Insurer and its agents failed to comply with Fla. Stat. 627.444 by not providing the Insured and the Insured's representatives with a loss run statement. On September 23, 2024, the Insured's legal counsel provided the Insurer with a letter of representation. Within the letter, legal counsel requested a copy of a loss run statement. The Insurer and its agents have not acknowledged the request for a loss run statement nor has a loss run statement been provided. Upon an Insurer receiving a written request for a loss run statement, the Insurer is required, within fifteen (15) calendar days, to provide either a loss run statement or information on how to obtain a loss run statement at no charge through a consumer reporting agency. There has been no response within fifteen (15) calendar days of the Insured's written request and the Insurer has not provided information on how to obtain a loss run statement at no charge through a consumer reporting agency. This Insurer has breached its duty to settle claims in good faith when, under all the circumstances, it could and should have done so. The Insurer and its agents have not acted fairly and honestly toward the Insured and the Insured's representative and have moreover failed or refused to promptly acknowledge the Insured's communications in an attempt to frustrate and delay the resolution of the Insured's claim.
Additionally, Insurer shifted the burden and cost of investigating and insuring the loss onto the Insured. During their investigation, the insurer's adjuster did not use a moisture meter, despite the presence of interior water damage. A moisture meter can be purchased online from Amazon for around $40 before tax. The Insurer could purchase a moisture meter and assess thousands of properties with one meter. Instead, the Insurer would rather place its financial interests over those of the Insured by failing to provide the adjuster with the necessary tools to correctly inspect the loss. As a result of the inadequate investigation and surrounding circumstances it is apparent that the Insurer significantly underestimated the scope of the loss to the Insured's property. The Insurer and its adjuster have colluded to misrepresent the true scope of damages to the insured property and the true replacement costs of the damages.
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 denied coverage for a loss that should have been covered under the subject policy. 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. Shifting the burden of investigating onto the Insured
10. Conducting inadequate investigations
11. Failing to render a written claims determination to the Insured within 60 days pursuant to Florida Statute 627.70131
12. Failing to provide a loss run statement
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:
Certain Underwriters at Lloyds, London Subscribing to Policy No. TMASDW318714
c/o: Crawford & Company, U.S. Property & Casualty
1605 N. Cedar Crest Blvd, Suite 407
Allentown, PA 18104
uslondonhub@us.crawco.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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