Filing Number: 796706
|
| Filing Accepted: 12/12/2024 |
| Last/Business Name
*
|
|
|
MUNCK
|
|
First Name |
|
GARY F. AND PAMELA KAY |
|
| Street Address
*
|
|
12351 CANNON LANE |
| City, State Zip
*
|
|
FORT MYERS,
FL
33912
|
| Email Address
*
|
|
ZUKWIZ@GMAIL.COM |
| Complainant Type:
*
|
|
Insured |
|
| Last/Business Name* |
|
MUNCK |
|
First Name |
|
GARY F. AND PAMELA KAY |
| Policy # * |
|
W013052026 |
|
Claim #* |
|
3300506319 |
|
Attorney is Applicable
|
| Last Name* |
ROSS
First Name *
VANESSA
Initial
|
| Street Address* |
|
1800 2ND STREET, SUITE 892 |
| City, State Zip* |
|
SARASOTA
,
FLORIDA
34236
|
| Email Address * |
|
ESERVICE@ROSSLEGALFL.COM |
|
|
| 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):*
JACQUELENE WEEDMAN, FL LICENSE #E135965, AND ALL OTHER ADJUSTERS, SUPERVISORS, MANAGEMENT AND INDIVIDUALS ASSOCIATED WITH OR RETAINED BY TOWER HILL INSURANCE EXCHANGE INVOLVED IN THE CLAIM.
|
| Type of Insurance
*
Residential Property & Casualty
|
|
|
| Reason for Notice
*
|
|
|
Unsatisfactory Settlement Offer
|
|
|
Claim Denial
|
|
|
Claim Delay
|
|
|
Unfair Trade Practice
|
|
|
Other
:
Failure to properly investigate claim and with due regard to the INSUREDS’ interest
|
|
|
*
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)(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.
|
|
*
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 Insured(s) may not be in possession of a complete copy the applicable policy of insurance, however, the specific policy language relevant to the violations outlined below is contained within INSURER’S policy, Policy No. W013052026, issued to the Insured including, but is not limited to, the following:
HOMEOWNERS 3 SPECIAL FORM HOMEOWNERS Form No. HO 00 03 04 91
***
SECTION I – PROPERTY COVERAGES
***
COVERAGE A – Dwelling
We cover:
1. The dwelling on the "residence premises" shown
in the Declarations, including structures attached
to the dwelling; and
2. Materials and supplies located on or next to the
"residence premises" used to construct, alter or
repair the dwelling or other structures on the
"residence premises."
This coverage does not apply to land, including land
on which the dwelling is located.
COVERAGE B – Other Structures
We cover other structures on the "residence premises"
set apart from the dwelling by clear space. This
includes structures connected to the dwelling by only
a fence, utility line, or similar connection.
This coverage does not apply to land, including land
on which the other structures are located.
We do not cover other structures:
1. Used in whole or in part for "business"; or
2. Rented or held for rental to any person not a tenant
of the dwelling, unless used solely as a private
garage.
The limit of liability for this coverage will not be more
than 10% of the limit of liability that applies to Coverage
A. Use of this coverage does not reduce the
Coverage A limit of liability.
COVERAGE C – Personal Property
We cover personal property owned or used by an
"insured" while it is anywhere in the world. At your
request, we will cover personal property owned by:
1. Others while the property is on the part of the
"residence premises" occupied by an "insured";
2. A guest or a "residence employee," while the
property is in any residence occupied by an
"insured."
Our limit of liability for personal property usually
located at an "insured's" residence, other than the
"residence premises," is 10% of the limit of liability for
Coverage C, or $1000, whichever is greater. Personal
property in a newly acquired principal residence is not
subject to this limitation for the 30 days from the time
you begin to move the property there.
***
COVERAGE D – Loss Of Use
The limit of liability for Coverage D is the total limit
for all the coverages that follow.
1. If a loss covered under this Section makes that
part of the "residence premises" where you reside
not fit to live in, we cover, at your choice, either of
the following. However, if the "residence premises"
is not your principal place of residence, we
will not provide the option under paragraph b. below.
a. Additional Living Expense, meaning any
necessary increase in living expenses incurred
by you so that your household can maintain its
normal standard of living; or
b. Fair Rental Value, meaning the fair rental
value of that part of the "residence premises"
where you reside less any expenses that do
not continue while the premises is not fit to live
in.
Payment under a. or b. will be for the shortest
time required to repair or replace the damage or,
if you permanently relocate, the shortest time required
for your household to settle elsewhere.
***
ADDITIONAL COVERAGES
1. Debris Removal. We will pay your reasonable
expense for the removal of:
a. Debris of covered property if a Peril Insured
Against that applies to the damaged property
causes the loss; or
b. Ash, dust or particles from a volcanic eruption
that has caused direct loss to a building or
property contained in a building.
This expense is included in the limit of liability that
applies to the damaged property. If the amount to
be paid for the actual damage to the property plus
the debris removal expense is more than the limit
of liability for the damaged property, an additional
5% of that limit of liability is available for debris
removal expense.
We will also pay your reasonable expense, up to
$500, for the removal from the "residence premises"
of:
a. Your tree(s) felled by the peril of Windstorm or
Hail;
b. Your tree(s) felled by the peril of Weight of Ice,
Snow or Sleet; or
c. A neighbor's tree(s) felled by a Peril Insured
Against under Coverage C;
provided the tree(s) damages a covered structure.
The $500 limit is the most we will pay in any one
loss regardless of the number of fallen trees.
2. Reasonable Repairs. In the event that covered
property is damaged by an applicable Peril Insured
Against, we will pay the reasonable cost incurred
by you for necessary measures taken
solely to protect against further damage. If the
measures taken involve repair to other damaged
property, we will pay for those measures only if
that property is covered under this policy and the
damage to that property is caused by an applicable
Peril Insured Against.
This coverage:
a. Does not increase the limit of liability that
applies to the covered property;
b. Does not relieve you of your duties, in case of
a loss to covered property, as set forth in
SECTION I – CONDITION 2.d.
***
The Declarations Page
Loss Payment or Loss Settlement provisions
Duties in Event of Loss Policy provisions
The insurance policy's definition sections
The insurance policy's exclusion of coverage provisions
ORDINANCE OR LAW – AMOUNT OF COVERAGE HOMEOWNERS Form NO. HP-0477-00 (01/09)
SECTION I – PROPERTY COVERAGES
ADDITIONAL COVERAGES
11. Ordinance Or Law is deleted and replaced by
the following:
a. You may use up to the percentage shown on
the Declarations that applies to Coverage A
(or for Form HO 00 04, you may use up to the
percentage shown on the Declarations that
applies to Building Additions And Alterations)
for the increased costs you incur due to the
enforcement of any ordinance or law which
requires or regulates:
(1) The construction, demolition, remodeling,
renovation or repair of that part of a covered
building or other structure damaged
by a Peril Insured Against;
(2) The demolition and reconstruction of the
undamaged part of a covered building or
other structure, when that building or
other structure must be totally demolished
because of damage by a Peril Insured
Against to another part of that covered
building or other structure; or
(3) The remodeling, removal or replacement
of the portion of the undamaged part of a
covered building or other structure necessary
to complete the remodeling, repair or
replacement of that part of the covered
building or other structure damaged by a
Peril Insured Against.
b. You may use all or part of this ordinance or
law coverage to pay for the increased costs
you incur to remove debris resulting from the
construction, demolition, remodeling, renovation,
repair or replacement of property as
stated in a. above.
c. We do not cover:
(1) The loss in value to any covered building
or other structure due to the requirements
of any ordinance or law; or
(2) The costs to comply with any ordinance or
law which requires any "insured" or others
to test for, monitor, clean up, remove,
contain, treat, detoxify or neutralize, or in
any way respond to, or assess the effects
of, pollutants on any covered building or
other structure.
Pollutants means any solid, liquid, gaseous
or thermal irritant or contaminant, including
smoke, vapor, soot, fumes, acids,
alkalis, chemicals and waste. Waste includes
materials to be recycled, reconditioned
or reclaimed.
This coverage is additional insurance.
(This is Additional Coverage 10. In Form HO 00
06.)
All other provisions of this policy apply.
***
LIMITED FUNGI, MOLD, WET OR DRY ROT, OR BACTERIA COVERAGE ENDORSEMENT HOMEOWNERS Form No. RPI HO 09 FCE 09 16
1. Section I – Property Coverage Limit of Liability for the additional
Coverage "Fungi", Mold, Wet or Dry Rot, Or Bacteria
$ Each Covered Loss
$ Policy Aggregate
DEFINITIONS
The following definition is added:
“Fungi”
a. "Fungi" means any type or form of fungus,
including mold or mildew, and any
mycotoxins, spores, scents, or by-products
produced or released by fungi.
b. Under Section II, this does not include any
fungi that are on, or are contained in, a good
or product intended for consumption.
SECTION I – PROPERTY COVERAGES
ADDITIONAL COVERAGES
The following Additional Coverage is added:
12. "Fungi", Mold, Wet or Dry Rot, Or Bacteria
a. We will pay up to the amount stated in the
Declarations for Limit of Liability for “Fungi”
Coverage for:
(1) The total of all loss payable under Section
I – Property Coverages caused by or
resulting directly or indirectly from "fungi",
mold, wet or dry rot, or bacteria;
(2) The cost to remove "fungi", mold, wet or
dry rot, or bacteria from property covered
under Section I – Property Coverages;
(3) The cost to tear out and replace any part
of the building or other covered property
as needed to gain access to the "fungi",
mold, wet or dry rot, or bacteria; and
(4) The cost of testing of air or property to
confirm the absence, presence or level of
"fungi", mold, wet or dry rot, or bacteria
whether performed prior to, during or after
removal, repair, restoration or
replacement. The cost of such testing will
be provided only to the extent that there is
a reason to believe that there is the
presence of "fungi", mold, wet or dry rot,
or bacteria.
b. The coverage described in a. only applies
when such loss or costs are a result of a Peril
Insured Against that occurs during the policy
period and only if all reasonable means were
used to save and preserve the property from
further damage at and after the time the Peril
Insured Against occurred.
c. The Each Covered Loss amount shown in
the Schedule for this coverage is the most we
will pay for the total of all loss or costs payable
under this Additional Coverage resulting from
any one covered loss; and
The Policy Aggregate amount shown in the
Schedule for this coverage is the most we will
pay for the total of all loss or costs payable
under this Additional Coverage for all covered
losses, regardless of the number of locations
insured under this endorsement or number of
claims made.
d. If there is covered loss or damage to covered
property, not caused, in whole or in part, by
"fungi", mold, wet or dry rot, or bacteria, loss
payment will not be limited by the terms of this
Additional Coverage, except to the extent that
"fungi", mold, wet or dry rot, or bacteria causes
an increase in the loss. Any such increase
in the loss will be subject to the terms of this
Additional Coverage.
This coverage does not increase the limit
of liability applying to the damaged covered
property.
SECTION I – EXCLUSIONS
The following Exclusion is added:
"Fungi", Mold, Wet Or Dry Rot, Or Bacteria
"Fungi", mold, wet or dry rot, or bacteria meaning
the presence, growth, proliferation, spread or any
activity of "fungi", mold, wet or dry rot, or bacteria.
This Exclusion does not apply:
a. When "fungi", mold, wet or dry rot, or
bacteria results from fire or lightning; or
b. To the extent coverage is provided for in the
"Fungi", Mold, Wet or Dry Rot, Or Bacteria
Additional Coverage under Section I –
Property Coverages with respect to loss
caused by a Peril Insured Against other than
fire or lightning.
Direct loss by a Peril Insured Against resulting
from "fungi", mold, wet or dry rot, or bacteria is
covered.
(This is exclusion i. in Form HO 00 03.)
SECTION II – LIABILITY
CONDITIONS
Condition 1. Limit Of Liability is deleted and replaced
by the following:
1. Limit Of Liability
Our total liability under Coverage E for all damages
resulting from any one "occurrence" will not be more
than the Coverage E limit of liability shown in the
Declarations. All "bodily injury" and "property
damage" resulting from any one accident or from
continuous or repeated exposure to substantially the
same general harmful conditions will be considered
to be the result of one "occurrence".
However, our total liability under Coverage E for the
total of all damages arising directly or indirectly, in
whole or in part, out of the actual, alleged or
threatened inhalation of, ingestion
of, contact with, exposure to, existence of, or
presence of any "fungi:, mold, wet or dry rot, or
bacteria will not be more than the Section II–
Coverage E Aggregate Sublimit of Liability for
"Fungi", Mold, Wet Or Dry Rot, Or Bacteria. That
Sublimit is the amount shown in the Schedule. This
is the most we will pay regardless of the:
a. Number of locations insured under the policy
to which this endorsement is attached;
b. Number of persons injured;
c. Number of persons whose property is
damaged;
d. Number of "insureds"; or
e. Number of "occurrences" or claims made.
This sublimit is within, but does not increase, the
Coverage E limit of liability. It applies separately
to each consecutive annual period and to any
remaining period of less than 12 months, starting
with the beginning of the policy period shown in
the Declarations.
With respect to damages arising out of "Fungi", Mold,
Wet or Dry Rot, or Bacteria described in 1. Limit Of
Liability of this endorsement, Condition 2. Severability of
Insurance is deleted and replaced with the following:
2. Severability of Insurance
This insurance applies separately to each
"insured" except with respect to the Aggregate
Sublimit of Liability described in this endorsement
under Section II – Conditions 1. Limit Of Liability.
This condition will not increase the limit of liability
for this coverage.
SECTIONS I and II CONDITIONS
Condition 1. Policy Period is deleted and replaced by
the following:
1. Policy Period
This policy applies only to loss or costs in
Section I or "bodily injury" or "property
damage" in Section II, which occurs during
the policy period.
All other policy provisions apply.
***
HURRICANE DEDUCTIBLE ENDORSEMENT Form No. RPI HO 09 HD 09 18
For the premium charged, we will pay only that
portion of the total of the loss for all Section I
coverages that exceeds the Hurricane Deductible
shown on the Declarations page for loss during a
“hurricane occurrence”. Such deductible applies
regardless of any other cause or event contributing
concurrently or in any sequence to the loss. No other
deductible provision in the policy applies to loss
during a “hurricane occurrence”.
Definitions
“Hurricane occurrence” means a storm system that
has been declared to be a hurricane by the National
Hurricane Center of the National Weather Service,
with a duration that:
a. Begins at the time a hurricane watch or
hurricane warning is issued for any part of
Florida by the National Hurricane Center of
the National Weather Service;
b. Continues for the time period during which the
hurricane conditions exist anywhere in
Florida; and
c. Ends 72 hours following the termination of the
last hurricane watch or hurricane warning
issued for any part of Florida by the National
Hurricane Center of the National Weather
Service.
“Windstorm(s)” means wind, wind gusts, hail, rain,
tornadoes, or cyclones caused by or resulting from a
hurricane which results in direct physical loss or
damage to property. The National Hurricane Center of
the National Weather Service published data shall be
the source used to identify if such windstorm is
caused by or results from a hurricane.
Calendar Year Hurricane Deductible
The hurricane deductible shown in the Declarations
applies for direct physical loss or damage to covered
property caused by all “windstorms” as defined above.
A hurricane percentage deductible is determined by
applying the percentage of the Coverage A – Dwelling
limit of liability at the time of loss. In the event of a
single “hurricane occurrence”, we will pay only that
part of the total of all losses or damages payable
under Section I that exceeds the hurricane deductible
shown in the Declarations. The hurricane deductible
shown in the Declarations applies on a calendar year
basis.
If there are “windstorm” losses in a calendar year on
more than one policy issued by the same insurer or
an insurer in the same insurer group, the hurricane
deductible shall be the highest amount stated in any
one of the policies.
If you had a “windstorm” loss under the prior policy
during the same calendar year and you lower your
hurricane deductible under a new or renewal policy,
the lower hurricane deductible will not apply until
January 1 of the following calendar year.
If there was a “windstorm” loss for a prior “windstorm”
or “windstorms” during the calendar year, we may
apply a deductible to the subsequent “windstorm” that
is the greater of:
a. The remaining amount of the hurricane
deductible; or
b. The amount of the deductible that applies to all
other perils.
In the event you should have any “windstorm” loss
which is less than your hurricane deductible, you must
report the loss to us so that such losses may be
applied to subsequent “windstorm” claims during the
same calendar year.
Except as specifically modified in this endorsement,
all provisions of the policy to which this endorsement
is attached also apply to the endorsement.
***
SPECIAL PROVISIONS – FLORIDA HOMEOWNERS Form No. RPI HO 09 SP3 08 21
***
SECTION I – PROPERTY COVERAGES
COVERAGE A – Dwelling
Item 1. is deleted and replaced by the following:
1. The dwelling on the “residence premises” used
mainly as your private residence, including
attached structures and attached wall-to-wall
carpeting if damage to the dwelling is caused by a
covered loss;
The following Item 3. is added:
3. In-ground swimming pools including related
permanently installed equipment such as pumps
and filters.
COVERAGE B – Other Structures is deleted and
replaced by the following:
COVERAGE B – Other Structures
We cover other structures on the “residence premises”
set apart from the dwelling by a clear space. This
includes structures connected to the dwelling by only a
fence, utility line, or similar connection.
This coverage does not apply to land, including land on
which the other structures are located.
We do not cover other structures:
1. Used in whole or in part for “business”; or
2. Rented or held for rental to any person not a tenant
of the dwelling, unless used solely as a private
garage.
The limit of liability for this coverage will not be more
than the limit shown on the declaration page for
Coverage B. Use of this coverage does not reduce the
Coverage A limit of liability.
COVERAGE A – Dwelling and COVERAGE B –
Other Structures
We do not cover “solar panels”, “solar roofs” and/or
“solar water heating systems” or any of their
components, whether attached to the dwelling or not.
This includes, but is not limited to, the cost to remove,
reset, repair and/or replace “solar panels”, “solar roofs”
and/or “solar water heating systems”, regardless of
whether or not said work is necessary to affect repairs
to covered property to which they are attached.
COVERAGE C – Personal Property
The following is added:
Our limit of liability for personal property owned or used
by an "insured" and located in a self-storage facility is
10% of the limit of liability for Coverage C, or $1,000,
whichever is greater. However, this limitation does not
apply to personal property:
1. Moved from the "residence premises" because it is
being repaired, renovated or rebuilt and not fit to
live in or store property in; or
2. Usually located in an "insured's" residence, other
than the "residence premises".
COVERAGE D – Loss Of Use
COVERAGE D – Loss Of Use is deleted and replaced
by the following:
We will pay 80% of the additional expenses you incur
for loss during a “hurricane occurrence”, and 100% of
the additional expenses you incur for other losses, but
no more than the limit of liability shown for Coverage D
in the Declarations for the following:
1. Additional living expenses incurred by you so that
your household can maintain its normal standard of
living when a loss covered under this Section
makes that part of the “residence premises” where
you reside not fit to live in.
Payment will be for the shortest time required to
repair or replace the damage or, if you permanently
relocate, the shortest time required for your
household to settle elsewhere.
2. If a civil authority prohibits you from use of the
“residence premises” as a result of direct damage
to neighboring premises by a Peril Insured Against
in this policy, we cover the Additional Living
Expenses as provided under 1. above for no more
than 2 weeks.
The periods of time for expenses described above are
not limited by the expiration of this policy. We do not
cover loss or expense due to cancellation of a lease or
agreement.
ADDITIONAL COVERAGES
2. Reasonable Repairs is deleted and replaced by
the following:
2. Reasonable Emergency Measures.
a. We will pay up to the greater of $3,000 or 1%
of your Coverage A limit of liability for the
reasonable costs incurred by you for
necessary measures taken solely to protect
covered property from further damage when
the damage or loss is caused by a Peril Insured
Against.
b. We will not pay more than the amount in 2.a.
above, unless we provide you approval within
48 hours of your request to us to exceed the
limit in 2.a. above. In such circumstance, we
will pay only up to the additional amount for the
measures we authorize.
If we fail to respond to you within 48 hours of
your request to us and the damage or loss is
caused by a Peril Insured Against, you may
exceed the amount in 2.a. above only up to the
cost incurred by you for the reasonable
emergency measures necessary to protect the
covered property from further damage.
c. If however, the Hurricane Deductible
Endorsement is part of your policy and a
covered loss occurs during a “hurricane
occurrence”, the amount we pay under this
additional coverage is not limited to the amount
in 2.a. above.
d. A reasonable measure under this additional
coverage may include a permanent repair
when necessary to protect the covered
property from further damage or to prevent
unwanted entry to the property. To the degree
reasonably possible, the damaged property
must be retained for us to inspect.
e. This coverage does not:
(1) Increase the limit of liability that applies to
the covered property;
(2) Relieve you of your duties, in case of a loss
to covered property, as set forth in
SECTION I – CONDITIONS 2. Duties
After Loss; or
(3) Pay for property not covered, or for repairs
resulting from a peril not covered, or for
loss excluded in this policy.
***
Item 10. Loss Payment is deleted and replaced by the
following:
10. Loss Payment. We will adjust all losses with you.
We will pay you unless some other person is
named in the policy or is legally entitled to receive
payment. Loss will be payable upon the earliest of
the following:
a. 20 days after we receive your proof of loss and
reach written agreement with you;
b. 60 days after we receive your proof of loss and:
(1) There is an entry of a final judgment; or
(2) There is a filing of an appraisal award or a
mediation settlement with us; or
c. Within 90 days of receiving notice of an initial
claim, “reopened claim” or “supplemental
claim” for property insurance. We will pay or
deny such claims, or portions thereof, unless
there are factors beyond our control that would
reasonably prevent payments.
Item 10.c. above does not form the basis for a
private cause of action against us.
***
17. Choice Of Law.
This policy and any performance thereunder shall
be construed with and governed by the laws of the
State of Florida.
***
18. Notice of Claims.
Any claim or “reopened claim” under an insurance
policy that provides property insurance for loss or
damage caused by any peril is barred unless you
give us or our agent notice of any claim or
“reopened claim” within 2 (two) years after the date
of loss. A “supplemental claim” is barred unless
you give us or our agent notice within 3 (three)
years after the date of loss.
***
LIMITED SCREENED ENCLOSURE AND CARPORT COVERAGE HOMEOWNERS Form No. RPI HO 09 WSE 09 18
For an additional premium, we insure for direct physical damage caused during a “hurricane occurrence” only to those items below:
a. Aluminum framed Screened enclosure(s) including frames, screen material, footings, supports or anchors of the enclosure; and
b. Aluminum framed Carport(s) permanently attached to the main dwelling.
This coverage does not increase the limit of liability for Coverage A or B. The limit of liability for this coverage will not be more than the limit shown on the Declarations page.
OTHER PROVISIONS
Any loss payments under this coverage will be subject to the calendar-year hurricane deductible as defined in your policy. In the event that a hurricane causes damage to other property covered under this policy, the hurricane deductible applies only once to all covered property.
All other provisions of this policy apply.
Please advise if there are other applicable policy provisions that are not cited above but would provide coverage to the Insured for the September 28, 2022, windstorm/hurricane force winds loss.
|
| |
*
Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
In Florida, the work of adjusting insurance claims engages the public trust. Tower Hill Insurance Exchange (“INSURER”) has breached the public’s trust by its adjustment of Gary F. Munck and Pamela Kay Munck (“INSURED”) claim of loss. Tower Hill Insurance Exchange’s mailing address is 7201 Northwest 11th Place, Gainesville, FL 32605.
INSURER has failed to create and implement adequate guidelines for the proper investigation and evaluation of claims, claims handling, and for training and supervision of employees resulting in statutory violations as set forth above. INSURER has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the INSUREDS’ insurance claim for damages.
INSURER has failed to promptly settle the INSUREDS’ insurance claim when the obligation to settle the insurance claim had become reasonably clear. To date, notwithstanding the INSUREDS’ pleas otherwise, INSURER has continued to refuse to acknowledge its obligation to conduct a proper investigation, and to tender the full amount of insurance monies due and owing its INSURED under the policy.
This claim involves the INSUREDS’ property located at 12351 Cannon Lane, Fort Myers, FL 33912 which sustained significant damage from windstorm/hurricane-force winds on or about September 28, 2022.
On or about September 28, 2022, Hurricane Ian struck the state of Florida. INSUREDS were a victim of Hurricane Ian’s destruction and subsequently incurred wind damage to the exterior and interior of their home due to hurricane-force winds, and ensuing damages. INSUREDS’ insured home suffered hurricane-force winds damage to the roof system, allowing subsequent water intrusion on or about June 13, 2024, into the home, causing interior water damage throughout the home. INSURED notified INSURER of the damages and opened a claim for the September 28, 2022, hurricane-force winds loss under Claim No 330050319 pursuant to the terms and conditions of the Policy. In response, the INSURER assigned the claim to its representative to adjust and investigate the loss and requested invoices for damages as a result of the loss. INSURER was provided with the INSUREDS receipts for temporary emergency repairs for tarps by BP Roofing, the invoice for damages to the pool enclosure from Liberty Aluminum for $4,281.00. See, Insured Receipts attached hereto.
MR. AND MRS. MUNCK notified TOWER HILL of the damages observed as a result of the losses and opened a claim for the September 28, 2022, hurricane-force winds damages and ensuing losses pursuant to the terms and conditions of the Policy. In response, TOWER HILL assigned the claim to its representative to adjust and investigate the loss and requested invoices for damages. TOWER HILL was provided with the MR. AND MRS. MUNCKS receipts for temporary emergency repairs for tarps by BP Roofing, the invoice for damages to the pool enclosure from Liberty Aluminum for $4,281.00. See, Mr. and Mrs. Munck Receipts attached hereto.
In response, TOWER HILL assigned the claim to its representative to adjust and investigate the loss, as well as a field adjuster to inspect the damage. TOWER HILL’S representative visited the property and performed a cursory and inadequate investigation of the damaged property which resulted in improper denial of insurance benefits owed to MR. AND MRS. MUNCK.
TOWER HILL had a duty to investigate the damages arising after the June 2024 loss and the adjusters assigned must adjust and treat all claims equally. Since the beginning of this claim the representatives on behalf of TOWER HILL have approached this investigation in a manner prejudicial to MR. AND MRS. MUNCK. TOWER HILL is using either untrained or improperly trained adjusters in connection with this claim. TOWER HILL should have been adjusting the loss with MR. AND MRS. MUNCK but instead, it was looking for ways not to pay the claim at all or pay the claim in full. If the TOWER HILL handles all the claims in the way MR. AND MRS. MUNCK’S claim was adjusted, then it is improperly handling all claims.
In correspondence dated July 28, 2024, TOWER HILL issued its claim determination letter regarding the ensuing water loss assigned claim number 330499651 to MR. AND MRS. MUNCK, and advised:
“During our inspection, we investigated an area of reported water intrusion within the family room. Florida Engineering Solutions observed an area of ceiling discoloration, a hole cut out at the ceiling, and an area of distortion at the wall, as well as temperature anomalies based on the thermal readings. At the time of our inspection, Florida Engineering Solutions found no evidence of any storm related damage to the tile roof covering system that could be attributed to the area of water intrusion within the family room. It is, therefore, our professional opinion that the distress observed has been caused by water intrusion through the aged and/or defective tile roof covering system.”
…
“Therefore, wind damage to the roofing system, exterior, and screened enclosure has been denied based upon the engineer report and no payment is warranted in that matter.”
See, Carrier Denial dated July 28, 2024. TOWER HILL retained experts from its preferred vendor list, instead of retaining objective experts to provide it with thorough and completely objective opinions and conclusions. This is unfair claims handling practices.
On August 22, 2024, MR. AND MRS. MUNCK reported their loss stemming from September 28, 2022.
In correspondence dated August 23, 2024, TOWER HILL acknowledged MR. AND MRS. MUNCK’S claim for loss for damages related to September 28, 2022.
On August 30, 2024, TOWER HILL requested a Sworn Proof of Loss for the September 28, 2022 damages.
Concerned TOWER HILL had no intention of fairly and adequately adjust the losses, MR. AND MRS. MUNCK retained the services of the undersigned counsel to assist in adjusting the loss with TOWER HILL and Pinnacle Engineering to assist in determining the causation of the damages to the MR. AND MRS. MUNCKS property. Pinnacle Engineering conducted a site visitation on August 27, 2024, and determined:
The property was subjected to substantially-elevated winds during Hurricane Ian in September of 2022 which appear to have involved the most-severe winds to have influenced the home.
• Box vent uplift, cap tile detachment, inter-tile chatter, and direct wind action on individual tiles appear to have caused storm-created openings near and around the north off-ridge vent.
• Temporary repair efforts reportedly implemented after Hurricane Ian appear to have prevented ongoing / repeated rainwater intrusion during the remainer of the 2022 wet season and 2023 wet season.
• Aging and UV degradation of the temporary repair materials appears to have allowed a redevelopment of the storm-created openings such that substantial rainwater intrusion initiated in June 2024, at the beginning of the 2024 wet season.
• The interior water damage at the living room and overlying attic space involves characteristics consistent with initial development within recent months, and lacked indications of multiple years of rewetting occurrences.
• The resulting water damage has critically affected the living room ceiling, rear living room wall, portions of the roof deck sheathing, and portions of the air-conditioning system at the living room duct boot. These materials shall be removed and replaced.
• Replacement of the damaged roof sheathing, damaged box vent, and damaged cap tiles will require removal of portions of the roof tile assembly. We recommend consultation with a qualified roof professional to determine if matching tiles or reinstallation of existing tiles can be implemented at the home.
See attached Pinnacle Engineering Report.
In correspondence dated August 29, 2024, TOWER HILL acknowledges Ross Legal Group’s representation of the MUNCKS for their September 28, 2022, date of loss. TOWER HILL stated they would be conducting a claim investigation.
On September 24, 2022, a recorded statement was performed with MR. AND MRS. MUNCK in which they outlined the losses suffered from both September 28, 2022 and June 13, 2024.
In correspondence dated October 15, 2024, TOWER HILL denied MR. AND MRS. MUNCKS claim as under the hurricane deductible amount. See, Carrier – Denial 10.15.24 attached hereto.
On October 27, 2024, TOWER HILL forwarded MR. AND MRS. MUNCK’S counsel TOWER HILL’S request for information dated August 29, 2024. See, Email and attachment 10.27.24, attached hereto.
In correspondence dated November 6, 2024, TOWER HILL wrongfully accused MR. AND MRS. MUNCK of submitting the claim after the notice of the claim deadline and stated such claims were barred by the policy and Florida Law. This is put nicely, incorrect. The claim for damages as a result of Hurricane Ian was submitted before the policy and statutory deadlines.
Pursuant to Florida Statute §627.70132 in effect on the date of loss (9/28/22):
627.70132 Notice of property insurance claim.—
(1) As used in this section, the term:
(a) “Reopened claim” means a claim that an insurer has previously closed, but that has been reopened upon an insured’s request for additional costs for loss or damage previously disclosed to the insurer.
(b) “Supplemental claim” means a claim for additional loss or damage from the same peril which the insurer has previously adjusted or for which costs have been incurred while completing repairs or replacement pursuant to an open claim for which timely notice was previously provided to the insurer.
(2) A claim or reopened claim, but not a supplemental claim, under an insurance policy that provides property insurance, as defined in s. 624.604, including a property insurance policy issued by an eligible surplus lines insurer, for loss or damage caused by any peril is barred unless notice of the claim was given to the insurer in accordance with the terms of the policy within 2 years after the date of loss. A supplemental claim is barred unless notice of the supplemental claim was given to the insurer in accordance with the terms of the policy within 3 years after the date of loss.
(3) For claims resulting from hurricanes, tornadoes, windstorms, severe rain, or other weather-related events, the date of loss is the date that the hurricane made landfall or the tornado, windstorm, severe rain, or other weather-related event is verified by the National Oceanic and Atmospheric Administration.
(4) This section does not affect any applicable limitation on civil actions provided in s. 95.11 for claims, supplemental claims, or reopened claims timely filed under this section.
History.—s. 10, ch. 2011-39; s. 10, ch. 2021-77.
See, Fla. Stat. 627.70132.
On November 12, 2024, MR. AND MRS. MUNCK submitted their estimate of damages for $151,002.35 to TOWER HILL, along with the documentation in support thereof and MR. AND MRS. MUNCK advised TOWER HILL they were in disagreement with TOWER HILL’S claim evaluation. See attached 11.12.24 RFI Response with attachments.
INSUREDS ARE NOT CLAIMING DUPLICATIVE DAMAGES under Claim Nos. 3300506319; 3300499651. RATHER ONE SET OF DAMAGES ARE BEING CLAIMED FOR BOTH CLAIM NUMBERS AS THE ORIGINAL LOSS started on 9/28/22 and was exacerbated on 6/13/24.
INSURER retained experts from its preferred vendor list, instead of retaining objective experts to provide it with thorough and completely objective opinions and conclusions. This is unfair claims handling practices.
To date, INSURER has failed to tender any insurance benefits. INSURER has admitted that INSURED sustained covered damages as a result of hurricane force winds loss that occurred on or about September 28, 2022., but has denied tendering all owed insurance benefits to INSURED.
Pursuant to Florida Statute §626.9541(1)(i)(4), INSURER is required to pay undisputed amounts of partial or full benefits owed under first-party property insurance policies within 60 days after INSURER received notice of the residential property insurance claim, determine the amounts of partial or full benefits, and agree to coverage, unless payment of the undisputed benefits is prevented by factors beyond the control of the insurer as defined in s. 627.70131(5). As INSURER has failed to do so, INSURER has wrongfully denied coverage.
Since the beginning of the claim, INSURER has engaged in a pattern of delay, denial, and reckless disregard for INSUREDS’ rights. The actions of INSURER listed herein have been continuing in nature and given the totality of the circumstances, which includes INSURER’S adjustment, actions and/or omissions post the filing of this CRN. INSURED contend that given the past experience in this matter with INSURER, it is reasonably foreseeable that INSURER’S current actions will extend to its entire conduct in the handing of their claim, including the acts or omissions of INSURER and/or its representatives, until the final resolution of their claim. As such, INSURED contend adequate notice has been given should INSURER’S actions and violations listed herein continue after the expiration of this notice.
INSURER has failed and/or refused to settle the claim when it could and should have done so had it acted fairly and honestly towards INSURED and has failed to take into account the information and evidence provided that contradict its decisions.
INSURER’S conduct has been reckless and unfair to INSURED and has caused and continues to cause additional damage throughout the property. This is evidenced by the delay in paying the claim and the failure of INSURER to evaluate the claim in total.
To date, INSURER has failed and/or refused to provide INSURED with all the necessary insurance benefits due and owing and has not tendered the full amount needed to repair the Property despite knowing that INSURED have sustained covered damages to their insured property.
As the INSURER must admit, it is implied within every insurance policy a duty of good faith and fair dealings. In an insurance contract, each party is prevented from interfering with the other’s right to benefit from the contract. The obligations of good faith and fair dealings encompass qualities of decency and humanity inherent in its responsibilities as a fiduciary. INSURER is bound to conduct itself with the utmost good faith for the benefit of INSURED. However, INSURER has failed to comply with the obligations in connection with this claim and has never looked at the claim or the contract for insurance with good faith and fair dealing. Instead, INSURER has looked for ways not to pay the claim in full, or pay the claim at all, and these actions have been to the detriment of INSURED.
The adjusters assigned to this claim have a duty to adjust and treat all claims equally. Since the beginning of this claim the representatives on behalf of INSURER have approached this investigation in a manner prejudicial to INSURED. INSURER is using either untrained or improperly trained adjusters in connection with this claim. INSURER should have been adjusting the loss with INSURED but instead, it was looking for ways not to pay the claim at all or pay the claim in full. If the INSURER handles all the claims in the way INSUREDS’ claim was adjusted, then it is improperly handling all claims.
Therefore, demand is hereby made as follows:
Estimate $155,783.35
Less Prior Payments $0.00
Less Deductible $10,760.00
TOTAL $145,023.35
The concept of insurance is that the insurer will investigate and grant timely and prompt indemnity or security against a contingent loss. Florida Statute §624.02 defines “insurance” as a contract whereby one undertakes to indemnify another or pay or allow a specified amount or a determinable benefit upon determinable contingencies. Inherent in that definition is the fact that payment must be made timely and promptly so that the INSURED may mitigate their damages and be put back into the position they were in prior to the loss as quickly as possible. INSURER has breached this duty.
The INSURED was, and still is, forced to expend out of pocket monies to submit her insurance claim, e.g., retaining an attorney and other experts to force INSURER to honor its obligations under the insurance policy and to pay all the insurance proceeds due and owing to them.
INSURER has refused and/or failed to tender all the insurance proceeds due and owing to the INSURED. INSURER’s refusal and/or failure to settle the insurance claim when under all circumstances it could have and should have done so had it acted fairly and honestly towards the INSURED is wrongful conduct. Furthermore, the INSURED contends that INSURER’s adjusters and/or representatives financially benefit from such wrongful conduct.
INSURER has refused and/or failed to comply with The Policy’s cooperation and/or “Loss Payment” provision. Under The Policy, INSURER was to timely tender undisputed insurance benefits to INSURED. INSURER has failed and/or refused to timely tender owed insurance benefits, undisputed or otherwise. This is a breach of The Policy.
INSURER has refused and/or failed to cooperate and/or “Adjust the Loss” by cooperating with INSURED during the claims adjustment process in compliance with The Policy’s “Loss Payment” provision. This is a breach of The Policy.
This notice is given in order to perfect the right to pursue the civil remedy authorized by Fla. Stat. §624.155.
Therefore, to cure the defects outlined in this Civil Remedy Notice, INSURER must:
(1) Create and implement adequate guidelines for the proper investigation and evaluation of claims and for the training and supervision of employees, which will avoid future statutory violations as set forth above, and prevent this from occurring in the future;
(2) INSURER must create and implement adequate guidelines for the proper investigation and evaluation of these types of claims and for the training and supervision of employees with regard to these claims to ensure that the claims handling procedure with regard to these types of losses are adequate to prevent other Insureds from being treated unfairly and wrongfully;
(3) INSURER must tender to the INSURED $155,783.35 as set forth above; and,
(4) INSURER must act fairly and honestly towards its INSURED and with due regard for her interests in attempting to settle its INSUREDS’ claim.
Or, in the alternative, should INSURER not be in agreement with INSUREDS’ reasonable demand for payment of their rightfully owed insurance benefits being submitted at this time, INSURED may still be willing to consider and potentially accept a reasonable counter-offer made by INSURER. As such, INSURED hereby request that INSURER now make a reasonable counter-offer before the expiration of the cure period. INSURED still hope that their claim can be resolved amicably.
Attachments:
1. Insured Receipts
2. Carrier – Denial with Engineer Report 07.28.24
3. Pinnacle Engineer Report
4. Carrier - Denial 10.15.24
5. Email with attachment 10.27.24
6. Carrier - 11.12.24 RFI Response with attachments
|
|
|
*
|
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
|