Filing Number: 796718
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| Filing Accepted: 12/13/2024 |
| Last/Business Name
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| Street Address
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444 CONOVER AVENUE NE |
| City, State Zip
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PALM BAY,
FL
32907
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| Email Address
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CFAUNTLEROY@FSATLAW.COM |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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QUEEN |
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First Name |
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GINGER |
| Policy # * |
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FPH5524319-00 |
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Claim #* |
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FPI244949 |
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Attorney is Applicable
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| Last Name* |
FAUNTLEROY
First Name *
CHRISTOPHER
Initial
B
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| Street Address* |
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100 S ASHLEY DRIVE, SUITE 600 |
| City, State Zip* |
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TAMPA
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FLORIDA
33602
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| Email Address * |
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CFAUNTLEROY@FSATLAW.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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FLORIDA PENINSULA INSURANCE COMPANY
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| Insurer Name* |
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| Street Address* |
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,
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NAIC Company Code 10132 |
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| Name of individual responsible for violation (if any):*
STEVEN HORSCHEL, ERIC ELLIS, MIGUEL MEDINA FLORIDA PENINSULA INSURANCE COMPANY AND ITS ADJUSTER
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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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Unfair Trade Practice
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Claim Delay
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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)(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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| 626.9541(1)(i)(3)(f) |
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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.
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| 626.9541(1)(i)(3)(g) |
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Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
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| 626.9541(1)(i)(3)(h) |
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Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
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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.
Specific policy language that is relevant to this violation:
SECTION I – _PERILS INSURED AGAINST
COVERAGE A – _DWELLING and COVERAGE B – _OTHER STRUCTURES
1. We insure for sudden and accidental direct loss to property described in Coverages A and B only if that loss is a physical loss to covered property.
I. Loss Payment
II. Loss Settlement
***ADDITIONAL STATUTORY PROVISIONS ALLEGED TO HAVE BEEN VIOLATED ARE AS FOLLOWS:***
§624.155(1)(B)(1) Any person may bring a civil action against an insurer when such person is damaged:
By the commission of any of the following acts by the insurer:
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 towards its insured and with due regard for her interests;
2. Making claims payments to insures or beneficiaries not accompanied by a statement setting forth the coverage under which payments are being made; or
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.
§624.155 (5) No punitive damages shall be awarded under this section unless the acts giving rise to the violation occur with such frequency as to indicate a general business practice and these acts are:
(a) Willful, wanton, and malicious;
(b) In reckless disregard for the rights of any insured; or
(c) In reckless disregard for the rights of a beneficiaries under a life insurance contract;
(8) The damages recoverable pursuant to this section shall include those damages which are a reasonably foreseeable result of a specified violation of this section by the authorized insurer and may include an award or judgment in an amount that exceeds the policy limits.
§627.70131 Insurer’s duty to acknowledge communications regarding claims; investigation
(1)(a) Upon an insurer’s receiving a communication with respect to a claim, the insurer shall, within 14 calendar days, review and acknowledge receipt of such communication unless payment is made within that period of time or unless the failure to acknowledge is caused by factors beyond the control of the insurer which reasonably prevent such acknowledgement. If the acknowledgement is not in writing, a notification indicating acknowledgement shall be made in the insurer’s claim file and dated. A communication made to or by an agent of an insurer with respect to a claim shall constitute communication to or by the insurer.
(4) For purposes of this section, the term “insurer” means any residential property insurer.
§626.9541(i) Unfair Claim Settlement Practices
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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.
In Florida, the work of adjusting insurance claims engages the public trust. Florida Peninsula Insurance Company (Florida Peninsula) has breached this duty in the adjustment of Ginger Queen’s (Queen’s) claim.
Furthermore, Florida Peninsula has engaged in unfair claim delay; has used business or outcome-oriented investigations and experts to determine the outcome of the claim; has wrongfully denied the claim without fully stating reasons and reserving unwritten reasons; has looked for ways to, delay payment and otherwise “stonewall” the claim; and has used improper claims practices to rush the claims process and profit from wrongful claims practices.
Queen’s claim results from hail and wind damage which resulted in subsequent water and roof leak damage to her home that occurred on or around May 10, 2024, which consequentially resulted in extensive damage to the roof of the property and ceiling of the property. In order to immediately mitigate the damages to her home, Queen contacted her insurance company, Florida Peninsula, to report the damages to her home. As part of their investigation, Florida Peninsula assigned a claim number FPI244949 and claims adjuster Miguel Medina and Steven Horschel to adjust the loss.
As part of the investigation of Queen’s claim, Florida Peninsula inspected the damages to Queen’s home. Subsequently, Florida Peninsula sent correspondence on September 30, 2024, denying Queen’s claim without providing any monetary compensation to repair the damages to return Queen’s property back to pre-loss condition.
In view of the foregoing, it is clear and unequivocal that Florida Peninsula has failed to provide proper and sufficient compensation to repair the damages caused to the Queen’s property. Due to Florida Peninsula’s handling of the Queen’s claim, Queen chose to retain a public adjuster to further assess the damages to her home. As such, upon inspection and view of the damages, it was clear that the entire dwelling roof elevations and interior ceiling required extensive repair. After the inspection, the public adjuster provided an estimate for repairs in the amount of $43,264.03 which is the full amount to return Queen’s home back to pre-loss condition. Florida Peninsula continues to hold their stance for their claim determination concerning Queen’s loss.
Queen has complied with all conditions under the policy. Nonetheless, Florida Peninsula failed to properly compensate Queen for her loss. The facts of this claim show that for whatever reason, Florida Peninsula not only substantially misinterpreted the scope of damages to Queen’s property, but also failed to conduct a thorough investigation as to the scope of damages to the roof and elevations. Upon view of Florida Peninsula’s claims handling procedures, it is clear Florida Peninsula conducted a limited and quick outcome orientated investigation in the hopes that Queen would make the required repairs with her own money. Queen now must incur costs for assistance to obtain what should have been paid had she been treated fairly and honestly by Florida Peninsula.
Florida Statute §626.9744(2) provides that “When a loss requires replacement of items and the replaced items do not match in quality color or size, the insurer shall make reasonable repairs or replacement of items in adjoining areas.” In the instance of Florida Peninsula, their adjusters and the estimate provided, it is clear that Florida Peninsula did not adhere to Florida law, as their estimate provides paltry repair items that would result in mismatching areas which fails to acknowledge the true extent of damage of Queen’s home as well as the surrounding areas that would need to be replaced. Florida Statute §624.02, defines “insurance” as a contract where one undertakes to indemnify another or pay or allow specified amounts, or a determinable benefit, upon determinable contingencies – inherent is the fact that payment must be made timely and promptly. The fact that payment must be made timely and promptly so that the insured may mitigate their damages, and to put the insured back into the position they enjoyed prior to the loss as quickly as possible. Florida Peninsula has breached this duty by improperly investigating Queen’s claim and failing to properly pay Queen for her loss. Florida Peninsula has refused and/or failed to tender insurance proceeds as required by the policy and/or Florida law. It has refused and/or failed to settle the claim when under all the circumstances it could have and should have done so if it had acted fairly and honestly towards Queen.
Florida Peninsula has failed to adopt and implement proper standards for investigation, evaluation, and adjustment of claims; has failed to properly train, manage, supervise, and promote claims adjusters so that policy holder receives good faith, fair, prompt adjustment of claim, service, and indemnity, has failed to conduct a full and fair investigation of the claim
In view of the facts surrounding Queen’s claim, it is evident that Florida Peninsula has failed to create and implement adequate guidelines for proper investigations to evaluate claims handling for training and supervision of employees in violation of Fla. Stat. §624.155 and §626.9541 statutory regulations, as well as the applicable provisions in the Florida Administrative Code resulting in the statute violations set forth herein. As stated, Florida Peninsula has failed and/or refused to investigate the insured’s claim thoroughly, accurately, and completely for damages.
Florida Statutes Violated by Florida Peninsula are as applied to the facts in this matter is as follows: § 626.951 engaging in acts defined as “unfair trade practices” relating to the business of insurance in accordance with the intent of congress as expressed in the act of congress of March 9, 1945 (pub. L. No. 15, 79th congress), by defining, or providing for the determination of, all such practices in this state which constitute unfair methods of competition or unfair or deceptive acts or practices and by prohibiting the trade practices so defined or determined.
§ 624.155(1)(b)(1) to tender all insurance proceeds monies due and owing the insured or assist the insured in the mitigation of their damages. The insurer breached these statutory duties. Not attempting in good faith to settle claims when, under all circumstance, insurer could have and should have done so, had the insurer acted fairly and honestly toward its insured and with due regard. § 624.155(1)(b)(3) failing to promptly settle claims, when the obligation to settle the 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 investigations of claims. § 626.9541(1)(i)(3)c Failing to acknowledge and to act promptly upon communications with respect to claims.
In view of the fact’s of Queen’s claim, Florida Peninsula has failed to adopt and implement proper standards for investigation, evaluation and adjustment of claims; has failed to properly train, manage, supervise and promote claims adjusters so that policy holder receives good faith, fair, prompt adjustment of claim, service and indemnity; has failed to conduct a full and fair investigation of the claim and has failed to provide full reasons and facts to the claimant for delay of the claim resulting in statutory violations as set forth in this notice.
Their actions are willful, wanton and in disregard of the rights of its insured and occur with such a frequency as to indicate a general business practice. Florida Peninsula can cure this default by the following:
A. Create, adopt and implement adequate standards and/or guidelines for the proper investigation and adjustment of claims.
B. Provide sufficient training and supervision of employees and agents to avoid further violations as set forth in the paragraphs above from occurring in the future.
C. Tender payment to Queen in the amount of $43,264.03 which is the amount to return Queen’s home back to pre-loss condition.
D. Tender prejudgment interest from the date the claim was reported through today.
E. Agree to pay Queen’s reasonable attorney’s fees pursuant to Florida Statute §627.428 and all taxable costs.
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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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