Civil Remedy Filing

Civil Remedy Notice of Insurer Violations

Filing Number: 798519

Filing Accepted: 12/27/2024

Print Filing

Complainant

Last/Business Name *

JACOBY

First Name

JAMES

Street Address *

538 CORTEZ DRIVE

City, State Zip *

DAVENPORT, FL 33837

Email Address *

ROADRUNNER69.5@HOTMAIL.COM

Complainant Type: *

Insured

Last/Business Name*		JACOBY		First Name		JAMES
Policy # *		7709HR031548		Claim #*		095549-GQ

Attorney

Attorney is Applicable

Last Name*	KRAPF First Name * GRANT Initial W
Street Address*		2790 SUNSET POINT RD
City, State Zip*		CLEARWATER , FL 33759
Email Address *		GRANT@KRAPFLEGAL.COM

Violation

Insurer Type *		Authorized Insurer Unauthorized Insurer

Insurer Name
Insurer Name*		NATIONWIDE PROPERTY AND CASUALTY INSURANCE COMPANY
Insurer Name*
Street Address*
City, State Zip*		,
NAIC Company Code 37877

Name of individual responsible for violation (if any):* BRANDON VOGEL, EDWARD ELLIOTT, AND ANY OTHER INDIVIDUAL FROM, OR AGENT OF, NATIONWIDE PROPERTY & CASUALTY INSURANCE COMPANY WHO WAS INVOLVED IN THE CLAIM.
Type of Insurance * Residential Property & Casualty

Reason for Notice *

	Claim Denial
	Claim Delay
	Unfair Trade Practice
	Other : Misrepresenting the terms of the insurance policy
	Other : Not treating the Insured with good faith claims conduct
	Other : Looking for ways to deny full recovery to the Insured
	Other : Looking for ways to delay full recovery to the Insured
	Other : Failing to properly investigate the Insured's loss
	Other : Failing to provide the Insured with the full benefits awarded under the contract of insurance in a
	Other : Not training, supervising, or managing adjusters properly so that prompt and full payments are made
	Other : Not adjusting claims and evaluating loss properly
	Other : Shifting the burden of insuring the loss to the Insured
	Other : Intentionally misstating the terms, conditions, and benefits of the insurance policy to the insured
	Other : Failing to implement proper standards for the adjustment and investigation of claims

* 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.
	626.9541(1)(i)(2)		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.
	626.9541(1)(i)(3)(a)		Failing to adopt and implement standards for the proper investigation of claims.
	626.9541(1)(i)(3)(b)		Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.
	626.9541(1)(i)(3)(c)		Failing to acknowledge and act promptly upon communications with respect to claims.
	626.9541(1)(i)(3)(d)		Denying claims without conducting reasonable investigations based upon available information.

* 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 (1)(a) - Upon an insurer's receiving a communication with respect to a claim, the insurer shall, within 7 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. If the acknowledgment is not in writing, a notification indicating acknowledgment shall be made in the insurer's claim file and dated. A communication made to or by a representative of an insurer with respect to a claim shall constitute communication to or by the insurer. 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).

* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

Nationwide Property & Casualty Insurance Company (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) failing to provide an estimate that complies with the Florida Building Codes; and 10)failing to acknowledge and act promptly upon communications with respect to claims. On or about October 10, 2024, while the subject policy was in full force and effect, the Insured's property was severely damaged by Hurricane Milton. The areas impacted include but are not limited to the roofing system. The Insured timely submitted a claim on October 17, 2024, to the Insurer for hurricane damage and the ensuing damage therefrom. Thereafter, the Insurer assigned claim number 095549-GQ to the loss and sent a field adjuster and engineer to inspect the property. Then in a letter dated December 4, 2024, the Insurer notified the Insured that it was extending coverage for the loss. However, the Insurer wrongfully determined that it would only require $690.64 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. Given the partial denial, the Insured's disagreement with the coverage decision, and the scope and nature of the damage resulting from Hurricane Milton, the Insured retained a public adjuster. After assessing the damage and the true scope of repairs, the public adjuster produced an estimate identifying $40,368.04 in covered damage to the dwelling. The foregoing estimate, photographs, and a letter of representation from the public adjuster were sent to the Insurer. 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 insured property but attributed the cause of this damage to 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. 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. Furthermore, the Insurer violated Fla. Stat. 627.70131 (1)(a). On December 10, 2024, the Insured's legal counsel sent the Insurer a letter of representation, which included a request for several documents. To date, the Insurer has neither acknowledged nor responded to this communication. The above statute requires a response within 7 days. 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 $690.64 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. Making material misrepresentations 13. Failing to acknowledge and act promptly upon communications with respect to claims. 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 Mail: Nationwide Property & Casualty Insurance Company PO BOX 182068 Columbus, OH 43218-2068 Nationwide-claims@nationwide.com

Comments

User Id		Date Added		Comment
everetd2@nationwide.com		02-07-2025		Pursuant to F.S. 624.155(3)(d), please accept this notice on the disposition of the alleged violations contained in the Civil Remedy Notice occurred on 2-5-25.

Acknowledgement
*	The submitter hereby states that this notice is given in order to perfect the rights of the person(s) damaged to pursue civil remedies authorized by Section 624.155, Florida Statutes. 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