Filing Number: 798977
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| Filing Accepted: 1/2/2025 |
| Last/Business Name
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WILLIAMS
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First Name |
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BRANDON AND PATRICIA |
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| Street Address
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536 CYPRESS VIEW DR |
| City, State Zip
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OLDSMAR,
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34677
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| Email Address
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BRANDON@BAYKINGSBAND.COM |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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WILLIAMS |
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First Name |
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BRANDON AND PATRICIA |
| Policy # * |
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EDH5411762-01 |
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Claim #* |
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EDI963450 |
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Attorney is Applicable
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| Last Name* |
SAPP
First Name *
MOLLY
Initial
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| Street Address* |
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203 FORT WADE ROAD, SUITE 260 |
| City, State Zip* |
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PONTE VEDRA
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FLORIDA
32081
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| Email Address * |
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MSAPP@WOOLSEYMORCOM.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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EDISON INSURANCE COMPANY
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| Insurer Name* |
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| Street Address* |
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| City, State Zip* |
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NAIC Company Code 12482 |
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| Name of individual responsible for violation (if any):*
TEVIN ALSTON (FLA. ADJ. LIC. #W434894), CARMEN TURNER (FLA. ADJ. LIC. #E017211), AND TIM BORK (FLA. ADJ. LIC. #W270369)
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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 Delay
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Other
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Wrongful claim denial
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Unfair Trade Practice
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Other
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Unfair claim settlement practices
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Other
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Unreasonable investigation
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Other
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Failure to act on claim
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Other
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Failure to conduct a reasonable investigation based on available information
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Other
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Failure to maintain proper complaint handling procedures
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Other
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Misrepresenting the insurance policy provisions to the insured
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Other
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Misrepresenting Florida statutory provisions to the insured
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Other
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Misrepresenting facts to the insured
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Other
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Failure to acknowledge and act promptly upon communications with respect to claims
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Other
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Denying claims without conducting reasonable investigations based upon available information
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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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| 626.9541(1)(i)(3)(e) |
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Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed.
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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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| 626.9541(1)(i)(4) |
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Failing to pay undisputed amounts of partial or full benefits owed under first-party property insurance policies within 60 days after an insurer receives notice of a residential property insurance claim, determines the amounts of partial or full benefits, and agrees 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).
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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.
SECTION I - PERILS INSURED AGAINST
A. 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.
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B. Coverage C – Personal Property
We insure for sudden and accidental direct physical loss to covered property described in Coverage C caused by any of the following perils unless the loss is otherwise excluded or limited in this policy . . . 12. Accidental discharge or overflow of water or steam
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[A]ny ensuing loss to property described in Coverages A and B not precluded by any other provision in this policy is covered.
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D. Coverage D – Loss of Use
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E. Additional Coverages
1. Debris Removal.
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2. Emergency Mitigation Services.
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11. “Fungi,” Mold, Wet or Dry Rot, Yeast or Bacteria. a. We will pay up to $10,000 for: (1) The total of all loss payable under SECTION I – PROPERTY COVERAGES caused by “fungi,” mold, wet or dry rot, yeast or bacteria; (2) The cost to remove “fungi,” mold, wet or dry rot, yeast 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, yeast, or bacteria.
12. Law and Ordinance
Also refer to:
Coverage A provision, coverage B provision, coverage C provision, coverage D provision, all additional coverages provisions, all coverages provided by endorsement or rider, the declarations page, loss payment or settlement provision, duties in event of loss policy provision, all terms and conditions of section I of the insurance policy, the insurance policy definitions section, the insurance policy‘s exclusion of coverage provisions, all insurance policy provisions that provide coverage to the insured property, and all policy provisions.
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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.
624.155(1)(a)(1) – violating 626.9541(1)(i)
626.9541(1)(a)(1) -- misrepresenting the terms of an insurance policy.
626.9541(1)(i) -- unfair claim settlement practices.
Facts of the case:
Edison Insurance Company (“EDISON”) has committed the following in handling the insured’s claim: 1) failure to pay benefits owed; 2) failure to act in due diligence and good faith to resolve claims; 3) placing the financial interest of the insurer before that of the policy holder and claimant; 4) failure to properly train, evaluate, and manage adjusters retained to represent the policies and procedures of EDISON; 5) looking for ways to delay benefit payments and otherwise “low ball” or “stone wall” claims; 6) looking for ways to deny the insured’s claim; 7) looking for ways to reduce recovery to the insured; 8) failure to perform a reasonable investigation; 9) misrepresenting Florida statutory provisions to its insured; 10) misrepresenting insurance policy provisions to the insured; 11) EDISON has failed and refused to acknowledge coverage and promptly pay the benefits due and owed to the insured; 12) the reasons for this may be attributed to improper training, supervision, and/or motivation of outside adjusters and claims supervisors to promptly and fairly adjust and pay full benefits available to the insured. The insurer may have failed to adopt proper standards of investigation and adjustment of losses or is otherwise not implementing those standards because a proper investigation and full and prompt payment for the loss is not occurring.
In Florida, the work of adjusting insurance claims engages the public trust. EDISON has breached this duty by its adjustment of the insured’s claim of loss. EDISON has failed to create and implement adequate guidelines for proper investigation to evaluate claims handling and for training and supervision of employees resulting in violations as set forth above. EDISON has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the insured’s insurance claim for damages. Despite the insured’s timely notification to EDISON of their insurance claim, EDISON has failed and refused to acknowledge the covered loss and pay all amounts due and owing to the insured under the policy of insurance. EDISON has failed to promptly settle the insured’s insurance claim, when the obligation to settle the claim had become reasonably clear, under one portion of the insurance, in order to influence settlements under other portions of the insurance policy coverage. Despite the insured’s pleas otherwise, EDISON has failed and refused to acknowledge its obligation to tender all insurance proceed monies due and owing the insured or assist the insured in mitigation of the damages.
In exchange for a premium paid by the insured, EDISON issued the subject all-risk insurance policy which provided coverage for the insured property from May 28, 2023, through May 28, 2024, for “sudden and accidental physical loss to covered property described in Coverages A and B unless the loss is otherwise excluded or limited in this policy.” As such, the subject all-risk Policy contains coverage for all direct physical losses to the insured property unless the loss is specifically and unambiguously excluded from coverage by the Policy. On or about April 3, 2024, the insured property suffered a sudden and accidental water loss, and the insured immediately submitted a claim to EDISON for extensive water damage throughout the insured property. Hence, the insured suffered a substantial loss regarding the real property and continue to suffer such loss. Having suffered such substantial damage, the insured promptly notified EDISON of the loss in an effort to mitigate the current damage and prevent the exacerbation of any additional losses. The desired result did not follow. EDISON since being presented the Insured’s claim has misrepresented policy provisions to avoid paying the insured what they are owed under the policy. Ultimately, EDISON has failed and refused to properly settle the insured’s claim in good faith. The insured has requested that EDISON conduct an investigation, admit coverage, and pay damages; EDISON has failed and refused to do so. In short, EDISON has failed to handle its insured’s claim in good faith in violation of Fla. Stat. 624.155(1)(b)(1), 624.155(1)(b)(3), and 626.9541(1)(i).
Based upon EDISON’s investigation and property inspection, which confirmed damage, EDISON nevertheless sent correspondence to the insured dated April 30, 2024, (signed by EDISON’s adjuster, Carmen Turner (Fla. Adj. Lic. #E017211)) confirming partial coverage, denying the remainder, and issuing payment(s) for only $23,944.93. In regard to insurance contracts, a specific refusal to pay a claim is the breach which triggers the cause of action. Allstate Ins. Co. v. Kaklamanos, 843 So. 2d 885, 892 (Fla. 2003); Donovan v. EDISON Fire and Cas. Co., 574 So. 2d 285, 286 (Fla. 2nd DCA 1991) (finding that a breach of contract takes place at the moment the insurance company refuses to pay a claim). Therefore, EDISON breached the Policy. Moreover, EDISON’s argued exclusions and/or limitations to coverage are devoid of anti-concurrent causation language. Thus, “coverage may exist where an insured risk constitutes a concurrent cause of the loss even when it is not the prime or efficient cause.” Sebo v. Am. Home Assurance Co., Inc., 208 So. 3d 694, 699 (Fla. 2016). In addition, under the Policy, any ensuing loss to property not excluded or excepted in this policy is covered. Hence, there are a myriad of coverages under the Policy that would provide coverage for the loss. Nevertheless, EDISON failed and refused to acknowledge the covered loss and pay all amounts due and owing for the loss. Therefore, EDISON breached the Policy.
Questioning the propriety of EDISON’s coverage denial and delay, and given the extensive nature of the physical damage, the insured retained a consulting licensed contractor, Tom Gannon, with LSC Construction Consultants, LLC (“LSC”), to perform an investigation and damage evaluation in accordance with industry standards and Florida law. Based on his investigation, Mr. Gannon likewise concluded that a sudden and accidental water loss on or about April 3, 2024, caused extensive water damage to the insured property. Mr. Gannon determined that at least $76,227.01 worth of repairs would be required to return the property to its pre-loss condition as a result of the sudden and accidental water loss. Additionally, Storm Masters Emergency Response (“Storm Masters”) determined at least $18,963.07 of water extraction and remediation services would be necessary. Storm Masters’ water extraction and remediation services were considered in the LSC report. Nevertheless, EDISON failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, EDISON breached the Policy.
On January 02, 2025, the insured sent correspondence to EDISON enclosing their Sworn Statement in Proof of Loss, the supporting LSC report outlining the cause, scope, and cost of the loss along with other supporting documents, the Notice of Intent to Initiate Litigation, and requested EDISON to reconsider its coverage denial. To date, EDISON has failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, EDISON breached the Policy.
As such, EDISON’S coverage denial is a blatant misrepresentation of the available coverages under the Policy in direct violation of Fla. Stats. 626.9541(1)(a)(1), 626.9541(1)(i)(3)(b), 626.9541(1)(a)(1), and 626.9541(1)(i)(2) and is nothing more than a mere pretext to wrongfully deny and delay this claim. As a result, EDISON has materially misrepresented the coverages under the subject policy to the insured for the purpose and with the intent of effecting settlement of the insured’s claim on less favorable terms than those provided in, and contemplated by, the subject policy in direct violation of Fla. Stat. § 626.9541(1)(i)(2). Further, EDISON is in violation of Florida statutes §§ 626.9541(1)(a)(1), 626.9541(1)(i)(3)(b), and 626.9541(1)(a)(1) by misrepresenting pertinent facts and insurance policy provisions relating to coverages at issue; and also in violation of Fla. Stat. 626.9541(1)(i)(3)(d) by denying the insured’s claim without conducting a reasonable investigation based upon available information.
In summary, the insured’s loss is clearly covered by the terms of the policy of insurance with EDISON. However, EDISON chose to deny coverage for the insured’s loss. Despite clear evidence that the damage was covered and caused by a covered peril, the claim was denied. To date, EDISON continues to deny the insured and its insured’s full indemnity for the claim. While EDISON refuses to honor this claim, a jury in Pinellas County will likely do what EDISON has refused; exercise the benefit of doubt in favor of the insured in finding full coverage for this loss. Indeed, the insured will undoubtedly meet the burden of proof at trial, under the EDISON all-risk policy, to show that, while EDISON provided insurance coverage, damage occurred to the insured property. See Jones v. Federated Nat'l Ins. Co., 235 So. 3d 936, 942 (Fla. 4th DCA 2018). With the data presented within EDISON’s investigation and LSC’s investigation, EDISON’s burden to demonstrate by the greater weight of the evidence that all the physical damage to the insured property was caused solely by excluded perils under the policy and not in combination with a covered peril has not and cannot be met. See Sebo v. Am. Home Assurance Co., Inc., 208 So. 3d 694 (Fla. 2016). Despite clear indicators of covered damage, EDISON nevertheless inexplicably denied the insured’s claim.
As of today, EDISON has failed and refused to inform the insured of their rights under the policy of insurance and Florida statutes, has improperly delayed the insured’s claim, has wrongfully denied the insured’s claim, and has failed and refused to adequately indemnify the insured for the loss and defiantly continues to do so. Indeed, from the time of receiving the claim, EDISON has purposely and maliciously delayed in adjusting the subject claim in an effort to either avoid paying the claim altogether or, at the very least, avoid paying the full extent of the loss. Notably, under Florida law, “[t]he filing of a lawsuit does not extinguish the insurer’s obligations under the policy to adjust and pay the claim.” Tristar Lodging, Inc. V. Arch Specialty Ins. Co., 434 F. Supp. 2d 1286, 1289 (M.D. Fla. 2006).
To date, the insured has made a good faith effort to comply with all of the requirements under the subject policy of insurance, and it is only fair that EDISON do the same. Yet, that is not the case. The insured feel that the insured property is a valuable asset, and, by continuously delaying the proper handling of this claim, EDISON is putting the insured property at risk. As responsible property owners, the insured purchased insurance to protect the property, paid all of the premiums, and have kept up to date with the responsibilities under the policy. Yet, when the insured needed to rely on the insurance because of this unforeseen loss, EDISON turned its back and delayed and wrongfully denied coverage that the insured are rightfully owed.
Ultimately, EDISON has failed and refused to properly investigate the loss. The insured has requested that EDISON admit coverage and pay damages, EDISON has failed and refused to do so, and continues to refuse to fully indemnify the insured for the loss and pay the amounts necessary to properly repair the insured’s property, despite knowing it is required to do so. In short, EDISON has failed to handle its insured’s claim in good faith.
In Florida, the work of adjusting insurance claims engages the public trust; EDISON has breached this duty by its insufficient adjustment of the insured’s claim. EDISON has failed to create and implement adequate guidelines for proper investigation to evaluate claims handling and for training and supervision of employees resulting in statutory violations set forth above. EDISON has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the insured’s insurance claim for damages.
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 is the fact that payment must be made timely and promptly so that the insured may mitigate their damages to put them back into the position they were prior to loss as quickly as possible. EDISON breached this duty.
The actions taken by EDISON in the handling / adjustment of the insured’s claim were willful, wanton, and with complete disregard for the rights of its insured and occur with such a frequency as to indicate a general business practice and are in violation of Fla. Stat. 624.155 and 626.9541.
EDISON’S actions amount to but are not limited to the following:
1. Claim delay
2. Wrongful claim denial
3. Unfair trade practice
4. Unfair claim settlement practices
5. Unreasonable investigation
6. Failure to act on claim
7. Failure to conduct a reasonable investigation based on available information
8. Failure to maintain proper complaint handling procedures
9. Misrepresenting the insurance policy provisions to the insured
10. Misrepresenting Florida statutory provisions to the insured
11. Misrepresenting facts to the insured
12. Failure to acknowledge and act promptly upon communications with respect to claims
13. Denying claims without conducting reasonable investigations based upon available information
14. Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed.
15. 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.
16. Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
17. Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
18. Failing to pay undisputed amounts of partial or full benefits owed under first-party property insurance policies within 90 days after an insurer receives notice of a residential property insurance claim, determines the amounts of partial or full benefits, and agrees to coverage, unless payment of the undisputed benefits is prevented by an act of God, prevented by the impossibility of performance, or due to actions by the insured or claimant that constitute fraud, lack of cooperation, or intentional misrepresentation regarding the claim for which benefits are owed.
Therefore, to cure the defects outlined in this civil remedy notice, EDISON must:
(1): Admit full coverage for the insured’s loss;
(2): Tender all insurance monies due and owing to the insured for the loss under the subject Policy;
A copy of this form submitted to the FDFS has been emailed and/or uploaded and also printed out and mailed to the following parties providing them notice of the filing of this civil remedy notice:
Edison Insurance Company
P.O. Box 21957
Lehigh Valley, PA 18002
claims@edisoninsurance.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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