Filing Number: 800604
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| Filing Accepted: 1/13/2025 |
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| Street Address
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178 SIMMONS TRAIL |
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GREEN COVE SPRINGS,
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32043
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| Email Address
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JORTIZ@REDPLATEGRADING.COM |
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Insured |
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| Last/Business Name* |
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ORTIZ |
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First Name |
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JACOB |
| Policy # * |
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GIC 02406 70 99 90A |
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Claim #* |
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024067099-014 |
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Attorney is Applicable
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| Last Name* |
O'NEIL
First Name *
JONATHAN
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| Street Address* |
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203 FORT WADE, SUITE 260 |
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PONTE VEDRA
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FLORIDA
32081
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JONATHAN@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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USAA GENERAL INDEMNITY COMPANY
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NAIC Company Code 18600 |
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| Name of individual responsible for violation (if any):*
ANDRES PIEDRAHITA (FLA. ADJ. LICENSE # P195910) AND ANDREA BRAGG (FLA ADJ. LICENSE # W823668)
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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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Unfair Trade Practice
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Other
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Wrongful claim denial
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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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Other
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Unfair claim settlement practices
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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.
COVERAGE A – DWELLING PROTECTION COVERAGE AND COVERAGEB – OTHER STRUCTURES PROPTECTION COVERAGE
We insure against sudden and accidental, direct, physical loss to tangible property described in PROPERTY WE COVER – DWELLING PROTECTION and PERSONAL PROPERTY PROTECTION caused by a peril listed below unless excluded in SECTION 1 – LOSSES WE DO NOT COVER.
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COVERAGE C – PERSONAL PROPERTY PROTECTION
We insure against sudden and accidental, direct physical loss to tangible property described in PROPERTY WE COVER – COVERAGE C caused by a peril listed below unless the loss is excluded in SECTION 1 -LOSSES WE DO NOT COVER UNDER DWELLING PROTECTION, OTHER STRUCTRES PROTECTION AND PERSONAL PROPERTY PROTECTION. …2. Windstorm or hail.
ADDITIONAL COVERAGES
Unless specifically addressed elsewhere in this policy, the coverages provided below are the only coverages provided for the following:
1. Debris Removal
2. Reasonable Repairs
In the event that covered property is damaged by an applicable loss under Section 1 – LOSSES WE COVER, we will pay the reasonable expenses incurred by you, for the necessary measures taken solely to protect against further damage.
3. Trees, Shrubs and Other Plants
We cover trees, shrubs, plants, lawns, or landscaping on the “residence premises”; for loss caused by the following Losses We Cover: Fire or lightning, Explosion, Riot or civil commotion, Aircraft, Vehicles not owned or operated by a resident of the “residence premises”, Vandalism or malicious mischief or Theft. We will pay up to 5% of the amount of insurance that applies to the dwelling for all trees, shrubs, plants, lawns or landscaping. No more than $500 of this limit will be available for any one tree, shrub or plant. We do not cover property grown for “business” purposes.
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14. Building Ordinance or Law
For loss caused by a loss under Section 1 – LOSSES WE COVER to buildings under Dwelling Protection and Other Structures Protection, we will pat the increased costs which are required and you actually incur to comply with any ordinance or law governing the rebuilding, repair, or demolition of the damaged property.
15. Temporary Living Expenses
We will pay up to $2,000 for necessary increase in costs which you incur to maintain your normal standard of living when the “residence premises” is uninhabitable due to a loss caused by earthquake, volcanic eruption, landslide, or if a civil authority prohibits your use of the “residence premises” because an earthquake, volcanic eruption or landslide has occurred.
16. Fungus, or Wet or Dry Rot
1. We will pay up to a total of $2,500 for:
a. The cost to treat, remove or dispose of “fungus” or wet or dry rot from covered property;
b. The cost to tear out and replace any part of the building or other covered property as needed to gain access to the “fungus”, or wet or dry rot; and/or
c. The cost to test, to detect, measure or evaluate air or property to confirm the absence, presence, or level of “fungus”, or wet or dry rot 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 reasonable probability that there is the presence of “fungus”.
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:
USAA General Indemnity Company (“USAA”) has committed the following in handling the insureds’ 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 USAA; 5) looking for ways to delay benefit payments and otherwise “low ball” or “stone wall” claims; 6) looking for ways to deny the insureds’ 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) USAA 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. USAA has breached this duty by its adjustment of the insureds’ claim of loss. USAA 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. USAA has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the insureds’ insurance claim for damages. Despite the insureds’ timely notification to USAA of their insurance claim, USAA has failed and refused to acknowledge the covered loss and pay all amounts due and owing to the insured under the policy of insurance. USAA has failed to promptly settle the insureds’ 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 insureds’ pleas otherwise, USAA 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 insureds, USAA issued the subject insurance policy which provided coverage for the insured property from May 19, 2023, to May 19, 2024, for “sudden and accidental, direct, physical loss to tangible property described in PROPERTY WE COVER – DWELLING PROTECTION and PERSONAL PROPERTY PROTECTION caused by a peril listed below unless excluded in SECTION 1 – LOSSES WE DO NOT COVER.” 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 January 9, 2024, the insured property suffered a hail and windstorm loss, and the insureds immediately submitted a claim to USAA for property damage, i.e., storm, hail, wind, rain, and/or water intrusion damages throughout the insured property. Hence, the insureds suffered a substantial loss regarding the real property and continue to suffer such loss. Having suffered such substantial damage, the insureds promptly notified USAA 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. USAA since being presented the Insureds’ claim has misrepresented policy provisions to avoid paying the insured what they are owed under the policy. Ultimately, USAA has failed and refused to properly settle the insureds’ claim in good faith. The insured have requested that USAA conduct an investigation, admit coverage, and pay damages; USAA has failed and refused to do so. In short, USAA has failed to handle its insureds’ 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 USAA’s investigation and property inspection, which confirmed hail and windstorm damages, USAA nevertheless sent correspondence to the insured dated April 15, 2024 (signed by USAA’s adjuster, Andrea Bragg - Fla. Adj. License #W823668) communicating its unequivocal denial of the claim. 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. State Farm 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, USAA breached the Policy. Moreover, USAA’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, USAA failed and refused to acknowledge the covered loss and pay all amounts due and owing for the loss. Therefore, USAA breached the Policy.
Concerned with the accuracy of USAA’s coverage denial, and given the extensive nature of the physical damage, the insureds retained a loss consultant, Coastal Claims Services (“CCS”), to perform an investigation and damage evaluation in accordance with industry standards and Florida law. Based on its investigation, CCS determined that a hail and windstorm on or about January 9, 2024, including wind and hail, caused damage throughout the exterior of the insured property (particularly the roof warranting its replacement), including openings, which allowed wind and rain to intrude into the interior causing additional damage. Moreover, CCS determined that at least $36,165.80 worth of repairs would be required to return the property to its pre-loss condition as a result of the hail and windstorm loss. Nevertheless, USAA failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, USAA breached the Policy.
Thereafter, the insureds sent correspondence to USAA enclosing the supporting CCS report outlining the cause, scope, and cost of the loss along with other supporting documents and requested USAA to reconsider its coverage denial. Nevertheless, USAA failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, USAA breached the Policy.
Concerned with the accuracy of USAA’s continued coverage denial, the insureds retained a consulting expert contractor, Thomas Gannon with LSC Construction, to perform an investigation and damage evaluation in accordance with industry standards and Florida law. Based on his investigation, Mr. Gannon determined that a hail and windstorm on or about January 9, 2024, including wind and hail, caused damage throughout the exterior of the insured property (particularly the roof warranting its replacement), including openings, which allowed wind and rain to intrude into the interior causing additional damage. Moreover, Mr. Gannon determined that at least $37,591.60 worth of repairs would be required to return the property to its pre-loss condition as a result of the hail and windstorm loss. Nevertheless, USAA failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, USAA breached the Policy.
On January 13, 2025, the insureds sent correspondence to USAA enclosing their Sworn Statement in Proof of Loss, the supporting CCS report and LSC Construction report outlining the cause, scope, and cost of the loss along with other supporting documents, the Notice of Intent to Initiate Litigation, and requested USAA to reconsider its coverage denial. To date, USAA has failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, USAA breached the Policy.
As such, USAA’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, USAA has materially misrepresented the coverages under the subject policy to the insured for the purpose and with the intent of effecting settlement of the insureds’ 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, USAA 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 insureds’ claim without conducting a reasonable investigation based upon available information.
In summary, the insureds’ loss is clearly covered by the terms of the policy of insurance with USAA. However, USAA chose to deny coverage for the insureds’ loss. Despite clear evidence that the damage was covered and caused by a covered peril, the claim was denied. To date, USAA continues to deny the insured and its insured full indemnity for the claim. While USAA refuses to honor this claim, a jury in Clay County will likely do what USAA has refused; exercise the benefit of doubt in favor of the insured in finding full coverage for this loss. Indeed, the insureds will undoubtedly meet the burden of proof at trial, under the USAA all-risk policy, to show that, while USAA 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 the USAA’s investigation, CCS’s investigation, and LSC’s investigation, USAA’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, USAA nevertheless inexplicably denied the insureds’ claim.
As of today, USAA has failed and refused to inform the insureds of their rights under the policy of insurance and Florida statutes, has improperly delayed the insureds’ claim, has wrongfully denied the insureds’ claim, and has failed and refused to adequately indemnify the insureds for the loss and defiantly continues to do so. Indeed, from the time of receiving the claim, USAA 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 insureds have made a good faith effort to comply with all of the requirements under the subject policy of insurance, and it is only fair that USAA do the same. Yet, that is not the case. The insureds feel that the insured property is a valuable asset, and, by continuously delaying the proper handling of this claim, USAA is putting the insured property at risk. As a responsible property owner, the insured purchased insurance to protect the property, paid all of the premiums, and has 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, USAA turned its back and delayed and wrongfully denied coverage that the insured are rightfully owed.
Ultimately, USAA has failed and refused to properly investigate the loss. The insureds have requested that USAA admit coverage and pay damages, USAA 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 insureds’ property, despite knowing it is required to do so. In short, USAA has failed to handle its insureds’ claim in good faith.
In Florida, the work of adjusting insurance claims engages the public trust; USAA has breached this duty by its insufficient adjustment of the insureds’ claim. USAA 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. USAA has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the insureds’ 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. USAA breached this duty.
The actions taken by USAA in the handling / adjustment of the insureds’ 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.
USAA’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, USAA must:
(1): Admit full coverage for the insureds’ loss; and
(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:
USAA Claims Department
P.O. Box 33490
San Antonio, TX 78265
3mpqjhlbdp33@claims.usaa.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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