Filing Number: 801522
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| Filing Accepted: 1/16/2025 |
| Last/Business Name
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DOWNES
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First Name |
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CHERYL AND WILLIAM |
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| Street Address
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810 BLUE HERON BOULEVARD |
| City, State Zip
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RUSKIN,
FL
33570
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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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DOWNES |
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First Name |
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CHERYL AND WILLIAM |
| Policy # * |
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AGH0111492 |
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Claim #* |
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CHO-00177848 |
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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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AMERICAN INTEGRITY INSURANCE COMPANY OF FLORIDA
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| Insurer Name* |
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| Street Address* |
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| City, State Zip* |
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,
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NAIC Company Code 12841 |
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| Name of individual responsible for violation (if any):*
AUBREY SMITH AND AMERICAN INTEGRITY AND ITS ADJUSTERS
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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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Claim Delay
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Unsatisfactory Settlement Offer
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Unfair Trade Practice
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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 violation:
COVERAGE A
COVERAGE A - Dwelling and COVERAGE B - Other Structures
1. We insure for sudden and accidental direct loss to property described in COVERAGE A - Dwelling and COVERAGE B - Other Structures only if that loss is a physical loss to covered property.?We do not insure, however, for loss:
a. Involving collapse, including any of the following conditions of property or any part of the property, whether above or below the ground:
1 An abrupt falling down or caving in:
2 Loss of structural integrity, including separation of parts of the property or property in danger of falling down or caving in: or
Any "spalling", crumbling, settling, cracking, shifting, bulging, racking, sagging, bowing, bending, leaning, shrinkage or expansion, or any other age or maintenance related issues, as such condition relates to (1) or (2) above; except as provided in 8. Collapse under Section I - Property Coverages;
COVERAGE C - Personal Property
We insure for sudden and accidental direct physical loss to the property described in COVERAGE C - Personal Property caused by a peril listed below unless the loss is excluded in SECTION I - EXCLUSIONS
3 Fire or lightning.
Windstorm or hail. This peril does not include loss to the property contained in a building caused by rain, snow, sleet, sand or dust unless the direct force of wind or hail damages the building causing an opening in a roof or wall and the rain, snow, sleet, sand or dust enters through this opening.?This peril includes loss to watercraft and their trailers, furnishings, equipment, and outboard engines or motors, only while inside a fully enclosed
II. LOSS SETTLEMENT
III. LOSS PAYMENT
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. American Integrity Insurance Company (American Integrity) has breached this duty in the adjustment of Cheryl Downes’ and William C. Downes’ (the Downes’) claim.
American Integrity 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.
Furthermore, American Integrity 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.
The Downes’ claim results from wind and water damage to the roof and interior of their home due to a hurricane that occurred on September 27, 2024. To mitigate the damages to their home, the Downes contacted their insurance company, American Integrity, to report the damages. As part of the investigation of the Downes’ claim, American Integrity assigned a claim number CHO-00177848 and independent adjuster Aubrey Smith. American Integrity inspected the damages to the Downes’ property. Subsequently, American Integrity concluded that the damage was the result of wear and tear to the roof, elevations, and fence. Furthermore, they stated that the damage from flood or surface water to the interior walls, floors, and contents, is not covered by the policy. As a result, American Integrity denied the claim of damages and did not provide any monetary compensation to repair the damages caused to the Downes’ property.
In view of the foregoing, it is clear and unequivocal that American Integrity has failed to provide proper and sufficient compensation to repair the damages caused to the Downes’ property. Due to American Integrity’s handling of the Downes’ claim, the Downes chose to retain a public adjuster to further assess the damages to their home. As such, upon inspection and view of the damages, it was clear that the roof and interior of the property required extensive repair. After the inspection, the public adjuster provided an estimate for repairs in the amount of $40,946.48, with an additional damages for ensuing water damages to the property.
The Downes have complied with all conditions under the policy. Nonetheless, American Integrity failed to properly compensate the Downes for their loss. The facts of this claim show that for whatever reason, American Integrity not only substantially misinterpreted the scope of damages to the Downes’ property, but also failed to conduct a thorough investigation as to the scope of damages to the roof and interior. Upon view of American Integrity’s claims handling procedures, it is clear American Integrity conducted a limited and quick outcome orientated investigation in the hopes that the Downes would make the required repairs with their own money. The Downes now must incur costs for assistance to obtain what should have been paid had they been treated fairly and honestly by American Integrity.
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 American Integrity, their adjusters and the estimate provided, American Integrity 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 the Downes’ 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 insureds may mitigate their damages, and to put the insureds back into the position they enjoyed prior to the loss as quickly as possible. American Integrity has breached this duty by improperly investigating the Downes’ claim and failing to properly pay the Downes for their loss. American Integrity 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 the Downes.
In view of the facts surrounding the Downes’ claim, it is evident that American Integrity 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, American Integrity has failed and/or refused to investigate the insureds’ claim thoroughly, accurately, and completely for damages.
Furthermore, American Integrity 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.
Florida Statutes Violated by American Integrity 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.
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. American Integrity 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 the Downes in the amount of $40,946.48 which is the amount to return the Downes’ home back to pre-loss condition for wind damage to the roof of the subject property.
D. Tender payment to the Downes for any ensuing water damage as a result of the loss.
E. Tender prejudgment interest from the date the claim was reported through today.
F Agree to pay the Downes’ 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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