Civil Remedy Filing

Civil Remedy Notice of Insurer Violations

Filing Number: 801545

Filing Accepted: 1/16/2025

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Complainant

Last/Business Name *

VELEZ

First Name

ARCADIO & ANGELA

Street Address *

3253 SISAL LOOP

City, State Zip *

ZEPHYRHILLS, FL 33544

Email Address *

WITHHELD

Complainant Type: *

Insured

Last/Business Name*		VELEZ		First Name		ARCADIO & ANGELA
Policy # *		AGH236960		Claim #*		CHO-00185981

Attorney

Attorney is Applicable

Last Name*	WALLACE First Name * BLAKE Initial
Street Address*		8635 W. HILLSBOROUGH AVE., STE. 401
City, State Zip*		TAMPA , FLORIDA 33544
Email Address *		BLAKE@KLINGLAW.COM

Violation

Insurer Type *		Authorized Insurer Unauthorized Insurer

Insurer Name
Insurer Name*		AMERICAN INTEGRITY INSURANCE COMPANY OF FLORIDA
Insurer Name*
Street Address*
City, State Zip*		,
NAIC Company Code 12841

Name of individual responsible for violation (if any):* TIMOTHY HUNTER IV
Type of Insurance * Residential Property & Casualty

Reason for Notice *

	Claim Denial
	Claim Delay
	Unsatisfactory Settlement Offer
	Unfair Trade Practice

* 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.
	624.155(1)(b)(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.
	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)(d)		Denying claims without conducting reasonable investigations based upon available information.
	626.9541(1)(i)(3)(f)		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.

* 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 1. We cover: a. The dwelling on the “residence premises,” shown in the Declarations, including attached structures and attached wall-towall carpeting if damage to the dwelling is caused by a covered loss. b. Materials and supplies located on or next to the “residence premises” used to construct, alter or repair the dwelling or other structures on the “residence premises.” c. In-ground swimming pools including related permanently installed equipment such as pumps and filters. 2. We do not cover land, including land on which the dwelling is located. 3. We do not cover “Carport(s),” “Pool Cage(s)” or “Screen Enclosure(s)” for a loss during a “Hurricane occurrence.” 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 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 (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 (3) 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; b. Caused directly or indirectly by: (1) Freezing of a plumbing, heating, air conditioning or automatic fire protective sprinkler system or of a household appliance, or by discharge, leakage or overflow from within the system or appliance caused by freezing. This exclusion applies only while the dwelling is “vacant,” “unoccupied” or being constructed, unless you have used reasonable care to: (a) Maintain heat in the building; or (b) Shut off the water supply and drain the system and appliances of water; (2) Freezing, thawing, pressure or weight of water or ice, whether driven by wind or not, to a: (a) Fence, pavement, patio or swimming pool; (b) Foundation, retaining wall, or bulkhead; or (c) Pier, wharf or dock; (3) Theft in or to a dwelling under construction, or of materials and supplies for use in the construction until the dwelling is finished and occupied; (4) Theft or attempted theft in or to a dwelling if the dwelling has been “vacant” for more than 30 consecutive days immediately before the loss. (5) Vandalism and malicious mischief, and any ensuing loss caused by any intentional and wrongful act committed in the course of the vandalism or malicious mischief, if the dwelling has been “vacant” or “unoccupied” for more than 30 A dwelling being constructed is not considered “vacant”; (6) Any of the following: (a) Wear and tear, “marring”, deterioration, scratching; (b) Inherent vice, latent defect, defect or mechanical breakdown; (c) Smog, rust, “spalling,” decay or other corrosion; (d) Smoke from agricultural smudging or industrial operations (e) Discharge, dispersal, seepage, migration, release or escape of “pollutants” unless the discharge, dispersal, seepage, migration, release or escape is itself caused by a Peril Insured Against under COVERAGE C – Personal Property of this policy. (f) Settling, shrinking, bulging or expansion, including resultant cracking, of pavements, patios, foundations, walls, floors, roofs or ceilings If any of these cause water damage not otherwise excluded or limited elsewhere in the policy, from a plumbing, heating, air conditioning or automatic fire protective sprinkler system or household appliance, we cover loss caused by the water including the cost of tearing out and repairing only that part or portion of a building or only that part or portion of another structure covered under Coverage A or B on the “‘residence premises” necessary to access and repair the system or appliance. The cost that we will pay for the tear out and repair above is only that cost necessary to access and repair only that part or portion of the system or appliance that caused the covered loss, whether the system or appliance, or any part or portion of the system or appliance, is repairable or not. However, such tear out and replacement coverage only applies if the water or steam causes actual damage to a covered building on the “residence premises.” In the event that additional tear out and repair are required beyond the coverage provided for access and repair in the provision immediately above, we will still pay only for our portion of the access and repair cost required to repair only that portion or only that part of the system or appliance that caused the covered loss as described above. However, we do not cover loss: (a) To the system or appliance from which this water or steam escaped; (b) On the “residence premises” caused by accidental discharge or overflow which occurs off the “residence premises”; (c) To a plumbing system, whether above or below the ground caused by: (i) Age, collapse, obsolescence, wear, tear; (ii) Fading, oxidization, weathering; (iii) Deterioration, decay, marring, delamination, crumbling, settling, cracking; (iv) Shifting, bulging, racking, sagging, bowing, bending, leaning; (v) Shrinkage, expansion, contraction, bellying, corrosion; (vi) The unavailability or discontinuation of a part or component of the system; or (vii) Any other age or maintenance related issue; (d) To a plumbing system, whether above or below the ground, caused by the impairment, state or condition of the system which prohibits repair or replacement including access, necessary to connect the adjoining parts of appliances, pipes or system; or (e) Otherwise excluded or limited elsewhere in the Policy. (7) Constant or repeated seepage or leakage of water or steam or the presence or condensation of humidity, moisture or vapor that occurs over a period of 14 or more days, whether hidden or not. In the event this exclusion applies, we will not pay for any damages sustained starting from the first day and instance the constant or repeated seepage or leakage of water or steam or the presence or condensation of humidity, moisture or vapor began. SECTION I - EXCLUSIONS 1. We do not insure for loss caused directly or indirectly by any of the following and such loss is excluded regardless of any other cause or event contributing concurrently or in any sequence to the loss: c. Water Damage mean means: (1) Flood, surface water, waves, tidal waves, tsunami, tides, tidal water, overflow of any body of water, or spray from any of these, all whether or not driven by wind, including storm surge; or (2) Water, water-borne material, sewage or any other substance which backs up through sewers or drains; or (3) Water, water-borne material, sewage or any other substance that overflows from a sump pump, sump pump well or other system designed for the removal of subsurface water which is drained from a foundation area of a structure; or (4) Water, water-borne material, sewage or any other substance on or below the surface of the ground, regardless of its source. This includes water or any other substance which exerts pressure on or flows, seeps or leaks through a building, sidewalk, driveway, patio, foundation, swimming pool or other structure; or (5) Escape, overflow or discharge, for any reason, of water or waterborne material from a dam, levee, seawall or any other boundary or containment system.

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

January 16, 2025 Sent Via Email AMERICAN INTEGRITY INSURANCE COMPANY OF FLORIDA claimsmail@aiiflorida.com RE: Insured : ARCADIO VELEZ AND ANGELA VELEZ (hereinafter, “Insured/Claimant”) Policy # : AGH236960 Claim # : CHO-00185981 Property Address : 3253 Sisal Loop, Zephyrhills, FL 33544 Persons most knowledgeable of facts giving rise to the Violations: Timothy Hunter IV Dear AMERICAN INTEGRITY INSURANCE COMPANY OF FLORIDA: Please find enclosed the civil remedy notice filed for the above referenced claim. This notice is given in order to perfect the right to pursue the civil remedy authorized by Florida Statute §624.155 As discussed in greater detail in the notice, the carrier has not attempted in good faith to settle the claimant’s claim when, under all the circumstances, it could and should have done so, had it acted fairly and honestly toward its claimant and with due regard for its interests. The carrier has done everything possible to delay the claim and refuses to provide any sort of status of the claim. Furthermore, the carrier is required to properly investigate and adjust claims and cannot place that burden upon the insured. This was made clear by the appellate court and the Florida Supreme Court in Allstate Indemnity Co. v. Ruiz, 899 So. 2d 1121 (Fla. 2005) (“The Legislature has clearly chosen to impose on the insurance companies a duty to use good faith and fair dealing in processing and litigating the claims of their insured…”). The carrier was put on notice of the insured’s water damage claim on October 2, 2024. Since the commencement of the claim the carrier has failed to timely communicate with the insured. It is obvious that the carrier is not attempting to pay for the clearly covered damages owed under the policy. The carrier assigned Timothy Hunter IV, who is not an engineer, to inspect the loss. On November 11, 2024, the carrier made the unilateral determinations that A) the damages to the property, including the interior would be excluded under the policy and therefore be denied and that B) the damages that were covered failed to exceed the deductible on the policy and that the insured would be entitled to $0 after the application of the deductible. It was clear that the damages exceeded the deductible. Moreover, in reaching those conclusions, American Integrity failed to adopt and implement standards for the proper investigation of claims. There was no explanation whatsoever as to how American Integrity determined which items of damage were caused by covered or excluded perils. Furthermore, the carrier’s failure to assign a qualified and experienced engineer further violates F.S. §626.9541(1)(i)(3)(a). Moreover, as the carrier denied coverage without conducting a reasonable investigation based upon available information, the carrier violated F.S. §626.9541(1)(i)(3)(d). Additionally, in response to the insureds request for information regarding the claim, the carrier’s adjuster refused to produce documentation that helped it reach its coverage determination. This is violation of F.S. §626.9541(1)(i)(3)(d) and F.S. §626.9541(1)(i)(3)(f) as the carrier is denying the claim without reasonable investigation and failing to promptly provide a reasonable explanation, such as the basis for the denial, 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. Instead the carrier has elected to rely on information that it has not made available to the insured as the basis for its decision. This additionally could be in violation of F.S. §626.9541(1)(i)(3)(b) as it is possibly a misrepresentation of the findings as it related to the claim and coverages at issue. The insured has been compelled to obtain an independent quote totaling in the amount of $30,450.00 that would be needed to repair the property back to its pre-loss condition. The insured has complied with all the carrier’s requests to date. The carrier has still refused to pay the fully covered amount owed under the policy, instead electing to stand by its unilaterally determined deficient valuation of the loss while denying the rest of the loss. This is in violation of F.S. 624.155(1)(b)(1) and 624.155(1)(b)(3) as the carrier is clearly placing the company’s interests before the claimant’s interests and not attempting in good faith to settle claims. Furthermore, it is further in violation of F.S. §626.9541(1)(i)(3)(a) as the carrier failed to adopt and implement standards for a proper investigation of the claim. It is clear that the carrier is not treating the claimant with good faith claims conduct; failing to pay a claim clearly owed; not adjusting the claim and evaluating the loss properly, promptly and fairly to provide full and prompt indemnity to the claimant; failing to implement proper standards for the adjustment and investigation of claims and placing the company’s interests before the claimant’s interests; not training, supervising or managing adjusters properly so that prompt and full payments are made; refusing to pay the full amount owed to the insured despite the fact that the damages are covered under the policy; looking for ways to delay full recovery or any recovery to the insured; and refusing to provide coverage for the claimant’s loss in a timely manner. The Carrier’s actions are in violation of Florida Statutes §§ 624.155(1)(b)(1), 624.155(1)(b)(3), 626.9541(1)(i)(3)(a), 626.9541(1)(i)(3)(b), 626.9541(1)(i)(3)(d), 627.4137(1), and Fla. Stat. §627.70131. The actions taken by American Integrity in the handling/adjustment of the insured’s claim were willful, wanton, malicious, and in reckless disregard for the rights of any insureds and occur with such frequency as to indicate a general business practice, and further are in violation of Florida Statutes §624.155 and F.S. §626.954. Indeed, when performing a search on the Florida Department of Financial Services website’s Civil Remedy Notice of Insurer Violation page the results of searches of violations of the statutes referenced herein by the carrier returned the following results thereby indicating that the number of times they occur rise to the level of a general business practice, and warrant punitive damages: §624.155(1)(b)(1) = 9,200 §624.155(1)(b)(3) = 6,174 §626.9541(1)(i)(3)(a) = 8,751 §626.9541(1)(i)(3)(b) = 6,870 §626.9541(1)(i)(3)(d) = 5,414 §626.9541(1)(i)(3)(f) = 5,044 Based upon the above-referenced acts and omissions, the carrier has breached the insurance contract by failing to pay the amount due to the insured, by denying coverage which existed under the insurance contract with the insured in the instant dispute, by failing to adjust the loss with the insureds, and by failing to perform an adequate investigation. These are violations and breaches of the policy language cited above. Therefore, to cure the defects outlined in this Civil Remedy Notice, the carrier must: 1) Pay the complete covered loss in the amount of $30,450.00 less any applicable policy deductible; and 2) Pay the statutory interest on the amount of unpaid damages from the date of loss to the date payment is finally made. A copy of this letter and filed form submitted to the FDFS has been emailed to the carrier. The specific policy provisions the carrier violated are the loss payment provision, the loss settlement provision, and the coverage provisions. Specifically, the loss payment provision states “we will adjust all losses with you.” Yet, the carrier did not consult the homeowner in deciding who would investigate the cause or amount of damages, and what the ultimate payment should be. The other provisions are pasted on the pages following the signature block. If you have any questions or concerns, please send all correspondence via email to Blake@klinglaw.com and Jorlyn@KlingLaw.com to ensure a prompt response. We ask that all correspondence be done via email rather than regular mail. Should you need to send something regular mail, please advise us prior to sending same via the emails above. Sincerely, Blake M. Wallace, Esq. Blake M. Wallace Attorney at Law Enclosed: Civil Remedy Filing

Comments

User Id		Date Added		Comment
swozniak@aii.com		02-04-2025		February 4, 2025 Via Electronic Submission Florida Department of Financial Services Consumer Assistance Civil Remedy Section Larson Building 200 E. Gaines Street Tallahassee, Florida 32399-0322 Blake Wallace, Esq. 8635 W. Hillsborough Ave. Suite 401 Tampa, Florida 33544 Blake@KlingLaw.com Re: DFS File No: 801545 Complainants: Arcadio and Angela Velez Insureds: Arcadio and Angela Velez Policy No: AGH236960 Insurer: American Integrity Insurance Company of Florida Claim No: CHO-00185981 To Whom It May Concern: We are in receipt of the Civil Remedy Notice (“CRN”) filed by Blake Wallace, Esq. on behalf of the above referenced Complainant and matter. The Florida Department of Financial Services (“DFS”) accepted the CRN on January 16, 2025 and assigned it DFS File No. of 801545. While American Integrity asserts that the subject CRN is legally insufficient and non-compliant with Florida law, American Integrity, without waiving any arguments regarding same, contends that it has at all times performed its obligations under the insurance policy in a prompt and diligent manner with due regard for the interest of its Insureds, Arcadio and Angela Velez. The CRN contains a list of purported violations which are alleged to have been committed by American Integrity. In fact, none of the listed violations/allegations have occurred and/or are irrelevant to the alleged violations and American Integrity categorically denies any violations of §624.155 and §626.9541, Fla. Stat., as well as any and all other statutes/regulations/codes/rules contained in the CRN. In addition, American Integrity denies any and all allegations of any kind and/or any inferences therefrom referenced and/or contained in the CRN. American Integrity believes this response adequately addresses the allegations and violations contained within the CRN. Sincerely, Michael S. Sperounes Michael S. Sperounes, Esq. Senior Vice President of Litigation American Integrity Insurance Group cc: Blake Wallace, Esq. via email at: Blake@KlingLaw.com CRN Response If this document contains an excerpt from an American Integrity Insurance Policy (“the Policy”) it is provided here for informational purposes only. This excerpt is not the official version of the Policy. The official version of the Policy is the policy issued to the Insureds on the policy effective date. In the event there is inconsistency between this document and the Policy, the Policy shall serve as the official version. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. F.S. 817.234

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