Filing Number: 803075
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| Filing Accepted: 1/23/2025 |
| Last/Business Name
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JOHNSON
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First Name |
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PEGGY ; BILLY |
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| Street Address
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559 SKY TOP DR |
| City, State Zip
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OCOEE,
FL
34761
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| Email Address
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PEGGYAJ0152@GMAIL.COM |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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JOHNSON |
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First Name |
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PEGGY ; BILLY |
| Policy # * |
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7709HR041609 |
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Claim #* |
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717420-GP |
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Attorney is Applicable
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| Last Name* |
BRAZ
First Name *
TAMARA
Initial
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| Street Address* |
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8865 COMMODITY CIR. STE. 12 |
| City, State Zip* |
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ORLANDO
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FLORIDA
32819
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| Email Address * |
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TBRAZ@THELAWGICALFIRM.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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NATIONWIDE PROPERTY AND CASUALTY 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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,
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NAIC Company Code 37877 |
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| Name of individual responsible for violation (if any):*
? IRLANDA RODRIGUEZ, DESK ADJUSTER ON BEHALF OF NATIONWIDE PROPERTY & CASUALTY INSURANCE COMPANY; ? JOSHUA TOMAK, FIELD ADJUSTER ON BEHALF OF NATIONWIDE PROPERTY & CASUALTY INSURANCE COMPANY;
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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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Unfair Trade Practice
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Other
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Improper Investigation
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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)(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)(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)(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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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
POLICY FORM: H 00 03 FL 07 16
***
SECTION I - PROPERTY COVERAGES
A. Coverage A - Dwelling
1. We cover:
a. The dwelling on the "residence premises" shown in the Declarations,
including structures attached to the dwelling[;]
***
SECTION I — PERILS INSURED AGAINST
A. Coverage A — Dwelling And Coverage B — Other Structures
1. We insure against direct physical loss to property described in Coverages A
and B.
***
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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.
On or about September 21, 2023, Peggy Johnson and Billy Johnson (Complainant(s)) suffered a loss to their Property, located at the address listed above due to wind and hail. After discovering the damage, Complainant(s) reported the loss to Nationwide Property & Casualty Insurance Company (“Insurer”) on or about May 23, 2024.
Throughout the Insurer’s investigation, Complainant(s) have fully cooperated with the Insurer and fully performed all duties and obligations under the policy by providing all information within Complainant(s) custody, possession and control.
The Insurer, however, has failed to fulfill its duties under the Policy and Florida law.
Upon discovering significant property damages, Complainant retained “Adjusters Group”, a public adjuster, (hereinafter "Public Adjuster"), on or about May 22, 2024.
On or about May 23, 2024, a field adjuster, Joshua Tomak, on behalf of Insurer inspected the property.
Shockingly, on or about May 31, 202, a mere eight days after the claim was reported, Insurer hastily issued a coverage denial letter, blatantly disregarding its obligation to conduct a proper, good-faith investigation.
The coverage denial letter issued by Insurer included the following statement:
"Our review showed that our inspection of the main roofing system found no signs of any wind or hail damage. The shingles were found to have non-storm-related wear, tear, and deterioration damages in the form of granular loss, zippering, improper installation, unsealed shingles, and blistering."
A filed adjuster’s role is limited to documenting observed damages and reporting findings, not determining causation. Determining causation, particularly regarding the roofing system, and assessing wherever the loss was accidentally or attributed to wear, tear, and inadequate maintenance, requires the expertise of qualified professionals.
Insurer’s statement highlights the egregious flaws in Insurer’s investigative approach. Rather than conducting a diligent, objective investigation, Insurer chose to rely on the sole observations of an unqualified field adjuster, whose expertise is grossly insufficient to assess whether the damages were the result of accidental direct physical loss or attributable to excluded causes such as wear and tear.
By rushing to deny the claim without performing a proper investigation, Insurer has outright violated the requirements under Fla. Stat. 626.9541(1)(i)(3)(a) which mandates Insurers adopt and implement standards for the proper investigation of claims.
Subsequently later that day, Public Adjuster conducted an inspection of the property the same day and took photographs.
On or about June 5, 2024, Public Adjuster prepared an estimate reflecting damages totaling $42,917.73 in actual cash value, which was subsequently provided to Insurer.
Insurer, in response, failed to respond, acknowledge, or even review the supplemental evidence in their possession. Here, Insurer violated Fla. Stat. 627.70131, by failing to review and acknowledge receipt of communication with respect to the claim.
On or about July 2, 2024, Complainant executed a Sworn Statement in Proof of Loss (“SPOL”) claiming $41,917.73 in losses, and this document was likewise sent to Insurer.
Despite these attempts to communicate with Insurer regarding the claim, including the submission of both the estimate and the SPOL, Insurer failed to respond in writing to either document. Insurer did not acknowledge, affirm, or deny coverage in connection with these submissions, nor did it take any action to progress the claim.
This failure constitutes a blatant violation of Fla. Stat. 626.9541(1)(i)(3)(e), which requires Insurer to affirm or deny coverage within 30 days after receiving a completed and signed SPOL.
On or about September 30, 2024, Complainant retained Lawgical for legal representation and submitted a Letter of Representation (“LOR”) to Insurer the same day.
By this date, an inconceivable 90 days had elapsed since Complainant executed and submitted the Sworn Statement in Proof of Loss (“SPOL”).
Insurer’s outright refusal to acknowledge both the estimate and the SPOL is not only indefensible but a blatant and willful disregard for the claim as a whole.
Insurer, already in flagrant violation for unconscionably delaying the claim, compounded its gross misconduct by ignoring critical documentation and blatantly neglecting Complainant’s persistent efforts to advance the claim.
To further exemplify its contempt for statutory requirements, Insurer failed to even acknowledge Lawgical’s Letter of Representation (“LOR”) in writing prior to litigation.
Under Fla. Stat. 627.70131(1)(a), Insurer is required to respond to claim-related communications within seven days. Yet, Insurer not only disregarded this statutory mandate but egregiously and inexcusably exceeded it, demonstrating a staggering level of apathy and defiance by failing to acknowledge the LOR altogether.
This outrageous disregard for communications constitutes a direct and undeniable violation of Fla. Stat. 626.9541(1)(i)(3)(c), which requires Insurer to promptly and adequately acknowledge claim-related communications.
Insurer’s deliberate and prolonged inaction is nothing short of a flagrant affront to both Florida law and the rights of the Complainant for a fair investigation of the claim.
Further, Insurer’s deliberate tactics of delay are glaringly evident through its decision to retain Donan Engineering for an additional inspection of the property.
It is truly unacceptable that Insurer, after initially rushing to determine the cause of damage as mere “wear, tear, and deterioration” based solely on the unqualified observations of a field adjuster, failed to engage an engineer at an appropriate and timely point.
Instead, Insurer chose to delay meaningful action for a shocking four months, willfully ignoring the findings of Public Adjuster’s inspection and disregarding proper claims handling.
On or about October 28, 2024, Donan Engineering contacted Complainant regarding questions about the property to conduct an inspection at a later date.
After several email exchanges between Complainant and their agents, and Donan Engineering, Complainant’s agents informed Insurer that the inspection would take place on or about November 18, 2024.
On or about November 18, 2024, Donan Engineering conducted an inspection of the property.
Despite Complainant’s full compliance with the inspection process, Insurer failed to provide any updates regarding the progress of the claim. Insurer chose to remain completely silent, offering no email, letter, or any written communication confirming the status of the claim or detailing next steps.
Complainant and their agents were forced to follow up with Insurer on December 3, 2024, to request a status update. In response, Insurer provided nothing more than a vague and inadequate explanation, stating they were “awaiting an additional report from the engineer” and that a mediation request would be filed.
It was not until on or about December 23, 2024, that Insurer finally issued a denial letter. This denial letter was sent only after Complainant and their agents requested another status update earlier that same day.
In its correspondence, Insurer attached a partial coverage denial letter along with an estimate. The estimate reflected a purported covered amount of $836.42, which, after subtracting the $1,000 deductible, resulted in no coverage whatsoever. Insurer’s failure to issue a reasonable payment underscores its unwillingness to acknowledge the actual damages incurred by Complainant.
Within the denial letter, Insurer included the following statement:
“Our review showed that the roof covering condition is due to wear and tear and deterioration in the form of heat blisters. The creased field shingles occurred from a different date of loss than what was being claimed. Accordingly, we respectfully deny coverage for the portion of your claim for wear and tear.”
Despite finally providing an update, Insurer merely repeated the same inadequate explanation given in the initial denial letter, offering no additional details or clarification.
Insurer failed to specify the precise areas of the property where damages were allegedly attributable to wear and tear. Additionally, although Insurer arranged for an engineering inspection of the property, Insurer failed to reference or include the resulting report in its denial letter.
This conduct constitutes a clear violation of Fla. Stat. 626.9541(1)(i)(3)(f), which requires Insurer to promptly provide a reasonable explanation for the denial of a claim.
By failing to include or disclose the engineering report, or even mention an engineer, despite months of awaiting such a report and merely repeating the same statements as before, Insurer not only violated statutory requirements but also deprived Complainant of the opportunity to retain their own expert to evaluate the damages and causation.
Further review of the denial letter reveals that Insurer did not reference, acknowledge, or address the estimate submitted by Public Adjuster.
To date, Complainant remains unaware of Insurer’s stance regarding the numbers and values outlined in that estimate. Moreover, Insurer has failed to acknowledge the SPOL submitted by Complainant, leaving Complainant in the dark regarding whether Insurer accepts or disputes the documented amounts.
Based on the events described above, it is clear that Insurer conducted an improper investigation to intentionally minimize its liability, contrary to the policy and Florida law’s requirements.
Moreover, Insurer has misrepresented pertinent facts and/or insurance policy provisions relating to coverages at issue, and delayed the resolution of the claim by engaging in conduct to deny or reduce recovery to the Insureds. These tactics are believed to be the general business practices of this Insurer.
Insurer can cure its bad faith conduct by: 1) accepting the Insureds’ damage claim as compensable, and agreeing to pay the claim in accordance with the policy in the amount of $41,917.73, plus interest, prior to the expiration of the cure period, 2) reviewing and responding to all communications from the Insureds and their agents, including the request for a complete copy of the Policy.
PLEASE GOVERN YOURSELF ACCORDINGLY.
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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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