Civil Remedy Notice of Insurer Violations
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Filing Number:     804917
Filing Accepted:  2/3/2025
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Complainant
Last/Business Name *  
GOLDSCHEIN   First Name   BRIAN
Street Address * 3932 ANISSA AVENUE
City, State Zip * ORLANDO, FL 32814
Email Address * BRIANGOLDSCHEIN@YAHOO.COM
Complainant Type: * Insured
Insured
Last/Business Name*   GOLDSCHEIN   First Name   BRIAN
Policy # * 030581470-90A Claim #* 030581470-801
Attorney
Attorney is Applicable
Last Name* MARTIN First Name * KIMBERLEE Initial
Street Address* 350 N. LAKE DESTINY ROAD
City, State Zip* MAITLAND , FLORIDA 32751
Email Address * KMARTIN@ITSABOUTJUSTICE.LAW
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   USAA CASUALTY INSURANCE COMPANY
NAIC Company Code 25968
 
Name of individual responsible for violation (if any):* MATTHEW WALKER
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Denial
Claim Delay
Unsatisfactory Settlement Offer
* 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)(2) 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.
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)(c) Failing to acknowledge and act promptly upon communications with respect to claims.
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.
626.9541(1)(i)(3)(g) Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
626.9541(1)(i)(4) 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).
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

A certified copy of the policy is not within counsel's possession at the time of this filing. Based on information and belief, the following policy provisions are relevant to this civil remedy notice. Section 1 – Coverage A – Perils Insured Against Section 1- Conditions – Loss Settlement Section 1 – Conditions - Loss Payment
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

During the policy period, the Insured, Brian Goldschein, suffered significant damage to his home during Hurricane Milton. Prior to the loss, USAA issued a policy of insurance (030581470-90A) for the Insured’s property located at 3932 Anissa Avenue Orlando, Florida 32814. Said policy was in full force and effect on date of loss and afforded coverage for damage caused by a hurricane. USAA was timely notified of the loss by the Insured and assigned claim number 030581470-801. During USAA's investigation, the Insured cooperated by making the property available as well as providing all facts and information requested regarding the loss, including video showing the damage as it was occurring. Despite this, USAA capriciously has denied or otherwise undervalue the Insured's claim. For example, the damage to the roof requires replacement; however, USAA has only opened coverage for a minor repair. Moreover, USAA has the Insured’s videos taken during Hurricane Milton showing water intrusion coming into the house on the second floor and causing a pool of water around the continuous wood floors ruining them yet USAA failed to provide any coverage. This water intrusion is a result of damage to the building envelope as well as to the roof (ex. pictures 51-53 and 71 of the Insured’s reinspection photographs dated December 13, 2024 provided to USAA). Notably, under a section of the roof with missing/damaged shingles there is staining to sheathing, which is in line with staining of the insulation and ultimately resulting in a ceiling stain in the kitchen (ex. pictures 11-42 of the Insured’s reinspection photographs). USAA seemingly attempts to blame AC line condensation; however, photographs provided by the Insured and his representative definitively shows that this cannot be the source of the water intrusion (ex. pictures 2-10 and 71 of the Insured’s reinspection photographs). In short, USAA has ignored relevant facts and information provided by the Insured and his representatives that establish damages to the roof, building exterior, and interior that are unquestionably the result of Hurricane Milton. Most concerning, it appears USAA and its representatives either underpaid or misrepresented the findings in order to avoid having to tender payment on a claim that it knows should be covered pursuant to the terms of the policy. It is clear that USAA has not acted honestly or fairly towards its Insured. USAA and its representatives have failed to conduct a proper investigation, misrepresented the scope and cause of damages, misapplied exclusions in the policy in order to avoid full coverage, and have taken every step possible to delay the resolution of the Insured’s claim. It has become a general business practice of USAA to not implement proper claims handling procedures, to hire consultants that routinely ignore or intentionally misidentify relevant evidence, and to not settle claims in good faith when under all circumstances it should have. In other words, it is a pattern and practice for USAA to arbitrarily deny and underpay claims without conducting reasonable investigations based upon information and evidence available to it. In order to cure this civil remedy notice, USAA must immediately issue notice in writing that it is opening coverage for a roof replacement of the house and garage, repairs for the left and right side of the building envelope, replacement of the damages flooring, repairs to the interior staining, and any applicable ordinance and law and/or matching that may be incurred. The Insured refers USAA to the estimate within its possession from Coastal Claims dated December 26, 2024. The notice should be tendered to the Insured's attorney, Kimberlee A. Martin, Esq. with by email at kmartin@itsaboutjustice.law or mail to 350 N. Lake Destiny Road Maitland, Florida 32751.
Comments
User Id Date Added Comment
logan.mcelwain@usaa.com 02-28-2025 10/10/24, claim filed with USAA. 10/13/24, claim assigned to Property Adjuster Specialist (PAS). PAS contacted the insured. PAS obtained additional information regarding the loss and scheduled an onsite inspection for 10/17/24. 10/17/24- Property inspected with insured and Seek Now Inspector (ladder assist). PAS provided the following inspection notes: Inspected loss on 10/17/2024 at 1PM with member and Seek Now present. MOI: Adjuster Walker Physical Inspection Inspection: Member answered door at the scheduled inspection time but was on a work meeting on his computer. Member briefly showed interior damages in office and upstairs then walked off to the back patio where he remained for most of the inspection. Member did not inform adjuster that he was represented by a PA prior to the inspection. PA LOR was received within hours after the inspection. Member signed PA contract on 10/16/24 and PA signed on 10/17. At the end of the inspection, adjuster walker asked member for mitigation company information to get progress on remediation efforts and member stated he would text the information. The mitigation company information has not been received to date. Will request from PA. Additional notes: Member claims windows potentially wind damaged by hurricane. No visible wind dmg to windows (other than screens). Explained to member during on-site inspection that we may need to get window expert out to assess the windows for any hurricane related damages. Task sent to MCO for window expert or engineer assignment. DAMAGE ASSESSMENT: Interior damage - loft, stairwell, living room, half bath and office. ---------------------------------- Exterior damage - Front - no wind damage observed. Right - window screen Rear - soffit, window screen Left - window screen ---------------------------------- Other structures - Right Front Fence Run. No other member owned fencing on property. --------------------------------- Personal Property - no wind damage observed. Member states he moved all patio furniture inside during the hurricane. ---------------------------------- Roof - INSPECTED BY SEEKNOW (2 STORY & 8/12 PITCH) Ridge cap had some missing shingles that Seek Now wrote as tree abrasion. However, we cannot rule out wind from the hurricane caused the damage to the ridge cap, which we included in our estimate. Front - W=0 Rear - W=0 10/17/24- Letter of Representation received into file from Public Adjuster (PA). 10/19/24- Requested certified policy ordered. 10/23/24- PAS detailed the following in the claim file: Called PA office and S/W Charles Mongiovi at 386-314-0074. Charles stated the mitigation has not begun out at the property. Also, advised Charles that we will be sending out a window expert to assess the damages to the window. Charles stated he has video of the water intrusion from the windows that he will send us. Finally, advised Charles that we will send over a copy of the certified policy and confirmed his email address (cmongiovi@costalclaims.net) 10/24/24- PAS detail in claim file: Completed and send over preliminary estimate to mbr and PA. Loss is less than deductible at this time totaling $3,171.32. Will await conclusion of mitigation and engineer inspection to make any necessary revisions. Summary for Dwelling Line Item Total 1,685.53 Material Sales Tax 19.75 Subtotal 1,705.28 Overhead 170.55 Profit 170.55 Replacement Cost Value $2,046.38 Less Deductible [Full Deductible = 8,855.06] (2,046.38) Net Claim $0.00 Summary for Other Structures Line Item Total 912.41 Material Sales Tax 25.05 Subtotal 937.46 Overhead 93.74 Profit 93.74 Replacement Cost Value $1,124.94 Less Deductible (1,124.94) Net Claim $0.00 10/28/24- Emails received from USAA initiated engineer and public adjuster. Date/time of inspection pending. 10/29/24- Confirmation from engineer that inspection will take place with Public Adjuster on 10/31/24, 4:00 EST. 11/2/24- PAS noted the file that the Public Adjuster was informed that mitigation was approved from the initial filing of the claim. 11/10/24- PAS noted the file with the following email sent to PA and CC’d insured: We are reaching out to check the status of mitigation. Also, we have reached out to the engineer on the status of their report for the roof and window assessment. Once the engineer report is received, we will be back in touch regarding our coverage decision on those items. 11/15/24, new PAS as reassigned to claim. Claim was reviewed by reassigned adjuster. 12/6/24- Engineering report reviewed, and the following was sent to PA: Reviewed received engineering report, and subsequent findings. Responded to PA, with the following: ***We have reviewed the engineering report received into the file. The damages to our member's home has been deemed as repeated and long-term water exposure, due to deterioration of materials, over time, and not a sudden and accidental result of Hurricane Milton. Drywall staining in the foyer, living room, and master bedroom/bathroom are concluded as intermittent plumbing leaks, with an HVAC unit, water heater, and washing machine positioned above the general locations. The roof presented with no storm related damages, and is consistent with age related wear/tear/deterioration/mechanical damage, which is excluded from coverage, per the policy. The partially detached windowsill beneath the living room window was consistent with mechanical damage and age-related deterioration of the wood sill. The observed displaced soffit panels on the south side of the residence were consistent with mechanical damage and were not related to the passage of Hurricane Milton. A historic photograph depicted the displaced soffit panels in January 2022, more than two years prior to the reported date of loss. The deteriorated sealant at the stucco expansion joints was the result of inadequate installation and/or age-related deterioration of the material. The dark staining and deterioration of the fascia on the west side of the rear covered porch was the result of long-term moisture exposure and weathering and was not the result of a single storm event. ***The following damage, and subsequent owed repairs, as determined as related to Hurricane Milton, do not exceed the member's hurricane deductible:*** The exposed drywall fastener in the living room ceiling was consistent with temperature and moisture related movements of the ceiling drywall due to excess humidity within the home after the water intrusion during Hurricane Milton. Due to the findings results of the certified engineering report, no further repair funds are warranted on this claim. Thank you.*** 12/10/24- Request received, via email, for copy of inspection report. PAS emailed the report to PA. 12/11/24- PA advised documents were received. 12/18/24- PA sent correspondence stating that he had reinspected the insured’s home and would be providing what he believed to be an accurate repair estimate. 12/18/24- PAS responded to PA, advising that documents would be reviewed once received. 12/21/24- PA submitted executed proof of loss into claim file. 12/27/24- PA submitted estimates for mitigation and repairs. Undisputed mitigation cost did not exceed the insured’s policy deductible. USAA’s stance remains unchanged regarding the repair scope, due to engineer’s findings. 1/16/24- Notice of Florida mediation notice received into file. 1/17/24- Demand for payment received from PA. 1/20/24- Email from Mediator received, checking parties’ availability for mediation on 2/17/25. PAS responded to Mediator that he was available on that date. 1/24/24- Email received, confirming all parties are available for mediation on 2/7/24, 12:00 PM, EST. 2/4/24- Civil Remedy Notice received into claim file. 2/7/24- Notes from mediation entered into file from PAS: Mediation: 2/7/25 Parties present: PAS Skalsky, mediator, Ni, ctr Discussed the facts of the claim to this point. PA states that the funds to repair DWG and APS from Hurricane wind will exceed $100,000.00. Current PA scope is $82,267.12. PA was unable to provide a revised scope, to account for additional owed, per their findings. PAS Skalsky discussed that USAA has provided for undisputed dmg, and in good faith, hired an engineer to evaluate accuracy of findings. Engineer concluded that the majority of the dmg to the DWG and APS is age related W/T/D, and long-term water dmg. PA disagrees w/ the findings. Engineer stated in the report that the flooring dmg does appear to be recent, and likely related to this claim. I advised PA that USAA is willing to work toward a settlement on the additional interior repairs and mitigation. PA and Ni unwilling to settle, unless all unrelated exterior dmg is covered as well. In reviewing the claim file, the storm related dmg to the roof is minor, and has been accounted for, w/ proper repairs. Full roof replacement is not warranted. Additionally, PA is scoping for full replacement of detached gar roof. No storm dmg was noted to this roof. The findings of the inspection and engineering report to not validate the exterior dmg. Mediator ultimately determined the claim is at an impasse. CRN has been received and will be filed accordingly.
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.

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DFS-10-363
Rev. 10/14/2008