Filing Number: 805623
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| Filing Accepted: 2/6/2025 |
| Last/Business Name
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MANDERSON
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First Name |
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OMAR |
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| Street Address
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720 SOUTH LAKE CLAIRE CIRCLE |
| City, State Zip
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OVIEDO,
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32765
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| Email Address
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MANDERSONKEN@YAHOO.COM |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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MANDERSON |
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First Name |
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OMAR |
| Policy # * |
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59CTK5368 |
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Claim #* |
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59-58T4-58S |
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Attorney is Applicable
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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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STATE FARM FLORIDA 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 10739 |
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| Name of individual responsible for violation (if any):*
ANITA MATTHEWS AND CARRIE JOHNSON
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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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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)(d) |
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Denying claims without conducting reasonable investigations based upon available information.
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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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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
SECTION I – LOSSES NOT INSURED
1. We will not pay for any loss to the property described in Coverage A that consists
of, or is directly and immediately caused by, one or more of the perils listed in
items a. through m. below, regardless of whether the loss occurs abruptly or gradually, involves isolated or widespread damage, arises from natural or
external forces, or occurs as a result of any combination of these:
f. seepage or leakage of water, steam, or sewage that occurs or develops over
a period of time:
(1) and is:
(a) continuous;
(b) repeating;
(c) gradual;
(d) intermittent;
(e) slow; or
(f) trickling; and
(2) from a:
(a) heating, air conditioning, or automatic fire protective sprinkler system;
(b) household appliance; or
(c) plumbing system, including from, within or around any shower stall,
shower bath, tub installation, or other plumbing fixture, including their
walls, ceilings, or floors.
We also will not pay for losses arising from condensation or the presence of
humidity, moisture, or vapor that occurs or develops over a period of time;
g. wear, tear, decay, marring, scratching, deterioration, inherent vice, latent
defect, or mechanical breakdown;
h. corrosion, electrolysis, or rust;
i. wet or dry rot;
However, we will pay for any resulting loss from items a. through l. unless the
resulting loss is itself a Loss Not Insured as described in this Section.
2. We will not pay for, under any part of this policy, any loss that would not have
occurred in the absence of one or more of the following excluded events. We will
not pay for such loss regardless of: (a) the cause of the excluded event; or (b)
other causes of the loss; or (c) whether other causes acted concurrently or in any
sequence with the excluded event to produce the loss; or (d) whether the event
occurs abruptly or gradually, involves isolated or widespread damage, occurs on
or off the residence premises, arises from any natural or external forces, or
occurs as a result of any combination of these:
g. Fungus, including:
(1) any loss of use or delay in rebuilding, repairing, or replacing covered
property, including any associated cost or expense, due to interference at
the residence premises or location of the rebuilding, repair, or
replacement, by fungus;
(2) any remediation of fungus, including the cost to:
(a) remove the fungus from covered property or to repair, restore, or
replace that property; or (b) tear out and replace any part of the building structure or other
property as needed to gain access to the fungus; or
(3) the cost of any testing or monitoring of air or property to confirm the type,
absence, presence, or level of fungus, whether performed prior to,
during, or after removal, repair, restoration, or replacement of covered
property.
3. We will not pay for, under any part of this policy, any loss consisting of one or
more of the items below. Further, we will not pay for any loss described in
paragraphs 1. and 2. immediately above regardless of whether one or more of
the following: (a) directly or indirectly cause, contribute to, or aggravate the loss;
or (b) occur before, at the same time, or after the loss or any other cause of the
loss:
b. defect, weakness, inadequacy, fault, or unsoundness in:
(2) design, specifications, workmanship, repair, construction, renovation,
remodeling, grading, or compaction;
(3) materials used in repair, construction, renovation, remodeling, grading, or
compaction; or
(4) maintenance;
of any property (including land, structures, or improvements of any kind)
whether on or off the residence premises; or
However, we will pay for any resulting loss from items 3.a., 3.b., and 3.c. unless
the resulting loss is itself a Loss Not Insured as described in this Section.
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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.
Violation
Insurer Name* STATE MUTUAL INSURANCE COMPANY
NAIC Company Code 69132
Name of individual responsible for violation (if any):* ANITA MATTHEWS AND CARRIE JOHNSON
Type of Insurance * Residential Property & Casualty
Reason for Notice *
Claim Denial
Claim Delay
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.
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)(g) Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
SECTION I – LOSSES NOT INSURED
1. We will not pay for any loss to the property described in Coverage A that consists
of, or is directly and immediately caused by, one or more of the perils listed in
items a. through m. below, regardless of whether the loss occurs abruptly or gradually, involves isolated or widespread damage, arises from natural or
external forces, or occurs as a result of any combination of these:
f. seepage or leakage of water, steam, or sewage that occurs or develops over
a period of time:
(1) and is:
(a) continuous;
(b) repeating;
(c) gradual;
(d) intermittent;
(e) slow; or
(f) trickling; and
(2) from a:
(a) heating, air conditioning, or automatic fire protective sprinkler system;
(b) household appliance; or
(c) plumbing system, including from, within or around any shower stall,
shower bath, tub installation, or other plumbing fixture, including their
walls, ceilings, or floors.
We also will not pay for losses arising from condensation or the presence of
humidity, moisture, or vapor that occurs or develops over a period of time;
g. wear, tear, decay, marring, scratching, deterioration, inherent vice, latent
defect, or mechanical breakdown;
h. corrosion, electrolysis, or rust;
i. wet or dry rot;
However, we will pay for any resulting loss from items a. through l. unless the
resulting loss is itself a Loss Not Insured as described in this Section.
2. We will not pay for, under any part of this policy, any loss that would not have
occurred in the absence of one or more of the following excluded events. We will
not pay for such loss regardless of: (a) the cause of the excluded event; or (b)
other causes of the loss; or (c) whether other causes acted concurrently or in any
sequence with the excluded event to produce the loss; or (d) whether the event
occurs abruptly or gradually, involves isolated or widespread damage, occurs on
or off the residence premises, arises from any natural or external forces, or
occurs as a result of any combination of these:
g. Fungus, including:
(1) any loss of use or delay in rebuilding, repairing, or replacing covered
property, including any associated cost or expense, due to interference at
the residence premises or location of the rebuilding, repair, or
replacement, by fungus;
(2) any remediation of fungus, including the cost to:
(a) remove the fungus from covered property or to repair, restore, or
replace that property; or (b) tear out and replace any part of the building structure or other
property as needed to gain access to the fungus; or
(3) the cost of any testing or monitoring of air or property to confirm the type,
absence, presence, or level of fungus, whether performed prior to,
during, or after removal, repair, restoration, or replacement of covered
property.
3. We will not pay for, under any part of this policy, any loss consisting of one or
more of the items below. Further, we will not pay for any loss described in
paragraphs 1. and 2. immediately above regardless of whether one or more of
the following: (a) directly or indirectly cause, contribute to, or aggravate the loss;
or (b) occur before, at the same time, or after the loss or any other cause of the
loss:
b. defect, weakness, inadequacy, fault, or unsoundness in:
(2) design, specifications, workmanship, repair, construction, renovation,
remodeling, grading, or compaction;
(3) materials used in repair, construction, renovation, remodeling, grading, or
compaction; or
(4) maintenance;
of any property (including land, structures, or improvements of any kind)
whether on or off the residence premises; or
However, we will pay for any resulting loss from items 3.a., 3.b., and 3.c. unless
the resulting loss is itself a Loss Not Insured as described in this Section.
* 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 around May 12, 2021 I purchased a homeowners policy with State Farm to insure my property and was given the policy number 59-CT-K536-8. On November 7, 2023 the strainer in the kitchen sink broke causing water to soak into the kitchen cabinets and adjacent laminate flooring. State Farm was called to report the loss.
The Insurance Company requested to come out to the subject property and perform a visual inspection of the property, and also take photographs of the home on or around the Nov 16,2023. The adjuster reviewed the damage and saw the water streaming from the pipe and advised that she would get estimates to see if the cabinet that was damaged could be repaired without damaging the counter tops (to avoid having to replace the counters on the adjacent cabinets). I was told there would be a decision letter sent out prior to Thanksgiving.
The adjuster did not send out a letter as promised. Weekly phone calls to the adjuster went unanswered. Then on January 2,2024. another adjuster sent a letter denying the entire claim.
There is no dispute that the damage was caused by a broken basket strainer. State Farm was provided a copy of the plumbers receipt stating this. However, State Farm claims that the leak was continuous and ongoing and therefore they do not owe for the resulting damage.
State Farm must prove that the leak was ongoing and continuous (it was not). They must provide the information that they relied on and any expert opinion to support their claim that the leak of Nov 7, 2023 did not cause any damage to the counter or the adjacent floors.
State Farm must prove that their adjuster receive proper training to determine when a leak starts and the resulting damage from any subsequent leaks.
State Farm must further define in their policy what timeframe they use to determine "continuous" or over a period of time.
State Farm unjustly delayed the investigation of the claim, and then they unjustly denied payment of the claim when they had the information needed to resolve the claim. State Farm did not request additional information that would have helped to resolve the claim in a timely manner. State Farm must admit that they did not properly investigate the claim or request information in a timely manner and as a result they continued to investigate the claim after issuing the denial letter.
State Farm must admit that they acted in bad faith by unjustly delaying the investigation and unjustly denying a properly submitted covered claim.
he following are the different statutes that the Insurance Company has violated:
Florida Statutes 624.155(1)(b)(1):
(1) Any person may bring a civil action against an insurer when such person is damaged:
(b) 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 toward its insured and with due regard for her or his interests;
Florida Statutes 626.9541(1)(i)(3)(a)
(i) Unfair claim settlement practices.—
3. Committing or performing with such frequency as to indicate a general business practice any of the following:
a. Failing to adopt and implement standards for the proper investigation of claims;
Florida Statutes 626.9541(1)(i)(3)(c)
(i) Unfair claim settlement practices.—
3. Committing or performing with such frequency as to indicate a general business practice any of the following:
c. Failing to acknowledge and act promptly upon communications with respect to claims;
Florida Statutes 626.9541(1)(i)(3)(d)
(i) Unfair claim settlement practices.—
3. Committing or performing with such frequency as to indicate a general business practice any of the following:
d. Denying claims without conducting reasonable investigations based upon available information;
Florida Statutes 626.9541(1)(i)(3)(f)
(i) Unfair claim settlement practices.—
3. Committing or performing with such frequency as to indicate a general business practice any of the following:
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;
Florida Statutes 626.9541(1)(i)(3)(g)
(i) Unfair claim settlement practices.—
3. Committing or performing with such frequency as to indicate a general business practice any of the following:
g. Failing to promptly notify the insured of any additional information necessary for the processing of a claim; or
Florida Statutes 626.9541(1)(i)(3)(h)
(i) Unfair claim settlement practices.—
3. Committing or performing with such frequency as to indicate a general business practice any of the following:
h. Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
Florida Statutes 626.9541(1)(i)(4)
(i) Unfair claim settlement practices.—
(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. 629.70131(5).
In addition to the statutory violations referenced above, the Insureds state that STATE FARM FLORIDA INSURANCE COMPANY violated the following Florida Administrative Code Sections: 69B-220.201(3)(b); 69B-220.201(3)(b)2; 69B-220.201(3)(c); 69B-220.201(3)(d); and 69B-220.201(3)(f).
First, an adjuster shall treat all claims equally and shall not provide favored treatment to any claimant. It has been made clear based on the factual circumstances of the claim, that the Insurance Adjuster, Jeremy Wilcox, did not treat the insured’s claim equally or in strict accordance with the insurance contract by actively taking steps to delay the adjustment of the Insurance Claim. The Insured substantially complied with all requests pursuant to the policy in a reasonable time frame, but the Insurance Adjuster, Jeremy Wilcox, failed to do the same.
Second, the Administrative Code Sections listed above state that an adjuster shall not approach investigations, adjustments, and settlements in a manner prejudicial to the insured. The facts of this claim clearly show that the voluminous requests for information and documentation were used by the Insurance Company as a sword in order to find any way possible to justify a denial of the Insurance claim; thereby, making the basis for the request specious at best.
Moreover, the Code states that an adjuster, upon undertaking the handling of a claim, shall act with dispatch and due diligence in achieving a proper disposition of the claim. It is the Insurance Adjuster’s duty under the Administrative Code to do this and the Insurance Company has shown that it is not acting with dispatch and due diligence in achieving a proper disposition of the claim by all of its actions on this claim.
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 in that definition is the fact that payment must be made timely and promptly so that the insureds may mitigate their damages and be put back into the position they were in prior to the loss as quickly as possible.
The conduct of STATE FARM FLORIDA INSURANCE COMPANY referenced above is a clear violation of § 624.155(1)(b)(1) as it constitutes an intentional, willful, wanton, and malicious conduct and shows that the Carrier did not attempt in good faith to settle the insured’s claim when, under all the circumstances, it could have and should have done so, had it acted fairly and honestly toward its Insured and with due regard for their interests. STATE FARM FLORIDA INSURANCE COMPANY’s refusal and/or failure to settle the claim when under all circumstances it could have and should have done so had it acted fairly and honestly towards the Insured is wrongful conduct.
Florida Statutes 626.9541(1)(i)(4) states that it is an Unfair Settlement Practice for an insurer, such as STATE FARM FLORIDA INSURANCE COMPANY, to 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 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.
STATE FARM FLORIDA INSURANCE COMPANY must: (1) create and implement adequate guidelines for the proper investigation and evaluation of these type of claims and for the training and supervision of employees, which will avoid future statutory violations; (2) create and implement adequate guidelines for the proper investigation and evaluation of these type of claims and for the training and supervision of employees with regard to these type of claims to ensure that the claims handling procedure with regard to these type of losses are adequate to prevent other insureds from being treated unfairly and wrongfully; (3) immediately tender all undisputed advance insurance proceeds to the insured while continuing to adjust the loss with the insured. The basis for this is the estimate for damages and repairs that was submitted to the Insurance Company which totals $ 41,239.83 less the applicable deductible; (4) pay statutory interest on untimely payments from the date of loss; and (5) exercise good faith efforts to resolve these claim(s) by acting fairly and honestly towards Paul Millard, on behalf of Tommy Crossman, and with due regard for their interests in attempting to settle the claim.
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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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