Filing Number: 807387
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| Filing Accepted: 2/18/2025 |
| Last/Business Name
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MANSUR, MANSUR
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First Name |
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LINDA, JOHN |
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| Street Address
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389 FRANCA ST |
| City, State Zip
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PUNTA GORDA,
FL
33983
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| Email Address
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BXVA389@GMAIL.COM |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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MANSUR, MANSUR |
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First Name |
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LINDA, JOHN |
| Policy # * |
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FLP210284 |
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Claim #* |
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1104367 |
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Attorney is Applicable
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| Last Name* |
MARTINEZ
First Name *
KELLI
Initial
A.
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| Street Address* |
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8130 LAKEWOOD MAIN STREET STE. 103 #345 |
| City, State Zip* |
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LAKEWOOD RANCH
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FL
34202
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| Email Address * |
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PRESUIT@SULIMARTINEZLAW.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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ASI PREFERRED INSURANCE CORP.
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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 13142 |
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| Name of individual responsible for violation (if any):*
RENE MALDONADO, AMY MILL, SIMON UTRERA, AND ANY OTHER INDIVIDUAL FROM, OR AGENT OF, ASI PREFERRED INSURANCE CORPORATION WHO WAS INVOLVED IN THE CLAIM.
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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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Unfair Trade Practice
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Unsatisfactory Settlement Offer
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Claim Delay
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Claim Denial
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Other
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Violation of Code of Ethics
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Other
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Not treating the Insured with good faith claims conduct
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Other
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Looking for ways to deny full recovery to the Insured
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Other
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Looking for ways to delay full recovery to the Insured
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Other
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Failing to properly investigate the Insured’s loss
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Other
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Failing to provide the Insured with the full benefits awarded under the contract of insurance in a t
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Other
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Not training, supervising, or managing adjusters properly so that prompt and full payments are made
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Other
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Not adjusting claims and evaluating loss properly
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Other
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Shifting the burden of insuring the loss to the Insured
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Other
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Failing to implement proper standards for the adjustment and investigation of claims
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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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| 626.9541(1)(i)(4) |
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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).
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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.
THE POLICY LANGUAGE RELEVANT TO THE VIOLATIONS INCLUDES ALL APPLICABLE LOSS PAYMENT AND COVERAGE PROVISIONS OF POLICY NUMBER FLP210284, INCLUDING THE DECLARATIONS PAGE AND ALL ENDORSEMENTS TO THE POLICY, WITH RESPECT TO COVERAGES A, B, C, AND D. ADDITIONALLY, ANY SECTIONS RELIED UPON BY THE INSURER IN ITS FAILURE TO FULLY PAY THE CLAIM, INCLUDING THE DUTIES IN THE EVENT OF LOSS PROVISIONS AND THE POLICY'S EXCLUSION OF COVERAGE PROVISIONS. THE VIOLATIONS ALLEGED ARE ALSO STATUTORILY BASED AND DO NOT RELY ON ANY SPECIFIC POLICY LANGUAGE.
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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.
ASI Preferred Insurance Corporation has committed the following in handling the insured’s claim:
1.
Failing to act in due diligence and good faith to resolve claims
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Placing the financial interest of the Carrier before that of the Insured
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Looking for ways to deny benefit payments and otherwise “low ball” or “stone wall” claims.
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Not adjusting the claims promptly and fairly
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Not attempting in good faith to settle claims
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Conducting Inadequate investigations
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Failing to employ policies and procedures to conduct adequate investigations
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Failing to provide an estimate that complies with the Florida Building Codes.
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Shifting the burden of investigating the loss onto the Insured.
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Misrepresenting the terms of the insurance policy.
Linda Mansur and John Mansur are homeowners with an all-risks insurance policy issued by ASI Preferred Insurance Corp/Progressive Home Claims (hereinafter “Carrier”),. On or about September 28, 2022, while the policy was in full force and effect, the Insured’s property located at 389 Franca St Punta Gorda, FL 33983 sustained significant damage as a result of wind damage. The insured promptly reported the claim and fully cooperated with the carrier’s investigation. The Carrier assigned claim number 1104367-221013 to the loss. After reporting the claim, Carrier retained an unqualified and biased field adjuster to adjust the loss. This adjuster had a financial incentive to adjust the loss in a manner that would minimize Carrier’s losses. Instead of adjusting the claim fairly, honestly, in good faith, and with due regard for the Insured’s interest, the adjuster made a conscious effort to ignore evidence of covered losses to the property. On April 4, 2023 Carrier sent a letter to Five Star Claims Adjusting, requesting additional information to investigate the disputed damages. Given the vastly underestimated cost of repairs, the Insured’s disagreement with the coverage decision, and the scope and nature of the damage resulting from the loss, the Insured through its retained representatives disputed the coverage determination and submitted an estimate prepared by Five Star Claims Adjusting for $113,888.56 which was a fair and reasonable assessment of the loss.
Then in a letter dated October 23, 2023, the carrier notified the Insured that it had completed its investigation into the loss and concluded that “while coverage has been provided on November 10, 2022, and December 20, 2022……we regret to inform you that there is no additional supplement coverage for the roof repairs, exterior and interior at this time.”
Worst still, Carrier failed to retain qualified experts necessary to identify the repairs necessary to restore the property to its pre-loss condition within reasonable time.
An attorney for the homeowners sent a letter of representation on August 19, 2024 and attempted to resolve the claim. On October 22, 2024 Carrier wrote a letter requesting a reinspection. The parties coordinated. On November 14, 2024 Carrier wrote another letter about assigning an adjuster and waiting for a report. The parties coordinated and participated in another inspection of the property. Then on December 14, 2024 it was requested that Carrier conduct yet another inspection and wait for a report. Based on telephone conversation between Amy Mill and counsel’s office, it is evident that no additional payments are being made. The re-inspections have been futile, and purely for the purposes of delaying the claim and harassing the insured.
Under the circumstances surrounding this claim, had Carrier acted fairly and honestly toward the Insured and with due regard for the Insured’s interests, Carrier could and should have attempted in good faith to settle this claim. Carrier did not and, instead, dishonestly and unfairly placed its own interests well ahead of those of the Insured. In doing so, Carrier violated Section 624.155(1)(b)(1), Florida Statutes.
Carrier’s use of unqualified and bias adjusters, and failure to retain experts necessary to identify the repairs necessary to restore the property to its pre-loss condition evidences Carrier’s failure to adopt and implement standards for the proper investigation of claims in violation of Section 626.9541(1)(i)(3)(a), Florida Statutes.
Carrier’s use of unqualified and bias adjusters, and failure to retain experts necessary to identify the repairs necessary to restore the property to its pre-loss condition, evidences Carrier’s failure to conduct a reasonable investigation based upon available information.
When applying the facts present here to Florida law, it is clear that Carrier is acting in bad faith. 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 based on determinable contingencies. Inherent is the fact that payment must be made timely and promptly so that insureds may mitigate their damages and be put back into the position they were in prior to the loss as quickly as possible. Carrier has breached this duty by refusing to properly and timely adjust the loss.
Moreover, Section 69B-220.201 of the Florida Administrative Code defines Carrier’s adjusters conduct here as an unfair claims settlement practice. Specifically, Section 69B-220.201(3) provides that “[a]n adjuster shall not approach investigations, adjustments, and settlements in a manner prejudicial to the insured” and that “[a]n adjuster shall make truthful and unbiased reports of the facts after making a complete investigation.” As detailed above, Carrier’s investigation and adjustment of this claim was done in a manner prejudicial to Insured, was incomplete, and lacked truthful and unbiased reports of the facts.
Upon receiving notice of the loss, the Insurer had the duty to provide the full benefits under the policy. This includes providing the Insured with a proper investigation and the funds necessary to return the home to its pre-loss condition. However, when the Insurer conducted its inspection of the insured property, the Insurer’s representatives failed to conduct a thorough and adequate investigation, or the representatives intentionally ignored the damage observed and failed to make truthful and unbiased reports of the facts after investigating. As a result, the Insurer breached the policy by failing to fully indemnify the Insured for the covered loss.
The conduct outlined above is done within the Insurer’s routine course of the business.
There may be further wrongful conduct which has not been made known to the Insured at this moment. Certain conduct or actions may be discovered throughout discovery or cannot be verified without a review of the Insurer’s claim file and standards and procedures for the adjustment and investigation of claims.
In short, the Insurer is not acting with due regard for the Insured’s interests or safety. In Florida, the work of adjusting insurance claims engages the public trust. The Insurer has breached this trust and its duty to the Insured. The Insurer and its agents conducted cursory and inadequate investigations and wrongfully denied full coverage for the claim. Moreover, the Insurer has engaged in bad faith practices designed to delay claims and prevent the Insured from recovering what is rightfully owed under the subject policy of insurance. The Insurer’s actions and inactions have continued to frustrate and delay the resolution of the Insured claim.
The Insurer knows or should know that when independent perils converge and no single cause can be considered the sole or proximate cause, it is appropriate to apply the concurring cause doctrine. Sebo v. Am. Home Assurance Co., 208 So. 3d 694, 697 (Fla. 2016). The concurring cause doctrine states that coverage may exist where an insured risk constitutes a concurrent cause of the loss even when it is not the prime or efficient cause. Id. at 698. A covered peril that meets with an uncovered peril may still provide for coverage under a policy when the covered peril triggered the events that eventually led to the loss. Id. at 697. The Insurer intentionally ignored covered damage to deny the reported loss and wrongfully fail to pay the Insured. This is an underhanded attempt to place the financial interests of the Insurer over those of the Insured and to delay and frustrate the Insured’s ability to have his claim adjusted promptly to begin restoring his property.
Additionally, Insurer shifted the burden and cost of investigating and insuring the loss onto the Insured. During their investigation, the insurer’s adjuster did not use a moisture meter, despite the presence of interior water damage. A moisture meter can be purchased online from Amazon for around $40 before tax. The Insurer could purchase a moisture meter and assess thousands of properties with one meter. Instead, the Insurer would rather place its financial interests over those of the Insured by failing to provide the adjuster with the necessary tools to correctly inspect the loss. As a result of the inadequate investigation and surrounding circumstances it is apparent that the Insurer significantly underestimated the scope of the loss to the Insured’s property. The Insurer and its adjuster have colluded to misrepresent the true scope of damages to the insured property and the true replacement costs of the damages.The Insurer has placed obstacles to the Insured’s ability to have the claim adjusted promptly to begin restoring the home by waiting more than ninety (90) days after receiving notice of the loss to make a claims determination. Under Fla. Stat. §627.70131(7)(a), “[w]ithin 90 days after an insurer receives notice of an initial, reopened, or supplemental property insurance claim from a policyholder, the insurer shall pay or deny such claim or a portion of the claim unless the failure to pay is caused by factors beyond the control of the insurer which reasonably prevent such payment." There were and are currently no factors outside of the Insurer’s control. As the Insurer has failed to make a timely determination, it has violated this code. As such, in addition to the below requirements to cure this CRN, any payment made to the Insured must contain interest for the damage as a result of the loss from the date the Insurer received first notice of the loss.
The claims determination letter failed to comply with Fla. Stat. 626.9541(1)(i)(3)(f) as it did not include a reasonable explanation of the basis in the insurance policy, in relation to the facts, for the denial. The letter simply copies several policy exclusions with no explanation.
The Insurer failed to allocate and pay for overhead and profit, pursuant to Florida Statute 627.7011(3)(a). Where the Insureds are reasonably likely to need a general contractor for the repairs, Florida Statute 626.7011(3) does not permit an Insurer to withhold overhead and profit pending the actual repair, unless absent a showing by the Insureds that it was likely to need a general contractor for the repairs. Trinidad v. Fla. Peninsula ins. Co., 121 So. 3d 433, 435 (Fla. 2013). The Insurer has implemented policies and procedures that are designed to wrongfully withhold costs associated with restoring the insured property to its pre-loss condition. This is an underhanded attempt to place the financial interest of the Insurer over that of the Insured.
The Insurer observed damaged to the roof but concluded no storm created openings were observed. The term “opening” is not defined by the policy. Cambridge English dictionary defines opening as “a hole or space that something or someone can pass through.” https://dictionary.cambridge.org/us/dictionary/english/opening. Here, subsequent water damage was observed to the interior of the property of the Insured’s home. As a result, the very simple question arises of “where did the water come from?” Utilizing the definition cited, the roof was damaged in a way that allowed something, here the water, to pass through the roofing structure and subsequently damaging the interior of the Insured’s property. However, the Insurer is instead interpreting the ambiguous term “opening” in a method most against the Insured’s interest, often utilizing it as a provision that requires a visible opening or even to the extent of a hole in which one can see through. When faced with this ambiguity in the policy the Insurer should err on the side of the Insured and not its bottom-line as is apparent in this matter and other claims like it. This duty is further emphasized by the Supreme Court of Florida who re-iterated in Berkshire Life Ins. Co. v. Adelberg, 698 So. 2d 828, 830 (Fla. 1997), that ““[i]t has long been a tenet of Florida insurance law that an insurer, as the writer of an insurance policy, is bound by the language of the policy, which is to be construed liberally in favor of the insured and strictly against the insurer. Citing Firemans Fund Ins. Co. v. Boyd, 45 So.2d 499, 501 (Fla.1950).” The Insurer is undoubtedly aware of this precedent and is handling the claims in abrogation of said case law. The Insurer completely disregarded the obvious wind created openings to the property, and interior water stains. Had the Insurer conducted a reasonable and adequate investigation, it would have revealed that the water intrusion stemmed from a roof leak due to peril created openings. The Insurer knows or should have known that water damage to a ceiling in conjunction with observable roof damage supports the Insured’s position that peril created opening and subsequent water intrusion caused the damage at the property. The Insurer is a for-profit business and as such the Insurer owes a duty to their owners, typically shareholders, to maximize their profits. The Insurer’s main goal is to make money. To do so, the Insurer sells as many insurance policies as possible and then denies or underpays as many claims as possible. The Insurer is under enormous financial pressure to mitigate losses from the Hurricane and as such, the Insurer has implemented a procedure of denying obvious damage caused by wind taking the position the damage was caused by flood. There were several steps available to the Insurer that should have taken to verify whether there was any support to conclude the damage was a result of a flood. It should have determined the property elevation, inspected the attic for interior water damage to conclude that the roof was not cause of water intrusion, and confirmed with the homeowner whether ground water damaged the property. Here, no flooding occurred in the neighborhood, the Insured did not report any flooding or source of ground water intrusion, and the ceilings had clear signs of interior water damage as a result of roof leaks. Additionally, Insurer shifted the burden and cost of investigating and insuring the loss onto the Insured. During their investigation, the insurer’s adjuster did not use a moisture meter, despite the presence of interior water damage. A moisture meter can be purchased online from Amazon for around $40 before tax. The Insurer could purchase a moisture meter and assess thousands of properties with one meter. Instead, the Insurer would rather place its financial interests over those of the Insured by failing to provide the adjuster with the necessary tools to correctly inspect the loss. As a result of the inadequate investigation and surrounding circumstances it is apparent that the Insurer significantly underestimated the scope of the loss to the Insured’s property. The Insurer and its adjuster have colluded to misrepresent the true scope of damages to the insured property and the true replacement costs of the damages.
The Insurer’s actions amount to but are not limited to the following:
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Claim Delay: The Carrier has delayed processing the claim, causing frustration and inconvenience to the Insured.
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Lack of Good Faith Conduct: The Carrier has not treated the Insured with good faith conduct expected when handling claims.
3.
Attempt to Reduce Recovery: The Carrier has actively sought ways to minimize the amount owed to the Insured under the policy.
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Attempt to Deny Recovery: The Carrier has looked for reasons to deny coverage altogether, rather than fulfill its obligations under the policy.
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Failure to Property Evaluate Loss: Claims have not been assessed accurately or promptly, resulting in delays and incomplete indemnity for the Insured.
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Inadequate Training and Supervision of Adjusters: The Carrier has not ensured its adjusters are adequately trained to handle claims promptly and fairly.
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Placing Company Interests over Insured Interests: The Carrier has prioritized its financial interests over the health and safety of the Insured.
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Failure to Provide Complaint Estimates: Estimates provided by the Carrier do not comply with Florida Building Codes.
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Shifting Investigation Burden to Insured: The Carrier has unfairly placed the burden of investigating the claim onto the Insured.
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Conducting Inadequate Investigations: The Carrier’s Investigation into the claim have been insufficient or cursory.
Therefore, to cure the defects outlined in this civil remedy notice, the Insurer must:
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Admit full coverage for the Insured’s loss and tender all additional amounts owed under the Policy for the covered loss to the insured property
Please email any responses to this civil remedy notice to presuit@sulimartinezlaw.com
A copy of this form submitted to the FDFS has been sent via email to the following parties, providing them notice of the filing of the civil remedy notice:
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ASI Preferred Insurance Corporation via DFS Filing
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Claims Department, ASI Preferred Insurance Corp, via email; claims@asicorp.org
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Linda Mansur and John Mansur via email bxva389@gmail.com
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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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