Filing Number: 807838
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| Filing Accepted: 2/21/2025 |
| Last/Business Name
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RIVERA
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First Name |
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WILMARIE ; EDGARDO |
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| Street Address
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2540 HUNLEY LOOP |
| City, State Zip
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KISSIMMEE,
FL
34743
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| Email Address
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TRINITYMEDICALSALES@GMAIL.COM |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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RIVERA |
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First Name |
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WILMARIE ; EDGARDO |
| Policy # * |
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HCPC-HO3-298665-13 |
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Claim #* |
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940391 |
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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
,
FL
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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HOMEOWNERS CHOICE PROPERTY & CASUALTY INSURANCE COMPANY, INC.
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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 12944 |
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| Name of individual responsible for violation (if any):*
? STEPHANIE BOLLERUD, CLAIMS EXAMINER ON BEHALF OF HOMEOWNERS CHOICE PROPERTY & CASUALTY INSURANCE COMPANY; ? JOSHUA FOSTER, FIELD ADJUSTER ON BEHALF OF HOMEOWNERS CHOICE PROPERTY & CASUALTY INSURANCE COMPANY; ? MELVIN MAYES, CLAIMS EXAMINER ON BEHAL
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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 Delay
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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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| 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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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
FORM: HC HO3 01 20
***
SECTION I – PROPERTY COVERAGES
COVERAGE A – Dwelling
We cover:
1. The dwelling on the "residence premises" shown in the Declarations, including
attached structures and attached wall-to-wall carpeting if damage to the
dwelling is caused by a covered loss;
2. 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"[;]
***
SECTION I – PERILS INSURED AGAINST
COVERAGE A – DWELLING and COVERAGE B –
OTHER STRUCTURES
We insure against risk of direct loss to property described in Coverages A and B only if that loss is a physical loss to property[.]
***
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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 June 23, 2023, Wilmarie Rivera and Edgardo Rivera (Complainant(s)) suffered a loss to their Property, located at the address listed above due to hail.
After discovering the damage, Complainant(s) reported the loss to Homeowners Choice Property & Casualty Insurance Company, Inc (“Insurer”) on or about January 26, 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 reporting the claim, Complainant retained the Lawgical firm (hereinafter “Lawgical”) for legal representation, and a Letter of Representation was sent to Insurer on or about January 26, 2024.
Later that same day, Insurer acknowledged Lawgical’s representation while simultaneously issuing a request for information and a Sworn Statement in Proof of Loss (“SPOL”).
However, nowhere in this request did Insurer explain the nature of the information requested or why such information was necessary as required by Fla. Stat. 626.9541(1)(i)(3)(h).
On or about January 30, 2024, Complainant and Insurer coordinated to schedule a field adjuster inspection for on or about February 8, 2024.
On or about February 7, 2024, Insurer sent a letter advising Complainant of the scheduled inspection and identifying the field adjuster assigned to the claim.
On or about February 8, 2024, Joshua Foster, acting in his capacity as a field adjuster on behalf of Insurer, conducted an inspection of the property and took photographs.
Later that same day, Complainant and their agents retained Alejandro Gonzalez on behalf of Property Claim Consultant to conduct an inspection of the property. The Loss Consultant inspected the property and took 27 photographs.
On or about February 23, 2024, Mr. Gonzalez completed an estimate totaling the damages at $36,522.62 in Actual Cash Value.
Complainant, having fully complied with all post-loss obligations and reasonably anticipating substantive communication following the field adjuster’s inspection, awaited Insurer’s assessment and determination.
The inspection constitutes a critical procedural step in advancing a claim toward resolution, yet Insurer’s conduct reflects a blatant disregard for this fundamental principle.
Insurer, rather than timely communicating its position, now asserts in bad faith that it attempted to contact Complainant regarding an additional expert inspection purportedly necessary for claim resolution.
Despite Insurer’s self-serving claim that it had initiated such contact, it was not until on or about March 4, 2024, that Insurer actually issued written correspondence explicitly advising Complainant that an expert investigation would be conducted.
Later that same day, Insurer issued a Reservation of Rights letter.
That same day, Complainant and their representatives submitted Mr. Gonzalez’s estimate and photographs, affording Insurer every opportunity to review and address the substantiated evidence of loss.
Despite Insurer’s dilatory conduct, Complainant, rather than allowing Insurer’s failure to act to serve as a roadblock to claim resolution, proactively engaged Hancock Claim Experts to facilitate an expert inspection, securing a scheduled date on or about March 5, 2024.
Following subsequent exchanges of communication, the expert inspection was finalized and occurred on or about March 14, 2024.
On or about March 14, 2024, Dujuan Diaz, an inspector operating under Hancock Claim Experts, conducted the expert inspection and documented the property’s damages and took photographs.
On or about March 21, 2024, Complainant and their representatives submitted an executed SPOL, dated on or about March 20, 2024.
Later that same day, Insurer issued a purported coverage determination letter.
Insurer’s letter included the following:
“We assigned a field adjuster to inspect… The damage consists of… deterioration and granule loss. We are unable to indemnify your loss… as the policy does not cover loss caused by ‘wear and tear, marring, or deterioration.’”
This cursory and conclusory statement, devoid of meaningful analysis, constituted the entirety of Insurer’s purported basis for denial.
Insurer, despite having conducted an expert inspection, entirely omitted any reference to its findings or conclusions.
The results of this inspection were neither disclosed to Complainant nor incorporated into the coverage determination. Insurer, in effect, deprived Complainant of any substantive explanation as to how the alleged “wear and tear” and “deterioration” were identified, let alone how such conclusions were reached.
The absence of any specificity in the denial letter reflects Insurer’s deliberate failure to articulate a reasonable basis for its coverage position.
Without any supporting expert analysis or supplemental documentation, Complainant can reasonably infer that Insurer’s determination was wholly predicated upon the observations of a field adjuster who lacked the requisite expertise to assess causation.
To Complainant’s knowledge and belief, a field adjuster’s role is strictly limited to documenting observed conditions and relaying factual findings. A field adjuster lacks the requisite qualifications to render causation determinations, and their subjective observations cannot form a legally sufficient basis for denying coverage.
Insurer’s reliance on such unqualified assessments, while simultaneously concealing the findings of an expert inspection, constitutes a clear failure to provide a reasonable explanation, in writing, of the basis in the insurance policy, in relation to the facts or applicable law, for the denial of Complainant’s claim. Such conduct amounts to a direct violation of Fla. Stat. 626.9541(1)(i)(3)(f).
Moreover, Complainant’s estimate, inspection photographs, and SPOL remain wholly unaddressed. Insurer has yet to formally acknowledge in writing, let alone substantively respond to, the supplemental documentation submitted by Complainant.
Insurer’s refusal to engage with this documentation, coupled with its failure to issue any formal response, constitutes a blatant violation of Fla. Stat. 626.9541(1)(i)(3)(c).
Upon information and belief, Insurer has implemented an unreasonable company-wide policy to rely solely and heavily upon homeowners, most of whom have no background or knowledge in any of the trades involved in diagnosing a loss, to report losses with almost expert accuracy.
This policy is not in line with the Insurer’s duty a “fair and honest treatment of the claimant” as it seeks only to protect the Insurer’s interests.
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 $35,522.62, 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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