Filing Number: 808512
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| Filing Accepted: 2/26/2025 |
| Last/Business Name
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BRISMAN
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First Name |
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VIVIAN |
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| Street Address
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16400 COLLINS AVE |
| City, State Zip
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SUNNY ISLES BEACH,
FL
33160
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| Email Address
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INSURED@MCDONALDBARNHILL.COM |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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BRISMAN |
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First Name |
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VIVIAN |
| Policy # * |
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02447151094A |
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Claim #* |
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024471510-800 |
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Attorney is Applicable
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| Last Name* |
GONTRUM
First Name *
RYAN
Initial
L
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| Street Address* |
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505 S. MAGNOLIA AVENUE |
| City, State Zip* |
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TAMPA
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FL
33606
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| Email Address * |
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TAL@MCDONALDBARNHILL.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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UNITED SERVICES AUTOMOBILE ASSOCIATION
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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 25941 |
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| Name of individual responsible for violation (if any):*
ROBERT BROSSETT
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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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Unsatisfactory Settlement Offer
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Unfair Trade Practice
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Statutory provision(s) which the insurer allegedly violated.
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| 626.9541(1)(i)(1) |
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Attempting to settle claims on the basis of an application, when serving as a binder or intended to become a part of the policy, or any other material document which was altered without notice to, or knowledge or consent of, the insured.
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| 626.9541(1)(i)(2) |
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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.
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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)(e) |
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Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed.
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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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| 626.9541(1)(i)(3)(j) |
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Altering or amending an insurance adjuster’s report without:
(I) Providing a detailed explanation as to why any change that has the effect of reducing the estimate of the loss was made; and
(II) Including on the report or as an addendum to the report a detailed list of all changes made to the report and the identity of the person who ordered each change; or
(III) Retaining all versions of the report, and including within each such version, for each change made within such version of the report, the identity of each person who made or ordered such change;
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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.
***ADDITIONAL STATUTORY PROVISIONS ALLEGED TO HAVE BEEN VIOLATED AS FOLLOWS:***
§624.155(1)(a) Any person may bring a civil action against an insurer when such person is damaged:
By the commission of any of the following acts by the insurer:
1. Section 626.9541(1)(i), (o), or (x);
§624.155(1)(a) Any person may bring a civil action against an insurer when such person is damaged:
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 towards its insured and with due regard for his interests;
2. Making claims payments to insures or beneficiaries not accompanied by a statement setting forth the coverage under which payments are being made; or
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.
§624.155 (5) No punitive damages shall be awarded under this section unless the acts giving rise to the violation occur with such frequency as to indicate a general business practice and these acts are:
a. Willful, wanton, and malicious;
b. In reckless disregard for the rights of any insured; or
c. In reckless disregard for the rights of a beneficiary under a life insurance contract;
(8) The damages recoverable pursuant to this section shall include those damages which are a reasonably foreseeable result of a specified violation of this section by the authorized insurer and may include an award or judgment in an amount that exceeds the policy limits.
§627.70131 Insurer’s duty to acknowledge communications regarding claims; investigation
(1)(a) Upon an insurer’s receiving a communication with respect to a claim, the insurer shall, within 14 calendar days, review and acknowledge receipt of such communication unless payment is made within that period of time or unless the failure to acknowledge is caused by factors beyond the control of the insurer which reasonably prevent such acknowledgement. If the acknowledgement is not in writing, a notification indicating acknowledgement shall be made in the insurer’s claim file and dated. A communication made to or by an agent of an insurer with respect to a claim shall constitute communication to or by the insurer.
(b) As used in this subsection, the term “agent” means any person to whom an insurer has granted authority or responsibility to receive or make such communications with respect to claims on behalf of the insurer.
(c) This subsection shall not apply to claimants represented by counsel beyond those communications necessary to provide forms and instructions.
(2) Such acknowledgement shall be responsive to the communication. If the communication constitutes a notification of a claim, unless the acknowledgement reasonably advises the claimant that the claim appears not to be covered by the insurer, the acknowledgement shall provide necessary claim forms, and instructions, including an appropriate telephone number.
(3) Unless otherwise provided by the policy of insurance or by law, within 10 working days after an insurer receives proof of loss statements, the insurer shall begin such investigation as is reasonably necessary unless the failure to begin such investigation is caused by factors beyond the control of the insurer which reasonably prevent the commencement of such investigation.
(4) For purposes of this section, the term “insurer” means any residential property insurer.
(5) Within 90 days after an insurer receives notice of a property insurance claim from a policyholder, the insurer shall pay or deny such claim unless the failure to pay such claim is caused by factors beyond the control of the insurer which reasonably prevent such payment. Failure to comply with this subsection constitutes a violation of this code.
***Specific policy language that is relevant to the violation***
United Services Automobile Association (“USAA”) failed to adequately adjust and pay the claim covered under the subject insurance policy. Specifically, but not limited to, USAA failed to properly apply the Loss Settlement and Loss Payment provisions of the policy. In addition to the policy sections specifically cited herein, any endorsements or changes to said sections are relevant to the Insured’s claim for civil remedy. There may be additional policy language relevant to this violation that may be discovered.
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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.
Vivian Brisman’s claim results from damage due to a water leak on or about November 13, 2024, to her property located at 16400 Collins Ave., Sunny Isles Beach FL 33160. The water leak caused damage to the walls, floors, and other building materials in throughout the master bathroom and adjacent areas. The property was insured under policy number 02447151094A. The claim was reported to United Services Automobile Association (“USAA”) and was assigned the claim number 024471510-800. The carrier assigned Robert Brossett as the desk adjuster, but never assigned a field adjuster to inspect the property. As such, USAA has failed to investigate the claim or do anything to indemnify Ms. Brisman for her loss.
Ms. Brisman hired Stellar Public Adjusting Services Inc. (“Stellar”) to represent her interests in the claim. Stellar inspected the property and found $329,842.89 worth of damages to the dwelling. Meanwhile, All 4 One Plumbing performed leak detection for $580, and Brickhouse Inspections, Inc. prepared a mold remediation estimate totaling $14,848.84. Stellar repeatedly requested USAA assign a field adjuster to inspect, but USAA refused to send a field adjuster, and instead demanded all documentation from the Insured and Stellar before even considering an inspection. There is no evidence USAA did anything to adjust the loss or ever considered any information provided by Stellar. USAA’s course of action has continuously delayed indemnification while the Insured’s costs continue to rise.
In Florida, the work of adjusting insurance claims engages the public trust. USAA has breached this duty in the adjustment of this loss by failing to investigate the claim, refusing to provide proper indemnity, unnecessarily delaying resolution of the claim, and failing to take into consideration documentation provided to them which would support further compensation. USAA has failed to create and implement adequate guidelines for proper investigation of claims handling and for training and supervision of employees and representatives which have resulted in some of the statutory violations set forth above.
USAA charged the Insureds a substantial premium for these coverages but has refused to tender any payment when under all circumstances it should have done so, had they acted fairly and honestly. As a result, the Insureds have been forced to consider legal counsel to protect their interests.
Therefore, to cure the defects outlined in this Civil Remedy Notice, USAA must:
1. Immediately tender all insurance monies due to the Insured for the loss;
2. Act fairly and honestly towards the Insured and with due regard for his interests in attempting to settle the claim;
3. Pay statutory interest on the amount of unpaid contractual damages from the date the claim was reported;
4. Cease and desist all present and future bad faith actions with regard to the Insured’s claim;
Failure to cure all defects during the 60-day safe harbor period may result in additional extra-contractual damages.
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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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