Filing Number: 813669
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| Filing Accepted: 3/28/2025 |
| Last/Business Name
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AYALA
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First Name |
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RUBEN COSME |
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| Street Address
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1002 SUFFRAGATTE CIR., |
| City, State Zip
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HAINES CITY,
FL
33844
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| Email Address
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SERVICE@LOUISLAWGROUP.COM |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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AYALA |
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First Name |
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RUBEN COSME |
| Policy # * |
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P005982887 |
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Claim #* |
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234265 |
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Attorney is Applicable
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| Last Name* |
LOUIS
First Name *
PIERRE
Initial
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| Street Address* |
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290 NW 165TH STREET, SUITE M-500 |
| City, State Zip* |
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MIAMI
,
FL
33169
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| Email Address * |
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SERVICE@LOUISLAWGROUP.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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SECURITY FIRST 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 10117 |
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| Name of individual responsible for violation (if any):*
UNKNOWN
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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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| 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)(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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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
Governed by the cited authorities, the insurance policy (“Policy”) provides coverage on an “all risk” basis, which clearly, unambiguously and per well-settled Florida Supreme Court case law, requires the insurer to issue full payment for all covered losses and damages that arise during the Policy period as a consequence of a direct physical loss to property. Specifically, the Policy states, “We insure for sudden and accidental direct loss to property described in Coverages A and B only if that loss is a physical loss to covered property.” SFI FL HO3 SP 07 21 pg. 38 of 80.
The only exceptions being fraud, intentional damage, and/or the determination that a Policy exclusion or limitation applies. That said, and to lawfully assert any exclusion and/or limitation, the insurer must have a good faith basis to conclude that it can prove the application of the exception or privilege by a preponderance of the evidence gathered during its reasonable and prompt investigation and adjustment of the claim. At a very minimum, the insurer is required to issue full payment for any losses or damages for which such exceptions and/or limitations cannot be promptly verified per the evidentiary considerations referenced, and for an amount that corresponds with the actual cash value of the loss, or the amount necessary to perform repairs in relation to the losses or damages.
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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.
The Complainant and Insured, RUBEN COSME AYALA, (including his authorized representative, hereinafter “Complainant”), maintained a homeowner’s insurance policy (hereinafter “Policy”) with SECURITY FIRST INSURANCE COMPANY DBA SECURITY FIRST FLORIDA (hereinafter “SFF”), which generally and broadly provided coverage for any direct physical loss to the residential property, 1002 Suffragatte Cir., Haines City, Fl 33844, (hereinafter “Property”), that occurred during the Policy period.
On or about, August 19, 2022, while the Policy was in full force and effect, Complainant suffered a covered loss; to wit: wind caused interior and exterior damage to the property (hereinafter “Covered Loss”). The interior of the Complainant’s property sustained significant damage, due to wind, to which loss SFF assigned claim number 234265. To date, SFF has refused to remit all proceeds due and owing to the Complainant for his loss, despite Complainant’s compliance with his post loss obligations, and despite SFF’s receipt of an estimate contradictory to its unilateral assessment of the loss’ value. On April 26, 2023, Complainant, with the assistance of counsel, filed a lawsuit against SFF.
Although hundreds of days have passed since the claims for losses and damages were presented for payment under the Policy, SFF has refused to remit all proceeds due and owing to Complainant for his loss. Despite Complainant’s compliance with his post loss obligations, despite no express language in the policy excluding damage caused to the Complainant’s property by wind, and despite SFF receipt of an estimate of damages contradictory to its unilateral assessment of the loss. The Complainant has established that the loss occurred during the policy, but SFF has failed to meet its burden that all of the damage is caused by a policy exclusion.
SFF has attempted, in bad faith, to close Complainant’s claim by denying coverage for the loss in violation of Florida Statutes 624.155(1)(b)(1), 624.155(1)(b)(3), and 626.9541(1)(i)(3)(d). Since this loss occurred, SFF’s strategy has been to prolong and delay the fair adjustment of Complainant’s claim. As a result of the deficient adjustment of the loss, Complainant’s property has remained in a state of disrepair, while SFF has collected a premium on a policy that was designed to protect insureds like the Complainant during his hour of need.
Complainant is requesting that SFF to live up to the insurance contract in which SFF promised to adjust all losses with its Complainant. This promise to adjust all losses with its Complainant is one that SFF must undertake in good faith, which means it cannot unilaterally determine the value of its Complainant’s losses and remit payment to the Complainant that is grossly insufficient to cover the estimated damages, or, as in this instance, refuse to remit any payment Complainant under the Policy and deny coverage of the loss. Complainant placed his trust in SFF and has paid all premiums due and owing, and in exchange for said premiums, he is asking SFF to pay the damages that it agreed to cover when it issued the insurance policy.
The work of adjusting insurance claims in Florida requires insurers to engage the public trust. SFF has clearly breached this trust with respect to its deficient handling of Complainant’s claim. SFF is obviously motivated by a desire to protect its own interest to the detriment of its Complainant, and has pursued a course, which is only advantageous to itself. See Fla. Stat. Sec. 624.155(1)(b)(1); 626.9541(1)(i)(3)(a). SFF’s general business practice of willful, wanton, deceptive and bad faith claim handling policies, procedures, guidelines, protocol, adjusting, investigating, drawing valuations and issuing payment for the claims has caused the Complainant to suffer further harm and extra-contractual damages that have accrued, and will continue to accrue. The stated misconduct is collectively referred to as “Bad Faith,” and the specific factual and/or legal considerations in relation thereto are further outlined below for its consideration in accordance with Fla. Stat. Sec. 624.155 and the cited legal authorities associated therewith.
SFF insures hundreds of homes throughout the area where the Complainant’s residence is located. That said, it failed to institute the necessary policies, procedures, guidelines, protocol, personnel and contingencies in relation to fully, promptly and equitably indemnify its insureds who are impacted by wind. Consequently, insureds such as the Complainant were forced to fend for themselves to mitigate damages arising from SFF’s Bad Faith; absorb the burden, expense, inconvenience and delay associated with an insurer who was not equipped (because it didn’t want to incur the expense associated therewith) to meet their contractual obligations; risk health hazards associated with the presence of moisture and/or mold due to SFF’s failure to perform pursuant to the Policy; hire experts/professionals/counsel to force SFF to abide by its fiduciary duty and avoid the consequential damages associated with SFF’s failure to perform; etc.
2. SFF knew that wind losses are of a nature that a thorough, nuanced and specialized investigation/adjustment of the claim needs to be promptly performed by qualified and prepared personnel in order to protect its insureds, satisfy its fiduciary duties and otherwise not engage in the Bad Faith claim handling practices at issue. That said to the detriment of its insureds and to maximize its financial interests, SFF disregarded the obvious and known obligations by way of the following:
a. Not developing, maintaining and/or instituting policies, procedures, protocol or guidelines to determine whether adjusters/personnel/vendors utilized to protect its insureds were qualified to duly assess the scope and/or value of the loss or damages.
b. SFF knew that it would have to promptly hire licensed contractors, uniquely qualified adjusters and/or engineers to fully, equitably and honestly assess the scope and/or value of the loss or damages suffered by its insureds.
c. SFF knew that it would be in its insureds’ interests and its obligation under the insurance policy to utilize personnel/vendors to perform moisture meter assessments throughout the insureds property to honestly assess the full extent of damages and losses suffered by its insureds. Such practice is a simple, inexpensive, efficient and industry wide accepted means of protecting its insureds, however, SFF knows that it does not serve its financial interest since it will increase its financial obligations to insureds such as the Complainant. Although SFF will implement such methods to establish a lack of coverage as it relates to a specific claim in which it determines coverage may be in dispute, it choose to avoid such expense for self-gain when it knows that the claim is covered.
d. SFF knew that it would be in its insureds’ interests and its obligation under the insurance policy to utilize personnel/vendors to perform thermal imaging assessments throughout the insured property to honestly assess the full extent of damages and losses suffered by its insureds. Such practice is a simple, inexpensive, efficient and industry wide accepted means of protecting its insureds, however, SFF knows that it does not serve its financial interest since it will increase its financial obligations to insureds such as the Complainant. Once again though, and although SFF will implement such methods to establish a lack of coverage as it relates to a specific claim in which it determine coverage may be in dispute, it choose to avoid such expense for self-gain when it knows that the claim is covered.
e. SFF knew that it would be in its insureds’ interests and its obligation under the insurance policy to retain a licensed mold assessor to determine whether there were concealed conditions within the home which necessitated mold remediation and the need for its insureds to take precautionary measures to preserve their physical health and property interests. Such practice is a simple, inexpensive, efficient and industry wide accepted means of protecting its insureds, however, SFF knows that it does not serve its financial interest since it will increase its financial obligations to insureds such as the Complainant. Once again though, and although SFF will implement such methods to establish a lack of coverage as it relates to a specific claim in which it determines coverage may be in dispute, it choose to avoid such expense for self-gain when it knows that the claim is covered.
f. SFF knew that it would be in its insureds’ interests and its obligation under the insurance policy to promptly issue payment for professional/qualified moisture assessments and remediation in order to, inter alia, avoid: the development of hazardous/toxic conditions within the residence; preclude the insured from suffering consequential and extra-contractual damages; the development of an uninhabitable residence and various risks that may develop; etc. Such practice is an accepted, reasonable, necessary and industry wide accepted means of protecting its insureds, however, SFF knows that it does not serve its financial interest since it will increase its financial obligations to insureds such as the Complainant.
g. SFF knew that it would be in its insureds’ interests and its obligation under the insurance policy to utilize a license mold remediator to consider a license mold assessor’s assessments and protocol in order to honestly determine the true scope and value of damages and/or the loss. Such practice is a simple, inexpensive, efficient and industry wide accepted means of protecting its insureds, however, SFF knows that it does not serve its financial interest since it will increase its financial obligations to insureds such as the Complainant.
h. SFF knew that it would be in it insureds’ interests and its obligation under the insurance policy to carefully consider all policy terms that afford coverage for losses and damages as the obligation to pay was made reasonably clear, and thereafter utilize counsel when an adjuster is in doubt to advise them on a claim-by-claim basis whether in fact it is duly indemnifying its insureds. Such practice is a simple, inexpensive, efficient and industry wide accepted means of protecting its insureds, however, SFF knows that it does not serve its financial interest since it will increase its financial obligations to insureds such as the Complainant.
i. SFF knew that it would be in its insureds’ interests and its obligation under the insurance policy to carefully evaluate on a claim-by-claim basis whether any amounts appropriated for “depreciation” are based on sufficient facts and data, reliable principles and methods, and/or the application of reliable principles and methods. SFF knows that it is arbitrarily, capriciously, deceptively, willfully and wantonly appropriating depreciation without any claim/item specific consideration to justify same. In the aggregate, and unbeknownst to its insureds, this sham practice allows SFF to unjustly avoid millions of dollars in benefits owed to its insureds who are consequently placed in a position wherein they are financially coerced into choosing whether to leave their home in a state of disrepair, or alternatively, searching for a handyman and non-licensed vendors to perform makeshift repairs which create secondary risks and potential damages that SFF will deny coverage for when they arise.
j. SFF knew that it would be in its insureds’ interests and its obligation under the insurance policy to carefully evaluate on a claim by claim basis, and only after equitably and fully investigating/adjusting claim, the amounts owed to the insured for: overhead and profit associated with the insured’s reasonable need to utilize a general contractor; taxes associated with the repairs; permit costs associated with the repair; costs associated with various licensed trades that will be needed to effectuate the repairs; whether benefits are owed to the insured for loss of use and/or additional living expenses; personal property that may have been affected by toxic/mold/moisture conditions that developed in the home; costs associated with maintaining the continuity of the finish/appearance for pairs or sets such as cabinets, flooring, roof covering/tile/shingles, walls, ceilings; etc.
k. SFF knew that it had an obligation to ensure that software programs, data bases and adjusting practices utilized to estimate the scope and value of the loss were being utilized in form that: honestly and fully delineated the line item repairs or costs that needed to be performed; pricing corresponded with licensed professionals - as opposed to handyman or non-licensed professionals; accounted for consideration of actual expenditures incurred by the insureds or otherwise compensable expenses on a repair cost basis; etc. Ultimately, SFF knows that the adjusting practices are guided to unlawfully depriving its insureds of benefits owed under the insurance policy, which in the aggregate, serves to maximize its profits to the detriment of its insureds.
l. SFF knew that it had an obligation to treat all insureds equally and honestly. However, and for its own financial interest, it will only start to fully consider its obligations as stated herein if the insured retains legal representation and pursues a legal action which exposes them to liabilities and costs associated with. Even then, SFF will withhold monies owed in an unjust effort to limit/delay its liabilities in relation to the statutory considerations and otherwise.
m. SFF knows that it has a continuous and ongoing duty to not engage in the Bad Faith conduct that is the subject of this Complaint. However, and to advance its own financial interest and avoid the liabilities pursuant to the above cited statutory authorities, SFF will direct and utilize non-qualified counsel to delay the equitable and prompt payment of the claim via delay tactics and otherwise not implementing policies, procedures and/or guidelines to ensure that its duties are fulfilled during the course of litigation. Moreover, SFF will insist upon the insureds to fulfill its own obligations by imposing upon them the burden to establish their full entitlement to benefits for which it knows, or should know, are owed.
n. SFF knows that it has to assess the application of the policy deductible on a case-by-case basis and only after the claim is fully adjusted and investigated. This practice is necessary to protect the interests of the insured since, pursuant to binding precedent and the policy, the deductible is subject to being absorbed by losses and/or damages that exceed a limitation of coverage under a certain section of the policy.
o. SFF knows that it has a duty to duly assess whether benefits are owed to the insured in relation to the costs associated with removing and resetting personal property in relation to repairs and/or remediation work that needs to be performed. This duty is ignored by HCPCIC in order to maximize its own financial interests.
p. SFF knows that it has duty to issue payment for interest owed in relation to payments that were untimely issued per governing authorities. With that said, and to the detriment of the insured, it foregoes and/or delays such considerations in order to maximize its financial interests.
q. Although SFF knows that it has a duty to treat all insureds/assignees equally, it will consistently act inconsistently in relation to: the application of policy limits; the manner in which valuations and/or the scope of repair is assessed; the manner in which an insured is required to comply with policy conditions; the application and/or consideration of policy conditions and/or exclusions to bar coverage; the timing and/or circumstances upon which undisputed payments will be made pre-suit and post-suit; etc. The lack of consistency and organization ultimately serves to deprive insureds of their rights under a policy and otherwise creates an inherently dishonest, immoral, and unfair means of adjusting and investigating claim.
3. SFF’s “toolbox” of Bad Faith claims handling practices as described above leaves insureds, the insured’s counsel, the SFF’s counsel and even the judiciary guessing as to when and how HCPCIC will duly perform. The continuously vacillating positions and cherry picking of the described Bad Faith conduct not only serves to maximize SFF’s prospective financial gains by being able to avoid paying benefits, it also serves to minimize SFF’s lost adjusting expense as it see fit and to the invariable detriment of its insureds, the Complainant, and ultimately the tax paying citizens of this State that bear the expense of the judicial system which needs to unravel the tangled web created by SFF.
4. To cure the above stated immoral, deceptive, unlawful and collectively defined general business practice of Bad Faith claims handling practices that are knowingly, willfully, wantonly and/or with a reckless disregard for the Complainant’s interests being implemented, SFF must perform as follows within 60 days of receiving this Complaint.
a. Take corrective action in association with the Bad Faith claims handling practices by way of rectifying same and thereafter duly adjusting, investigating and issuing payment for all benefits owed to the Complainant in the amount of $70,383.02, for indemnity;
b. Take corrective action in association with the Bad Faith claims handling practices by way of rectifying same and thereafter duly adjusting, investigating and issuing payment for all benefits owed to the Complainant;
c. To the extent verified after duly performing under the policy pursuant to cited authorities and considerations, issuing any and all payments owed to the Complaint for interest on benefits that were untimely paid;
d. To the extent verified after duly performing under the policy pursuant to cited authorities and considerations, confess judgment in relation to the pending action brought forth by the Complainant;
g. As it relates to any claims/benefits that may remain in dispute or undetermined, fairly, honestly, specifically, meaningfully and substantively disclosing to the Complainant’s counsel the basis therefor and the means to promptly reach resolution; and/or
h. Otherwise fulfilling any and all obligations under the policy that it knows, or should know, remain to be performed.
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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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