Filing Number: 847588
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| Filing Accepted: 9/29/2025 |
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BOND AUTO GLASS OF ORLANDO, LLC
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First Name |
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11540 MANISTIQUE WAY |
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NEW PORT RICHEY,
FL
34654
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SERVICE@CPCALKIN.COM (IN CARE OF COMPLAINT) |
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Other |
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LOLI |
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First Name |
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WENDY |
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J305236-C09-59C4 |
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Claim #* |
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UNKNOWN |
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Attorney is Applicable
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CALKIN
First Name *
CHRISTOPHER
Initial
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808 W DE LEON ST |
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TAMPA
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FL
33606
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SERVICE@CPCALKIN.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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STATE FARM GENERAL INSURANCE COMPANY
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,
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NAIC Company Code 25151 |
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| Name of individual responsible for violation (if any):*
CLAIMS ADJUSTER AND MANAGEMENT
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| Type of Insurance
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Auto
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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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Other
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VIOLATIONS ADJUSTORS CODE OF ETHICS; STATUTORY VIOLATIONS
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Other
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IMPROPER PAYMENT
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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)(2) |
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Making claims payments to insureds or beneficiaries not accompanied by a statement setting forth the coverage under which payments are being made.
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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)(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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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
Not applicable because the violations set forth below are statutory in nature. Moreover, the Insurance Company has not provided a copy of the policy prior to submitting this CRN.
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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.
Specific Facts CRN Language:
Reason for notice: Improper payment / Unfair Trade Practice / Claim Delay
626.9541(1)(i) Unfair claim settlement practices.
This Civil Remedy Notice as filed against the Authorized Insurer identified above provides notice as required under Fla. Stat. Section 624.155(3) to all entities associated with State Farm that may have handled the subject claim, including but not limited to State Farm, State Farm Mutual Insurance Company, and/or any affiliate and/or subsidiary of State Farm Insurance Company (i.e. – State Farm Fire and Casualty Company, State Farm Mutual Automobile Insurance Company, State Farm Insurance Company, State Farm Indemnity Company, State Farm General Insurance Company, State Farm Guaranty Insurance Company), (hereinafter “Insurer” or “Insurance Company”). At the time of filing this Notice, based upon information and good faith belief, and upon the action or inaction (i.e. – failure to identify, concealment, conducting claims handling under the single name of only “State Farm”), of the Insurer, Complainant has filed this Notice identifying a single Authorized Insurer, as required above. However, the aforementioned Insurance entities, affiliates, and/or subsidiaries have an identity of interest, and are in all material aspects, the same and inextricably intertwined. Moreover, the policy language upon which the Insurer relies that creates the violations identified herein is the same or substantially similar. Thus, any allegation that the “Authorized Insurer” is allegedly improperly named is legally insufficient to defeat Notice of the violations identified herein, and this Notice is effective upon the Insurer and persons who are most responsible for/knowledgeable of the facts giving rise to the allegations in this notice. Under Section 626.9541(1)(i)2, Florida Statutes, it is an unfair claim settlement practice for an insurance company to make "a material misrepresentation … 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[.]" Moreover, under Section 626.954(1)(i)3.f, Florida Statutes, it is an unfair claims settlement practice for an insurance company to "fail[] 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" when committed or performed with such frequency as to indicate a general business practice. The Insurer routinely and regularly fails to pay or underpays the Claimant's bills for windshield repair and replacement services, including calibration services. When failing to pay or underpaying the claims, the Insurer routinely fails to explain or even address how it calculated the reduced amount paid, or the statutory or contractual basis for its reduction of the charged amount. Due to the Insurer’s failure to properly and clearly identify the appropriate insurer handling the subject claim, the Claimant hereby incorporates all State Farm entities and subsidiaries. Claimant asserts the Insurer is incapable of providing said explanations and identifications, because the Insurer does not administrate its own automobile windshield repair or replacement claims. The Claimant asserts that the unfair and deceptive trade practices, and all actions, omissions, business practices, and violations identified herein, apply to each of the Insurer’s entities and the Insurer’s third-party administrator(s), regardless of the specific State Farm insurer that covered this particular claim.
Background Information Concerning Insurer’s
Windshield Insurance Coverage
In the case at hand, the insured was covered under an automobile insurance policy issued by the Insurer, which provided coverage benefits for the repair and/or replacement of damage to automobile glass. The insured suffered damage to automobile glass of a covered vehicle in a covered accident. As provided for in the insured’s insurance policy, the insured sought replacement and/or recalibration services from the Claimant's windshield repair shop. The insured assigned their post loss insurance benefits to the Claimant. The insured authorized and directed the Claimant to replace and/or recalibrate the windshield on their insured automobile, and the Claimant subsequently submitted a timely bill to the Insurer for the reasonable and necessary charges of labor and materials, as per the insurance policy, also advised the Insurer of the valid, enforceable, and legally binding assignment of benefits with the insured customer; Claimant also possesses an equitable assignment of benefits. Insurer was also on notice of all details surrounding the claim including the valid and legally binding assignment of benefits. The Claimant's bill reflected the Claimant's usual and customary charges, which are consistent and competitive within the industry standard, and were well within the range of reasonable fair market charges for similar quality, like-kind labor, and materials.
The Insurer delegated the handling of the claim to its third party-administrator, Lynx Services, (hereinafter, “Lynx” or “third party administrator”). Lynx is not an insurance company, who is otherwise known as an unlicensed, non-insurer, who is not qualified or authorized by Florida law to adjust claims. Specifically, none of the Insurer’s windshield glass claims are actually administered by the Insurer, but instead, they are administered by Lynx, a completely different entity with which the Insurer has a specially negotiated and private contract. Importantly, Lynx is not a party to the contract of insurance between the Insurer and its insured/the insured’s assignee. Nevertheless, and even though there is no contract between Lynx and the insured/insured’s assignee, nor is Lynx mentioned anywhere in the subject contract of insurance, Lynx unlawfully transacts insurance and performs contractual insurance duties on behalf of the Insurer for windshield replacement and/or recalibration services claims.
When attempting to contact the Insurer to submit an automobile windshield replacement and/or recalibration services claim to the insurer, by contacting the Insurer at the number identified on the Insurer’s website and requesting to report an automobile windshield claim, the claimant (Insurer or assignee), is immediately directed to Lynx, which administrates all of Insurer’s automobile glass claims. Thereafter, Lynx proceeds to transact insurance duties under the subject policy of insurance for each claim reported to the Insurer, including adjustment of insurance claims as it pertains to automobile windshield replacement and/or recalibration services claims. The Insurer further misrepresents policy provisions within its policy of insurance defining “we”, “us”, and “our” to mean the underwriting company providing the insurance, as shown on the declarations page. However, to the contrary, as it pertains to automobile windshield repair or replacement claims, including replacement and/or recalibration services, “we”, “us”, and “our” is not the Insurer, but instead is the undisclosed third-party administrator, Lynx, with which the Insurer is contracted directly, even though no such contract exists between the insured/the insured’s assignee. State Farm issues a policy which promises to pay for each loss to repair or replace glass under the comprehensive and/or collision provisions. The policy contains a Limit of Liability provision which states:
Insuring Agreement
1. Comprehensive Coverage
a. We will pay for loss, except loss caused by collision, to a covered vehicle.
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c. The deductible does not apply to damage to the windshield of any covered vehicle.
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Limits and Loss Settlement – Comprehensive Coverage and Collision Coverage
1. We have the right to choose to settle with you or the owner of the covered vehicle in one of the following ways:
a. Pay the cost to repair the covered vehicle minus
any applicable deductible.
(1) We have the right to choose one of the
following to determine the cost to re-
pair the covered vehicle:
(a) The cost agreed to by both the
owner of the covered vehicle and us;
(b) A bid or repair estimate approved by us;
or
(c) A repair estimate that is written
based upon or adjusted to:
(i) the prevailing competitive
price;
(ii) the lower of paintless dent
repair pricing established by
an agreement we have with a
third party or the paintless
dent repair price that is com-
petitive in the market; or
(iii) a combination of (i) and (ii)
above.
The prevailing competitive price means prices charged by a majority of the repair market in the area where the covered vehicle is to be repaired as determined by a survey made by us. If asked, we will identify some facilities that will perform the repairs at the prevailing competitive price. The estimate will include parts sufficient to restore the covered vehicle to its pre-loss condition.
You agree with us that the repair estimate may include new, used, recycled, and reconditioned parts. Any of these parts may be either original equipment manufacturer parts or non –original equipment manufacturer parts.
You also agree with us that replacement glass need not have any insignia, logo, trademark, etching, or other marking that was on the replaced glass.
(2) The cost to repair the covered vehicle does not include any reduction in the value of the covered of the covered vehicle after it has been repaired, as to compared to its value before it was damaged.
(3) If the repair or replacement of a part results in betterment of that part, then you or the owner of the covered vehicle must pay for the amount of the betterment.
(4) If you and we agree, then windshield glass will be repaired instead of replaced;
b. Pay the actual cash value of the covered vehicle minus any deductible.
(1) The owner of the covered vehicle and we must agree upon the actual cash value of the covered vehicle. If there is disagreement as to actual cash value of the covered vehicle, then the disagreement will be resolved by mediation or appraisal. Either the owner or we may request mediation or appraisal.
State Farm does not clearly and unambiguously engage in any meaningful exchange of information with the Plaintiff or the Insured to determine how State Farm will reimburse for windshield losses.
State Farm does not inform whether they chose section 1.a.(1)(a); 1.a.(1)(b); 1.a.(1)(c); 1.a.(4), OR 1.b.(1) to determine the amount to reimburse for the subject loss. Instead of determining the limitation of reimbursement in accordance with the terms and conditions of the Policy language, State Farm has applied a “competitive bid process,” or some other confidential, closed-market, network pricing standard which is not contemplated in the Policy.
State Farm is in breach of the terms set forth in the policy in the following, non exhaustive manners: (1) By engaging in practices so as to manipulate the “prevailing competitive price” (2) By determining the scope of the replacement, kind and quality of product, or repair work with certain vendors in order to cost-save instead of paying a true “prevailing competitive price” (3) By pre-determining the price of the work to windshield projects which is lower than the true prevailing competitive price so as to provide an incentive for certain approved vendors, from which competitive prevailing price is determined; or (4) By not properly utilizing any of the expressed provisions as set forth in the Limit of Liability; or (5) By improperly utilizing an inapplicable provision in the policy to set the reimbursement amount to Plaintiff for the replacement of the windshield glass; or (6) By not paying any amount to Plaintiff for the services provided.
Further, Defendant generally provides, along with its payment in an amount less than the full invoiced amount, a letter which provides that “payment was determined by a bid process.” Defendant then recites two alleged “bids,” compared said “bids” with Defendant’s alleged “program pricing,” and then allegedly pays the amount of Defendant’s “program pricing.” Defendant’s policy does not state, in any way, shape, or form, that claims will be processed and paid in accordance with any Program or Program Pricing. Further, Defendant’s Program Pricing is based upon unlawfully suppressed and privately negotiated and fixed pricing, developed by way of Defendant’s Offer and Acceptance Program, and associated with Defendant’s Third Party Administrator and network/affiliate shops.
Defendant’s unlawful business practices and bad faith also include, but are not limited to, failing to properly and fully pay based upon the insurance policy applicable to the loss, failing to conduct reasonableness analysis to determine whether the Plaintiff’s claim was compensable under the insurance policy, by developing and accepting Defendant’s own internal pricing and holding said internal pricing out as an “estimate,” determining the amount to reimburse the subject claim without securing a bid or repair estimate, determining the amount to reimburse the subject claim based upon extra-contractual agreements that neither Plaintiff nor the insured customer are parties or privy to, determining the amount to reimburse the subject claim based upon bids or repair estimates windshield repair and/or replacement shops that have a contractual relationship with Defendant and/or Defendant’s third party administrator (Lynx), whereby said companies are contractually required (or incentivized) to produce estimates and/or bids reflecting fixed prices previously established between the parties (i.e. – “program pricing”), by relying upon bids from windshield repair and/or replacement shops that have a contractual relationship with Defendant and/or Defendant’s third party administrator, by improperly using a fixed calculation, price, methodology, or formula to determine the amount to be reimbursed for the subject service, by improperly utilizing an inapplicable and/or nonexistent policy provision(s) to set the amount of reimbursement determined by Defendant for the subject loss, by allowing Defendant’s third party administrator to receive, review, adjust, and pay the loss, including but not limited to, securing “bids” from shops within Defendant’s preferred provider network (i.e. – “Offer and Acceptance Program”), wherein Defendant maintains no actual knowledge as to the process of securing said bids, by misrepresenting that the amount paid for windshield replacement claims to be a product of an “estimate,” and when it is instead a product of fixed, program pricing, by misrepresenting that Defendant will secure “repair estimates” when it is instead creating and approving Defendant’s own internally fixed pricing parameters.
With respect to the comprehensive claim associated with the insured customer, Defendant insurer breached its duty of good faith by not attempting in good faith to settle the claim when, under the circumstances, it could have and should have done so, had it acted fairly and honestly towards its insured, and with due regard for her interests, in violation of Section 624.155(1)(b)(1), Florida Statutes. In addition, or alternatively, Defendant insurer breached its duty of good faith by failing to promptly settle the claim, when the obligation to settle a claim has become reasonably clear, under one portion of the insurance policy’s coverage in order to influence settlements under other portions of the insurance policy’s coverage, in violation of Section 624.155(1)(b)3, Florida Statutes. In addition, or alternatively, Defendant insurer breached its duty of good faith, and/or engaged in unfair methods of competition or unfair or deceptive acts or practices involving the business of insurance, by failing to adopt and implement standards for the proper investigation of claims, with such frequency as to indicate a general business practice, in violation of Sections 624.155(1)(a)1 and 626.9541(1)(i)3.a, Florida Statutes. In addition, or alternatively, Defendant insurer breached its duty of good faith, and/or engaged in unfair methods of competition or unfair or deceptive acts or practices involving the business of insurance, by misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue, with such frequency as to indicate a general business practice, in violation of Sections 624.155(1)(a)1 and 626.9541(1)(i)3.b, Florida Statutes. In addition, or alternatively, Defendant insurer breached its duty of good faith, and/or engaged in unfair methods of competition or unfair or deceptive acts or practices involving the business of insurance, by failing to acknowledge and act promptly upon communications with respect to claims, with such frequency as to indicate a general business practice, in violation of Sections 624.155(1)(a)1 and 626.9541(1)(i)3.c, Florida Statutes. In addition, or alternatively, Defendant insurer breached its duty of good faith, and/or engaged in unfair methods of competition or unfair or deceptive acts or practices involving the business of insurance, by denying claims without conducting reasonable investigations based upon available information, with such frequency as to indicate a general business practice, in violation of Sections 624.155(1)(a)1 and 626.9541(1)(i)3.d, Florida Statutes. In addition, or alternatively, Defendant insurer breached its duty of good faith, and/or engaged in unfair methods of competition or unfair or deceptive acts or practices involving the business of insurance, by 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, with such frequency as to indicate a general business practice, in violation of Sections 624.155(1)(a)1 and 626.9541(1)(i)3.e, Florida Statutes. In addition, or alternatively, Defendant insurer breached its duty of good faith, and/or engaged in unfair methods of competition or unfair or deceptive acts or practices involving the business of insurance, by 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, with such frequency as to indicate a general business practice, in violation of Sections 624.155(1)(a)1 and 626.9541(1)(i)3.f, Florida Statutes.
In addition, or alternatively, Defendant insurer breached its duty of good faith, and/or engaged in unfair methods of competition or unfair or deceptive acts or practices involving the business of insurance, by failing to promptly notify the insured of any additional information necessary for the processing of a claim, with such frequency as to indicate a general business practice, in violation of Sections 624.155(1)(a)1 and 626.9541(1)(i)3.g, Florida Statutes. In addition, or alternatively, Defendant insurer breached its duty of good faith, and/or engaged in unfair methods of competition or unfair or deceptive acts or practices involving the business of insurance, by failing to clearly explain the nature of requested information and the reasons why such information is necessary, with such frequency as to indicate a general business practice, in violation of Sections 624.155(1)(a)1 and 626.9541(1)(i)3.h, Florida Statutes. In addition, or alternatively, Defendant insurer breached its duty of good faith, and/or engaged in unfair methods of competition or unfair or deceptive acts or practices involving the business of insurance, by failing to pay personal injury protection insurance claims within the time periods required by Section 627.736(4)(b), Florida Statutes, with such frequency as to indicate a general business practice, in violation of Sections 624.155(1)(a)1 and 626.9541(1)(i)3.i, Florida Statutes.
None of the references to “us”, “our”, or “we” apply to the Insurer. The Insurer further misrepresents policy provisions and conditions to extension of coverage because the Insurer does not perform any contractual duties as it pertains to automobile windshield repair or replacement claims, including calibration, including but not limited to adjusting, inspection, receipt of notice, receipt of claims, setting of pricing, and payment of claims. Specifically, as it pertains to the aforementioned policy endorsement provisions, the Insurer doesn’t receive “notice” about any claim or loss, but instead, Lynx does. Claim reporting is also done through Lynx. When attempting to contact the Insurer via the Insurer’s “claim reporting functionality on [the Insurer’s] website” said contact is immediately redirected to Lynx. No employee or adjuster of the Insurer handles any portion of any automobile windshield claim. The Insurer does not inspect damaged autos, but rather, Lynx does. Finally, when submitting a claim, photographs, and invoice for replacement and/or recalibration services of an automobile windshield, the submission is sent to Lynx, not the Insurer. Thus, not one alleged requirement within the Insurer’s policy of insurance applies to the Insurer. These provisions are unlawful, and invalid.
The duty to adjust claims is non-delegable, and the Insurer remains responsible for the adjustment and handling of the claim by Lynx and for proper payment of the claim. The Insurer, through the unlawful use of Lynx failed or refused to pay the Claimant's reasonable charges as required by the terms of the relevant insurance coverage and Florida law. Instead, the Insurer through its unlawful use of Lynx refused to pay any amount at all or paid less than the reasonable charges in violation of the terms of the insurance policy and Florida law. Upon information and belief, Lynx and/or the Insurer contend that the payment to the Claimant should be limited by or consistent with various contractual agreements between the Insurer and Lynx. However, such agreements are not mentioned anywhere in the subject insurance policy and the Claimant is not a party to those agreements and is not bound by them. The Insurer performed no investigation to determine whether the Claimant was a party to such agreements or is otherwise bound by said agreements, instead of being reimbursed pursuant to the terms of the insured customer's applicable insurance policy. Statements by Lynx, the Insurer’s unlicensed third-party administrator and/or the Insurer materially misrepresent the pertinent facts of the transaction, and materially misrepresent the insurance policy provisions and coverages available regarding payment of the claim.
In return for providing third party administration services for the Insurer, the Insurer through Lynx, provides preferential treatment to Lynx’s windshield repair and replacement division.
The Insurer’s delegation of the handling of all glass claims, including the claim subject to this Notice, is in violation of Sections 624.155(2), 624.401(1) and (4)(a), and 624.10(5)(d).
The Insurer’s insurance policy promises payment of the amount necessary to repair damaged property. The limit of liability states:
The prevailing competitive price means prices charged by a majority of the repair market in the area where the covered vehicle is to be repaired as determined by a survey made by us. If asked, we will identify some facilities that will perform the repairs at the prevailing competitive price. The estimate will include parts sufficient to restore the covered vehicle to its pre-loss condition.
However, the term “prevailing competitive price” is undefined in the insurance policy. Instead of actually determining the reasonable fair market prevailing competitive prices charged, the Insurer by its own corporate representative’s admission, utilizes reduced and discounted reimbursement rates agreed to by repair shops that belong to networks which are either controlled by or accessible to the Insurer. The Insurer’s Third Party Administrator obtains “bids” reflecting artificially reduced prices for the subject repair work, which are controlled by private agreement and “repair network” shops. The Claimant does not belong to said network. Thus, the term "prevailing competitive price" is vague and rendered illusory as the Insurer claims that the reduced and discounted in-network rate is the maximum reimbursement. When the Insurer pays the reduced charge, the payment is accompanied by a letter stating that the Insurer has paid a reasonable amount based upon “bid(s).” Yet, no bid is ever obtained by the Insurer, and any “bid” allegedly obtained by the insurer’s third party administrator identifies pricing that is reflective of closed-market, anti-competitive pricing, certainly not the product of the open or “majority” market. Pursuant to the insurance policy, the standard for payment, however, is not based on a reasonable amount, but based on an amount that does not exceed the "prevailing competitive price" where the service is rendered. When failing to pay or underpaying the Claimant's bills, the Insurer never makes that determination. In reality, the sole determination of pricing occurred prior to the subject claim being made with the Insurer, and the Insurer’s pricing is a product of a specially negotiated private contract between the Insurer and Lynx.
Despite the fact that in order to pay the loss properly and in full pursuant to the limit of liability, the policy requires State Farm to make a certain determinations as to “bids and repair estimates” they have instead engaged in unfair claims practices act by utilizing data intentionally designed to artificially skew reimbursements for glass repairs in a manner that bore no relationship to the “prevailing competitive price,” or any true “estimate or bid.” Instead of adequately and clearly notifying its insureds in the policy that State Farm would use a “bidding process” or adequately explaining the methodology it used to determine the reimbursement amount, they simply pay out claims without explanation.
State Farm further misrepresents that its insureds have the freedom to use any repair facility they choose, and State Farm will allegedly pay the claim in compliance with the ambiguous terms of the policy. However, if an insured does chose their own repair facility State Farm initiates their unlawful claims processes, including but not limited to an alleged "bidding process" and confidentially arrives at a reimbursement amount that is non-compliant with the terms of the policy.
Additionally, when the Insurer underpays the Claimant's invoice, the Insurer sends the Claimant and the insured customer a form letter stating that a payment was made that "represents the amount that the [Insurer] has determined to be the reasonable amount that is necessary to repair or replace the damage property." Further, the letter goes on to state "In the event that you and/or the Shop disagree with the amount of the payment, please be advised that the [Insurer] immediately places you and the Shop on notice that it invokes its right to appraisal as set forth in the applicable policy." The letter also advises that the Insurer chose an "impartial" appraiser, but in direct conflict with the Insurer’s policy language, the appraiser selected by the Insurer is not "impartial" but is instead biased and closely aligned with and loyal to the Insurer. The Insurer routinely sends such form letters after underpaying the Claimant's bills for windshield repair or replacement services.
The corresponding appraisal provision contained in the insured customer's insurance policy is unlawful from several perspectives. The appraisal provision does not explain that the appraisal process is intended by the Insurer to replace and circumvent the insured's constitutional rights of access to the courts, to a jury trial, and to due process of law, and it purports to unlawfully circumvent and eliminate the insured's statutory right to recover its reasonable attorneys' fees and costs from the Insurer pursuant to Section 627.428, Florida Statutes. Participation in the appraisal process typically costs more than the amount of the Insurer's underpayment amount, and therefore, the appraisal provision is obviously intended to chill and dissuade the insured from enforcing his or her contractual and statutory rights to recover full payment for his or her windshield claim. The appraisal provision is also unenforceable and invalid because it does not describe any procedural rules that will govern the appraisal process and the manner in which the amount of the claim must be fairly determined. In essence, the appraisal provision purports to allow the appraisers and/or an umpire reach a determination that is completely arbitrary and capricious, without evidence, and without any agreed upon and controlling methodology for determining the loss.
The Insurer's form letters invoking the appraisal process contain material misrepresentations for the purpose and with the intent of effecting settlement of the claims under such contract or policy on less favorable terms than those provided in, and contemplated by, such contract or policy. Firstly, the Insurer is not invoking appraisal, rather the Insurer is putting the burden to demand appraisal on the insured or the assignee windshield shop. The Insurer is suggesting that appraisal would be demanded only if there was a disagreement on the amount of the payment. However, in the claim at hand, although coverage was confirmed for the glass damage, the only issue that could be in dispute would be what coverage is available to pay the Claimant's invoice pursuant to the terms of the limits of liability set forth in the insurance policy. This is a coverage dispute that is not appropriate for appraisal. Secondly, even if appraisal was applicable to this claim, the Insurer waived such provision by authorizing the glass replacement and/or recalibration services to be performed before inspecting or appraising the damage. The Insurer also waived its right to invoke the appraisal process by disagreeing with the Claimant's billed amount and unilaterally paying a lower amount before invoking the appraisal process. The Insurer also waived its right to invoke the appraisal process by selecting a biased appraiser in violation of the express requirements of the appraisal provision which requires the Insurer to select an "impartial" appraiser.
The letter further misrepresents and/or breaches the insurance policy's limits of liability provision, by stating that the amount paid "represents the amount that the [insurer] has determined to be the reasonable amount that is necessary to repair or replace the damage property." The limits of liability policy provision, upon information and belief, is reflected herein and above.
Instead of determining the limitation of liability in accordance with the terms and conditions of the insurance policy language, the Insurer admittedly has applied a so-called “bid” or “fair and reasonable” standard which is not the standard identified in the insurance policy. Before determining whether the parties have a disagreement on the amount of loss, the Claimant is entitled to know (A) how the Defendant defines the term “Prevailing Competitive Price,” (B) the basis for its definition of this term, (C) the methodology or formula used to calculate the prevailing competitive price, (D) the area considered by the Insurer in determining the prevailing competitive labor rate, (E) whether the cost of repair or replacement was based on new, reconditioned, remanufactured or used parts and equipment, (F) whether any “bid” obtained was controlled by in-network or contractual pricing, (G) the duties assigned to the Insurer’s third party administrator.
Further, the Insurer's form letters request the insured or the Claimant to invoke appraisal themselves only if they disagree with the partial payment that was tendered. This is not an invocation of appraisal; it is a request to have the Insured or the Claimant invoke appraisal. However, by underpaying the Claimant's bill, the Insurer has already disputed the amount due and this creates an inherent dispute over the insurance policy's limit of liability provision, which is an issue than is not lawfully within the scope of an appraisal process. The Insurer is simply attempting to avoid litigation surrounding the breach of contract due to its improper underpayment of the claim. The reimbursement of an amount less than the full invoiced amount is the Insurer’s determination of the maximum amount of insurance benefits payable for the claim, and that determination makes the appraisal process inapplicable. The Insurer’s determination of the maximum amount payable is a product of the aforementioned specially negotiated private contract between the Insurer and Lynx. This agreement and pricing structure is not a product of the competitive, independent, non-affiliate windshield replacement market, nor does the pricing structure represent “prevailing competitive” rates, or the true “amount necessary to repair the damaged property.”
The only reason the Insurer seeks to invoke the appraisal process (which is rigged with a biased appraiser and typically costs more than the amount in controversy) is to force the Claimant and similarly situated shops to abandon their right to collect the full amount that is actually due pursuant to the terms of the insurance policy. Insurer only attempts to invoke the appraisal process to delay the claim, increase the Claimant's costs of collecting the full amount due, and to avoid paying the full amount due pursuant to the limits of liability set forth in the insurance policy. The Insurer treats the Claimant differently than the Insurer's in-network glass shops, because the Claimant is not a contracted member of Lynx and has not agreed to accept an arbitrary, pre-determined contracted rate of reimbursement in an amount less than what is contemplated by the full amount required by the insurance policy. In fact, in other claims that went to appraisal with the Claimant, the appraisal process has always resulted in the Claimant being awarded more than the Insured's initial underpayment amount.
Moreover, based upon an exemplar of what is believed to be the policy (without being able to confirm the exact language of the operative policy as a result of Insurer not providing a copy of same), the Claimant references the policy language referenced herein describing the facts and circumstances of the Insurance Company violation.
As previously noted, the appraiser (i.e., Auto Glass Inspection Services (AGIS)) chosen by the Insurer in its form letters is not impartial or disinterested as expressly required by the appraisal provision of the insurance policy. AGIS is biased and closely aligned with the Insurer. Further, AGIS is not even located in Florida and is the Insurer does not provide AGIS with any information on how to apply the limits of liability provision of the insurance policy to any claim that is supposedly appraises. Thus, any amount determined by AGIS is not based on the insurance policy's provisions that govern the limits of liability, and instead, is typically an arbitrary and capricious amount that has no evidentiary or lawful basis. Even if the invocation of appraisal was proper, which it is not, and the Insurer’s appraisal provision was legal, which it isn’t, the Insurer has the burden to prove any other appraiser selected is impartial and competent. The Insurer never provides proof of same.
Moreover, Insurer and Insurer’s Third-Party Administrator employs the unlawful tactic of tendering invalid and/or cancelled payment instruments. Insurer and Insurer’s Third-Party Administrator regularly tender invalid instruments (checks) to the Claimant, thereafter cancelling said checks then unlawfully tendering payment to the insured customer, in direct violation of the Claimant’s contractual agreement (i.e. – Assignment) on the subject claim. Insurer and Third-Party Administrator thereafter cause the Claimant to incur additional damages in the form of processing the invalid and cancelled check. Insurer’s and Insurer’s third party administrator’s tactics are in direct breach of the assignment of benefits, the policy of insurance, and Florida law, and such tactics reflect intentional interferences with contractual relationships between the Claimant and the insured customers, for the subject claim and all others wherein Insurer and Insurer’s Third Party Administrator employ the above-stated unlawful tactic(s).
In sum, the Insurer attempts to circumvent and pay less than the full amount of benefits required by the insurance policy, by either relying upon invalid “bids”, immediately and unilaterally demanding a rigged appraisal process, or by tendering unlawful cancelled checks and redirecting payment to the insured customers in violation of the assignment of benefits. By doing so, the Insurer seeks to avoid compliance with its own policy of insurance, prevent the insured and the Claimant from being apprised as to the how the reduced amount paid was determined, and whether that reduced amount inconsistent with the insurance policy’s coverage requirements and limits of liability; the Insurer and Insurer’s Third-Party Administrator also attempt to place the Claimant at odds with the insured customers by tendering payment to the insured customer’s despite no money being owed to the insured customers, and depriving the Claimant for payment in full for the covered goods and services rendered on behalf of the insured customers.
In order to avoid judicial scrutiny and interpretation of its insurance policy provisions and its unlawful claims settlement practices, the Insurer maintains a general business practice of denying payment, improperly paying a reduced amount, invoking its rigged appraisal process without disclosing its methodology for determining the reduced amount paid, and/or cancelling payment and unlawfully redirecting money rightfully and contractually owed to the Claimant, to the insured customers.
Further, Insurer is acutely aware that the Claimant's cost of participating in the appraisal process is typically much more than the amount of the Insurer's underpayment of the claim. As such, it makes no financial sense to agree to or participate in the Insurer's rigged appraisal process.
In essence, the Insurer’s appraisal provision attempts to substitute the insured’s or assignee’s contractual right to full payment for a windshield claim, and the insured's or assignee’s constitutional right of access to the courts and due process of law, and the insured's statutory right to prevailing party attorneys' and costs, with a rigged "heads I win, tails you lose" appraisal process that provides none of those rights. This violates public policy. Insurer's appraisal provision violates the insured's constitutional right of access to the courts, provides no due process of law, and purports to eliminate the insured's right to recover his costs from his insurance company, in exchange for reducing (or even exceeding) the insured's insurance benefits for the windshield claim by requiring the insured or the Claimant to pay for this appraisal process.
At the onset of the subject claim, Insurer and their insured customers will provide proof of comprehensive collision insurance coverage. Insurer and Third-Party Administrator receives all information needed at the time of reporting/receiving notice of the claim, and as a part of the windshield replacement facility’s submission of the invoice and accompanying documents. Still, insurer will improperly deny the claim in full and misrepresent the nature of coverage on the subject policy.
The Insurer’s conduct in this case occurs with such frequency as to constitute a general business practice. The Insurer and its employees, including management, have a financial incentive to use this claim reduction/denial system to share in profits of denied or reduced payments. By failing to fully and timely pay the charges, and employing the reduction/denial unfair business practice explained above, the Insurer has violated the following statutes:
624.155 Civil remedy.—
(1) Any person may bring a civil action against an insurer when such person is damaged:
(a) By a violation of any of the following provisions by the insurer:
1. Section 626.9541(1)(i), (o), or (x);
2. Section 626.9551;
3. Section 626.9705;
4. Section 626.9706;
5. Section 626.9707; or
6. Section 627.7283.
(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;
2. Making claims payments to insureds 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. Notwithstanding the provisions of the above to the contrary, a person pursuing a remedy under this section need not prove that such act was committed or performed with such frequency as to indicate a general business practice.
(2) Any party may bring a civil action against an unauthorized insurer if such party is damaged by a violation of s. 624.401 by the unauthorized insurer.
(3)(a) As a condition precedent to bringing an action under this section, the department and the authorized insurer must have been given 60 days’ written notice of the violation. If the department returns a notice for lack of specificity, the 60-day time period shall not begin until a proper notice is filed.
(b) The notice shall be on a form provided by the department and shall state with specificity the following information, and such other information as the department may require:
1. The statutory provision, including the specific language of the statute, which the authorized insurer allegedly violated.
2. The facts and circumstances giving rise to the violation.
3. The name of any individual involved in the violation.
4. Reference to specific policy language that is relevant to the violation, if any. If the person bringing the civil action is a third party claimant, she or he shall not be required to reference the specific policy language if the authorized insurer has not provided a copy of the policy to the third party claimant pursuant to written request.
5. A statement that the notice is given in order to perfect the right to pursue the civil remedy authorized by this section.
(c) Within 20 days of receipt of the notice, the department may return any notice that does not provide the specific information required by this section, and the department shall indicate the specific deficiencies contained in the notice. A determination by the department to return a notice for lack of specificity shall be exempt from the requirements of chapter 120.
(d) No action shall lie if, within 60 days after filing notice, the damages are paid or the circumstances giving rise to the violation are corrected.
(e) The authorized insurer that is the recipient of a notice filed pursuant to this section shall report to the department on the disposition of the alleged violation.
(f) The applicable statute of limitations for an action under this section shall be tolled for a period of 65 days by the mailing of the notice required by this subsection or the mailing of a subsequent notice required by this subsection.
(4) Upon adverse adjudication at trial or upon appeal, the authorized insurer shall be liable for damages, together with court costs and reasonable attorney’s fees incurred by the plaintiff.
(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.
Any person who pursues a claim under this subsection shall post in advance the costs of discovery. Such costs shall be awarded to the authorized insurer if no punitive damages are awarded to the plaintiff.
(6) This section shall not be construed to authorize a class action suit against an authorized insurer or a civil action against the commission, the office, or the department or any of their employees, or to create a cause of action when an authorized health insurer refuses to pay a claim for reimbursement on the ground that the charge for a service was unreasonably high or that the service provided was not medically necessary.
(7) In the absence of expressed language to the contrary, this section shall not be construed to authorize a civil action or create a cause of action against an authorized insurer or its employees who, in good faith, release information about an insured or an insurance policy to a law enforcement agency in furtherance of an investigation of a criminal or fraudulent act relating to a motor vehicle theft or a motor vehicle insurance claim.
(8) The civil remedy specified in this section does not preempt any other remedy or cause of action provided for pursuant to any other statute or pursuant to the common law of this state. Any person may obtain a judgment under either the common-law remedy of bad faith or this statutory remedy, but shall not be entitled to a judgment under both remedies. This section shall not be construed to create a common-law cause of action. 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.
624.10 Other definitions.—As used in the Florida Insurance Code, the term:
(1) “Affiliate” means an entity that exercises control over or is directly or indirectly controlled by the insurer through:
(a) Equity ownership of voting securities;
(b) Common managerial control; or
(c) Collusive participation by the management of the insurer and affiliate in the management of the insurer or the affiliate.
(2) “Affiliated person” of another person means:
(a) The spouse of the other person;
(b) The parents of the other person and their lineal descendants, or the parents of the other person’s spouse and their lineal descendants;
(c) A person who directly or indirectly owns or controls, or holds with the power to vote, 10 percent or more of the outstanding voting securities of the other person;
(d) A person, 10 percent or more of whose outstanding voting securities are directly or indirectly owned or controlled, or held with power to vote, by the other person;
(e) A person or group of persons who directly or indirectly control, are controlled by, or are under common control with the other person;
(f) An officer, director, partner, copartner, or employee of the other person;
(g) If the other person is an investment company, an investment adviser of such company, or a member of an advisory board of such company;
(h) If the other person is an unincorporated investment company not having a board of directors, the depositor of such company; or
(i) A person who has entered into a written or unwritten agreement to act in concert with the other person in acquiring or limiting the disposition of securities of a domestic stock insurer or controlling company.
(3) “Control,” including the terms “controlling,” “controlled by,” and “under common control with,” means the direct or indirect possession of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise. Control is presumed to exist if a person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing 10 percent or more of the voting securities of another person.
(4) “NAIC” means the National Association of Insurance Commissioners.
(5) “Transact” with respect to insurance includes any of the following, in addition to other applicable provisions of this code:
(a) Solicitation or inducement.
(b) Preliminary negotiations.
(c) Effectuation of a contract of insurance.
(d) Transaction of matters subsequent to effectuation of a contract of insurance and arising out of it.
624.401 Certificate of authority required.—
(1) No person shall act as an insurer, and no insurer or its agents, attorneys, subscribers, or representatives shall directly or indirectly transact insurance, in this state except as authorized by a subsisting certificate of authority issued to the insurer by the office, except as to such transactions as are expressly otherwise provided for in this code.
(2) No insurer shall from offices or by personnel or facilities located in this state solicit insurance applications or otherwise transact insurance in another state or country unless it holds a subsisting certificate of authority issued to it by the office authorizing it to transact the same kind or kinds of insurance in this state.
(3) This state hereby preempts the field of regulating insurers and their agents and representatives; and no county, city, municipality, district, school district, or political subdivision shall require of any insurer, agent, or representative regulated under this code any authorization, permit, or registration of any kind for conducting transactions lawful under the authority granted by the state under this code.
(4)(a) Any person who acts as an insurer, transacts insurance, or otherwise engages in insurance activities in this state without a certificate of authority in violation of this section commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
626.9541(1)(e)
(1) UNFAIR METHODS OF COMPETITION AND UNFAIR OR DECEPTIVE ACTS--The following are defined as unfair methods of competition and unfair or deceptive acts or practices:
(e) False statements and entries--
1. 1. Knowingly:
a. Filing with any supervisory or other public official,
b. Making, publishing, disseminating, circulating,
c. Delivering to any person,
d. Placing before the public,
e. Causing, directly or indirectly, to be made, published, disseminated, circulated, delivered to any person, or placed before the public, any false material statement.
626.9541(1)(i)
Unfair claim settlement practices—
(i) Unfair claim settlement practices.—
1. 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;
2. 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; or
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;
b. Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue;
c. Failing to acknowledge and act promptly upon communications with respect to claims;
d. Denying claims without conducting reasonable investigations based upon available information;
e. 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;
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;
g. Failing to promptly notify the insured of any additional information necessary for the processing of a claim; or
h. Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
627.7288:
Comprehensive coverage; deductible not to apply to motor vehicle glass.—The deductible provisions of any policy of motor vehicle insurance, delivered or issued in this state by an authorized insurer, providing comprehensive coverage or combined additional coverage shall not be applicable to damage to the windshield of any motor vehicle covered under such policy.
This willful and wanton business practice of the Insurer, in reckless disregard for the rights of its insureds and assignees of its insureds, violates Section 624.155(1)(b)3, because it results from and involves the Insurer's “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.”
This willful and wanton business practice in reckless disregard for the rights of Insurer’s insureds and their assignees also violates Section 624.155(1)(b)1, because it results from and involves the Insurer's “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.”
The Insurer’s willful and wanton business practice in reckless disregard for the rights of its insureds and their assignees, as described hereinabove, also violates Section 626.9541(1)(i)3.a, because it results from and involves the Insurer’s “Failing to adopt and implement standards for the proper investigation of claims.”
The Insurer’s willful and wanton business practice in reckless disregard for the rights of its insureds and assignees of its insureds, as described hereinabove, also violates Section 626.9541(1)(i)(3)b, because it results from and involves the Insurer's “Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.”
The Insurer’s willful and wanton business practice in reckless disregard for the rights of its insureds and assignees of its insureds, as described hereinabove, also violates Section 626.9541(1)(i)3.d, because it results from and involves the Insurer’s “Denying claims without conducting reasonable investigations based upon available information.”
The Insurer’s willful and wanton business practice in reckless disregard for the rights of its insureds and assignees of its insureds, as described hereinabove, also violates Section 626.9541(1)(i)3.f, because it results from and involves the Insurer’s “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.”
The Insurer’s willful and wanton business practice in reckless disregard for the rights of its insureds and assignees of its insureds, as described hereinabove, also violates Section 624.155(1)(b)2, because it results from and involves the Insurer's "Making claims payments to insureds or beneficiaries not accompanied by a statement setting forth the coverage under which payments are being made."
The Insurer’s willful and wanton business practice in reckless disregard for the rights of its insureds and assignees of its insureds, as described hereinabove, also violates Section 624.155(1)(b)3, because it results from and involves the Insurer's "… 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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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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