Underwriters At Lloyd's, London: a $111,657 claim called wear and tear

A Civil Remedy Notice is a formal complaint filed against an insurance company with Florida's Department of Financial Services. Filing one is the step Florida law requires before a policyholder can sue an insurer for bad faith. It is a public record, and the insurer gets 60 days to fix the problem before that right opens up.

So this is the policyholder's side of a dispute, written by their side, and it is an allegation rather than a finding. The insurer answered it, and its answer is published below alongside the complaint. Read both. Names, addresses, and policy and claim numbers have been removed here; everything else is quoted from the filing.

Certain Underwriters at Lloyds, [name redacted] to Policy no. [redacted] (the "Insurer") has committed the following in handling the Insured's claim: 1) failure to act in due diligence and good faith to resolve claims; 2) placing the financial interest of Insurer before that of the policyholder and the Insured; 3) looking for ways to deny benefit payments and otherwise "low ball" or "stone wall" claims; 4) not adjusting the claims promptly and fairly; 5) not attempting in good faith to settle claims; 6) conducting inadequate investigations; 7) failing to employ policies and procedures to conduct adequate investigations; 8) denying a claim which it knew or should have known the policy and Florida law provided coverage for; 9) shifting the burden of investigating the loss onto the Insured; 10) failing to render a claims determination within sixty (60) days; 11) failing to provide a loss run statement; and 12) misrepresenting the terms of the insurance policy. On or about April 24, 2023, while the subject policy was in full force and effect, the Insured's suffered a loss caused by wind. The areas impacted include but are not limited to the roofing system, exterior surfaces, upstairs den, back porch, front porch, foyer, guest bedrooms, hallways, windows, and doors. The Insured timely submitted a claim on February 13, 2024, to the Insurer for wind damage and the ensuing damage therefrom. Given the scope and nature of the damage, the Insured retained a public adjuster. After assessing the damage and the true scope of repairs, the public adjuster prepared an estimate identifying $111,657.82 in covered damage to the dwelling. The foregoing estimate, photographs, and a letter of representation from the public adjuster were sent to the Insurer who thereafter assigned claim no. [redacted] to the loss and sent a field adjuster to inspect the property on March 14, 2024. It was not until June 24, 2024, one-hundred thirty-two (132) days after the insured reported their loss, that the Insurer issued a coverage determination letter in which it notified the Insured that it was denying coverage for the loss. The Insurer misrepresented the loss and issued a wrongful denial. The Insurer based this denial on the rationale that the damage sustained was a result of " wear and tear, deterioration and prior deficiencies." As the discovery process will uncover, the Insurer's adjuster intentionally ignored the damage observed and has failed to make truthful and unbiased reports of the facts following the investigation. Although the Insurer and Insured are in dispute about how the dwelling was damaged, the Insurer knows or should know that when independent perils converge and no single cause can be considered the sole or proximate cause, it is appropriate to apply the concurring cause doctrine. Sebo v. Am. Home Assurance Co., 208 So. 3d 694, 697 (Fla. 2016). The concurring cause doctrine states that coverage may exist where an insured risk constitutes a concurrent cause of the loss even when it is not the prime or efficient cause. Id. at 698. A covered peril that meets with an uncovered peril may still provide for coverage under a policy when the covered peril triggered the events that eventually led to the loss. Id. at 697. The Insurer observed damage to the roof but concluded no storm created openings were observed. The term "opening" is not defined by the policy. [name redacted] dictionary defines opening as "a hole or space that something or someone can pass through." https://dictionary.cambridge.org/us/dictionary/english/opening. Here, subsequent water damage was observed to the interior of the property, including the ceiling, of the Insurer's home. As a result, the very simple question arises of "where did the water come from?" Utilizing the definition cited, the roof was damaged in a way that allowed something, here the water, to pass through the roofing structure and subsequently damaging the interior of the Insured's property. However, the Insurer is instead interpreting the ambiguous term "opening" in a method most against the Insurer's interest, often utilizing it as a provision that requires a visible opening or even to the extent of a hole in which one can see through. When faced with this ambiguity in the policy the Insurer should err on the side of the Insured and not their bottom-line as is apparent in this matter and other claims like it. This duty is further emphasized by the Supreme Court of Florida who re-iterated in Berkshire Life Ins. Co. v. Adelberg, 698 So. 2d 828, 830 (Fla. 1997), that ""[i]t has long been a tenet of Florida insurance law that an insurer, as the writer of an insurance policy, is bound by the language of the policy, which is to be construed liberally in favor of the insured and strictly against the insurer. [name redacted] Fund Ins. Co. v. Boyd, 45 So.2d 499, 501 (Fla.1950)." The Insurer is undoubtedly aware of this precedent and is handling the claims in abrogation of said case law. Upon receiving notice of the loss, the Insurer had the duty to provide the full benefits under the policy. This includes providing the Insured with a proper investigation and the funds necessary to return the home to its pre-loss condition. There may be further wrongful conduct which has not been made known to the Insured at this moment. Certain conduct or actions may be discovered throughout discovery or cannot be verified without a review of the Insurer's claim file and standards and procedures for the adjustment and investigation of claims. The Insurer has placed obstacles to the Insured's ability to have the claim adjusted promptly to begin restoring the home by waiting more than sixty (60) days after receiving notice of the loss to make a claims determination. Under Fla. Stat. 627.70131(7)(a), "[w]ithin 60 days after an insurer receives notice of an initial, reopened, or supplemental property insurance claim from a policyholder, the insurer shall pay or deny such claim or a portion of the claim unless the failure to pay is caused by factors beyond the control of the insurer which reasonably prevent such payment." There were and are currently no factors outside of the Insurer's control. As the Insurer has failed to make a timely determination, it has violated this code. As such, in addition to the below requirements to cure this CRN, any payment made to the Insured must contain interest for the damage as a result of the loss from the date the Insurer received first notice of the loss. Furthermore, the Insurer and its agents failed to comply with Fla. Stat. 627.444 by not providing the Insured and the Insured's representatives with a loss run statement. On September 23, 2024, the Insured's legal counsel provided the Insurer with a letter of representation. Within the letter, legal counsel requested a copy of a loss run statement. The Insurer and its agents have not acknowledged the request for a loss run statement nor has a loss run statement been provided. Upon an Insurer receiving a written request for a loss run statement, the Insurer is required, within fifteen (15) calendar days, to provide either a loss run statement or information on how to obtain a loss run statement at no charge through a consumer reporting agency. There has been no response within fifteen (15) calendar days of the Insured's written request and the Insurer has not provided information on how to obtain a loss run statement at no charge through a consumer reporting agency. This Insurer has breached its duty to settle claims in good faith when, under all the circumstances, it could and should have done so. The Insurer and its agents have not acted fairly and honestly toward the Insured and the Insured's representative and have moreover failed or refused to promptly acknowledge the Insured's communications in an attempt to frustrate and delay the resolution of the Insured's claim. Additionally, Insurer shifted the burden and cost of investigating and insuring the loss onto the Insured. During their investigation, the insurer's adjuster did not use a moisture meter, despite the presence of interior water damage. A moisture meter can be purchased online from Amazon for around $40 before tax. The Insurer could purchase a moisture meter and assess thousands of properties with one meter. Instead, the Insurer would rather place its financial interests over those of the Insured by failing to provide the adjuster with the necessary tools to correctly inspect the loss. As a result of the inadequate investigation and surrounding circumstances it is apparent that the Insurer significantly underestimated the scope of the loss to the Insured's property. The Insurer and its adjuster have colluded to misrepresent the true scope of damages to the insured property and the true replacement costs of the damages. In short, the Insurer is not acting with due regard for the Insured's interests or safety. In Florida the work of adjusting insurance claims engages the public trust. The Insurer has breached this trust and its duty to the Insured. The Insurer and its agents conducted cursory and inadequate investigations and wrongfully denied coverage for a loss that should have been covered under the subject policy. Moreover, the Insurer has engaged in bad faith practices designed to delay claims and prevent the Insured from recovering what is rightfully owed under the subject policy of insurance. The Insurer's actions and inactions have continued to frustrate and delay the resolution of the Insured claim. The Insurer's actions amount to but are not limited to the following:

1. Claim denial

2. Claim delay

3. Not treating the Insured with good faith claims conduct

4. Looking for way to reduce recovery to the Insured

5. Looking for ways to deny recovery to the Insured

6. Not adjusting claims and evaluating loss properly, promptly and fairly to provide full and prompt indemnity to the Insured

7. Not training, supervising or managing adjusters properly so that prompt and full payments are made, but rather placing the company's interests before the Insured's interests

8. Placing the financial interest of the Insurer over that of the health and safety of the Insured

9. Shifting the burden of investigating onto the Insured 10. Conducting inadequate investigations 11. Failing to render a written claims determination to the Insured within [address redacted]atute 627.70131 12. Failing to provide a loss run statement 13. Making material misrepresentations Therefore, to cure the defects outlined in this civil remedy notice, the Insurer must: (1). Admit full coverage for the Insured's loss. (2). Tender full benefits owed to the Insured under the insurance contract. A copy of this form submitted to the FDFS has been sent via e-mail to the following parties providing them notice of the filing of the civil remedy notice. Please e-mail any response to this civil remedy notice to [email redacted]. Via E-mail: Certain Underwriters at Lloyds, [name redacted] to Policy no. [redacted] c/o: Crawford & Company, U.S. Property & Casualty [address redacted], Suite 407 Allentown, PA 18104 [email redacted]

(1). Admit full coverage for the Insured's loss. (2). Tender full benefits owed to the Insured under the insurance contract.

Florida DFS Civil Remedy Notice, filing number 795332. Read the filing on the state's site ↗

A Civil Remedy Notice records an allegation, not a finding. Nothing here has been decided by a court or by the Department. Not legal advice; consult an attorney about your specific claim.

Fla. DFS Civil Remedy Notice, Filing No. 795332 (Sebring), accepted 12/4/2024 · public record ↗

Quotes are verbatim from the cited public record. Case status and statute summaries drafted August 2026; verify against the current docket and statute. Not legal advice; consult an attorney about your specific claim.