Insurance Company Disputes Health, Disability or Property Damage Claims

If you have come to this web page, it means that you are having difficulty getting your own insurance company to pay a health, disability or property damage claim. Quite often, the insurance company is simply waiting for you to obtain representation before doing what they should have done in the first place… pay the claim. If you are having difficulty with your insurance company in getting them to resolve a claim, please contact our office or the office of another attorney immediately. Often times, your insurance policy has a very strict procedure you need to follow in appealing a denial of benefits or in contesting an insurance claim. If you fail to follow these procedures, your claim may be barred or substantially hurt. For these reason, you should not delay in speaking with our Staff about obtaining representation immediately.

If you need to retain an attorney to recover the full value of your claim, the attorney may be able to recover his attorney’s fees from the insurer. In order to be entitled to attorney’s fees, you must “prevail” in your claim. This means that you must obtain a judgment greater than any offer of settlement previously tendered by the insured. In order to determine if your case is one that meets this criterion, you should speak with one of our legal staff as soon as possible.

If you have spoken with several attorneys and are still unable to retain an attorney to handle your claim, we suggest that you consider filing a Civil Remedy Notice pursuant to Section 624.155 of the Florida Statutes. This Civil Remedy Notice (CRN) gives the insurance company 60 days to correct the problem that is the source of the complaint or face sanctions, including the imposition of attorney’s fees.

How to File a Civil Remedy Notice

You can print a copy of a Civil Remedy Notice from the Florida Department of Financial Services’ website Consumer Services. Once there, click on the link to "Civil Remedy Form” on the left side of the page. You must have an Adobe Acrobat Reader to view and print a copy of the Civil Remedy Notice. The second page of the Notice has instructions for completion and mailing of the form.

For general consumer information about insurance and insurance companies, visit the Dept. of Financial Services webpage at http://www.fldfs.com/ and select the link to "Consumer Guides" or "Consumer Resources".

Information to Include in a Civil Remedy Notice

This form is self explanatory, with the exception of Sections 5, 6, and 7.

Section 5: In order to complete this section, you first need to know what statutory provisions have been violated. Because each circumstance is different, I have included some of the more common violations to assist you in completing the form. This is not intended to be a complete list of all possible violations that can subject the insurance company to sanctions. For more information, see Section 624.155 and 626.9541 and the statutes cited therein.

1. 624.155(1)(b)(1): Not attempting in good faith to settle claims when, under the circumstances, it could and should have done so, had it acted fairly and honestly toward its insured and with due regard for her injuries.
   
2. 626.9541(1)(i)(2): A material misrepresentation made to an insured or any other person having an interest in the proceeds payable under the 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.

The following sections require that the insurance company commit or perform the violation with such frequency as to indicate that it is a general business practice. The repeated violations can occur in your case or in cases throughout the area in which the insurance company practices. If you suspect the insurance company is committing these violations, you should include them in your complaint.

1. 626.9541(1)(i)(3)(a): Failing to adopt and implement standards for the proper investigation of claims which is committed or performed with such frequency as to indicate a general business practice.

2. 626.9541(1)(i)(3)(b): Misrepresenting pertinent facts or insurance policy provisions relating to coverage issues which is committed or performed with such frequency as to indicate a general business practice.

3. 626.9541(1)(i)(3)(c): failing to acknowledge and act promptly upon communications with respect to claims which is committed or performed with such frequency as to indicate a general business practice.

4. 626.9541(1)(i)(3)(d): Denying claims without conducting reasonable investigations based upon available information, which is committed or performed with such frequency as to indicate a general business practice.

5. 626.9541(1)(i)(3)(g): Failing to promptly notify the insured of any additional information necessary for the processing of a claim, which is committed or performed with such frequency as to indicate a general business practice.

6. 626.9541(1)(i)(3)(h): Failing to clearly explain the nature of the requested information and the reasons why such information is necessary, which is committed or performed with such frequency as to indicate a general business practice.

Section 6: In this Section, you may refer to specific policy provisions, as applicable. If you haven’t already done so, now is a good time to review the policy to see what your rights are under the policy. If you don’t have the policy, then state you are not in possession of a policy.

Section 7: This section needs to be filled our carefully, as the insurer will likely only be required to respond to those allegations set forth in this section. You should specifically state your grievance and the appropriate remedy for the grievance. Be as specific as possible without painting yourself into a corner (such as demanding less than your entitled to because you don’t know the full extent of your damages.

Follow the directions on the back of the form for mailing the form to both the Department of Financial Services and your insurance company. If the insurance company fails to address your concerns within 60 days, you should immediately contact an attorney and inform him/her that the insurance company has failed to respond to your CRN within the 60 days. The insurance company’s failure to address your concerns will allow an attorney to pursue an action against the insurance company and make it responsible for costs and attorney’s fees. Please remember that the 60 day time period begins to run only if you file a CRN. It is not sufficient to simply call the Department of Financial Services and voice a complaint or submit an online New Service Request.

Please remember that it is important that you keep copies of all paperwork, including receipts, appraisals and a copy of the CRN. Also, please make sure that you comply with all the provisions of your policy. Typically, there are time limitations for bringing a claim against your insurer; that is, failing to act promptly may bar or substantially hinder your ability to bring a claim. Therefore, you should contact an attorney immediately to see if he/she will handle your claim, or begin the steps necessary to resolve the claim yourself.

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