Shared Services Update Dawn Sexton, Director. Claims Committee Update

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Lawrence Watkins
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1 Dawn Sexton, Director Update

2 Quality Assurance On-going Annual Staff Business Unit Audits Expansion of Continuous Independent Adjuster Closed File Review Audits MCM BLT Sinkhole Mediation Appraisal Ongoing refinement of Quality Assurance Intents to continue to increase technical file quality and customer experience Continued refinement of Quality Assurance workflows to support catastrophe and noncatastrophe scalability and sustainability Ongoing Quality Assurance calibration with Citizens' Supervisors, Managers and Independent Adjuster Firms, continuing to build consistency of Closed File Reviews Recovery Subrogation Gross Recovery through October 2011 is $3,988,527.96, against a target of $4,000,000, by year end 2011 Returned $371, in policyholder deductibles thru October 2011 SIU Fraud Awareness Campaign Identify it. Report it. Help Stop it. Claims business unit specific training Implemented August 2011 Additional business unit specific training (UW, Agents, CCC) targeted to begin Q4 International Fraud Awareness Week 11/6 /11 11/12/2011 External Fraud Awareness portal community targeted January 2012 Development of Phase II - External stakeholders 2012 Expansion of SIU throughout Insurance Operations SIU Coordinator placed in Underwriting Operation Strengthening Citizens' Brand around Fraud Awareness through industry participation: Property Fraud Task Force Industry Intel Meetings Florida Advisory Committee on Arson Prevention (FACAP) International Association of Special Investigation Units (IASIU) Sinkhole Industry Workgroup 12

3 SIU Investigations of Interest Miami / Water Pipe Leak: Insured reported a water leak that allegedly caused water damage to the kitchen cabinets of his residence. Investigation revealed that he filed a previous claim for a supply line leak in 2007 and was indemnified for the lower cabinets; however, he failed to replace the cabinets after the initial loss. After pursuing the recorded statement, it was alleged the insured did not realize that he was paid for the cabinets and consequently withdrew his claim. Miami / Dropped Object: Claim involved a dropped object causing damage to the tile flooring, which was discovered by the insured s public adjuster while inspecting the property for a water leak claim. During the recorded statement, SIU inspected the property and located several additional chips throughout the residence and photographed the damages. The claim was denied for marring. Homestead / Theft: The insured reported theft of jewelry and electronics as well as damage to the front door and floor tile, which was alleged to have occurred during the burglary of the residence. Photos taken after the loss by the insured and provided to SIU depicted items that the insured was claiming as being stolen. The claim was denied for failure to cooperate due to the insured not attending the requested EUO s. The claim was closed without payment. Davie / Fire Loss: Insured reported a kitchen fire loss and a claim for additional living expenses (ALE). SIU investigation determined the insured had a previous fire with similar circumstances and similar ALE claim. SIU investigation determined the insured submitted an altered receipt in support of the ALE claim. The insured admitted under oath that he manufactured the ALE receipt. The ALE claim was denied. A DIF referral was submitted. Miami Dade/ Dropped Object: The insured claimed damages to the tile floor resulting from a dropped statue but was unable to produce the statue at the time of Citizens inspection. Based upon ISO claim search, SIU requested copies of prior loss claim records which confirmed indemnity payment of $79, had been made to the insured for the replacement of the tile floors in the home by a previous carrier. Citizens inspection photos documented hat the floors were in fact the same and had not been replaced since the previous loss and that existing damages claimed in the loss to Citizens were found to be related to the prior loss. The claim was denied for pre-existing damages. Referral to DIF has been made. 13

4 SIU Investigations of Interest Tampa / Water Roof Leak: The insured reported a water loss resulting in damage to his residence. Contrary to his initial statements to the adjuster that the residence had never previously sustained a water loss from roof leak, SIU investigation obtained claim file documents from of a prior claim with another carrier which depicted the same dilapidated condition of the roof that the insured was previously paid for. The insured had never repaired or replaced the roof after the previous claim. The claim was denied. A referral to DIF was submitted. Miami/Dade / Water Plumbing: The claim involved an alleged blockage in the main waste line, causing damage within the residence. Due to discrepancies in the facts and circumstances of the claim, SIU recommended an expert, who opined that the damage predated the date of loss reported by the insured. The SIU investigation revealed the insured had a similar loss in 2007 with a different public adjuster. The insured and the public adjuster failed to provide proof of the incurred services from the plumber and the remediation company. The claim was subsequently denied. A DIF referral was submitted. Miami/Dade/ Water Roof Leak: The insured alleged a roof leak resulting in interior damage to the insured residence. SIU Investigator obtained a recorded interview from the insured in which she stated that the damages were new and had just occurred on the date of loss reported. The SIU investigation proved that the insured had submitted two previous claims with the same roof damage. The claim was denied. A DIF referral was submitted. Lighthouse Point / Plumbing Leak: This claim involved a residential water loss caused by a hot water tank leak, resulting in wood floor damage. The adjuster found the insured had an identical previous claim with Citizens, for which she was indemnified and the repairs had not been performed. The insured declined an interview with SIU and withdrew the claim. The claim was closed without payment. Miami / Water: This claim was submitted for roof failure with ensuing water damages to the insured s residence. The insured s claim history showed multiple claims for similar losses. During the SIU investigation, it was discovered that the roof and interior damage presented to Citizens was paid by the prior insurance carrier. Claim was denied. SIU submitted a referral to DIF. 14

5 Subrogation Cases of Interest Water Damage: This loss involves black water damage to an owner occupied dwelling. The damage resulted from a clogged drain line under the driveway which resulted from an installation error in 2009, when the cable company installed an underground cable at this risk. It was necessary to drill under the driveway to install their cable. When they did this, they drilled through the PVC drain line, allowing the drain line to eventually clog, causing the water back-up. 100% recovery made in the amount of $16, Fire Loss: Loss involved a fire due to faulty installation by an HVAC contractor. With reduction for depreciation and compromise based on liability proof issues, recovery was made in the amount of $35, Fire loss: Fire loss was caused due to careless smoking on the part of another condo unit owner. Recovery was made in the amount of $32, Water Damage: Loss involved leaking refridgerator water line that a contractor failed to reconnect while making other repairs. We recovered $20, Water Damage: Loss involved improper installation of a plumbing fitting. Recovered $80, from the builder and their sub-contractor. Water Damage: Loss resulted from a failed water supply line. Recovery of $21, from water supply line manufacturer. Vehicle Damage: Loss resulted from driver losing control of their car and colliding with the insured risk. Recovery made in the amount of $36, from the adverse carrier. Vehicle Damage: Loss resulted from driver losing control of their vehicle and drove into the insured risk. Reovery in the amount of $30, from the adverse carrier. Fire Loss: A fire started within the insured s A/C unit due to faulty repairs. Recovered $45,000 from the A/C company. Fire Loss: Fire loss was caused by a lightning strike with damages exaserbated by negligent fire spread due to improperly installed insulation and a foundation sealant that made a volatile combination. When lightning struck the home, the combination of the sealant and installation fed the fire increasing the resulting damages beyond normal expectations for this type of fire. Recovery made in the amount of $300,000 against builder. 15

Dawn Sexton, Director. Claims Committee Update

Dawn Sexton, Director. Claims Committee Update Shared Service Update Dawn Sexton, Director Update Quality Assurance Expansion of QA staff On going Staff Business Unit Audits Continuous IA Audits Cat Preparation Updated Cat Audit Templates QA Cat Testing