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 Recovery Subrogation Mandatory Subrogation CE training Gross Recovery through May 2011 is $1,611,842.92 Returned $122,722.88 in policyholder deductibles thru May 2011 Salvage Gross Recovery thru May 2011 $19,879.31 Continue to actively seek salvage disposal opportunities SIU Fraud Awareness Campaign Identify it. Report it. Help Stop it. General Fraud Awareness mandatory training launched organizationwide Claims business unit specific training targeted August 2011 Additional business unit specific training (UW, Agents, CCC) targeted Q3 and Q4 Fraud Awareness portal community launched Initial development of Phase II External stakeholders 2012 Sinkhole Industry Workgroup Property Fraud Task Force led by Division of Insurance Fraud SIU Participation on the following committees: Claims Fraud Committee Underwriting Fraud Committee Public Awareness and Outreach Committee Joint Legislative Committee 21
SIU Investigations of Interest Sarasota/Water & Mold: The insured risk was alleged to have sustained water and mold damage resulting from water overflow from the AC unit. The claim was referred as the tenant of the subject property stated that the AC unit has never worked and so they added a window AC unit. In addition, the AC receipt was from a repairmen located in Miami. The insured withdrew the claim, following the SIU recorded interview and during our attempts to verify the repairs with the Miami AC repairman. New Port Richey/Sinkhole: SIU located the prior owner of the insured risk and secured testimonial evidence that our insured was made fully aware during the sale of the property that the property had a prior sinkhole. After the claim was denied, the insured filed suit and based on the facts developed during the SIU investigation, a minimal negotiated settlement was reached. Miami/Fire loss: This loss involved an unattended frying pan on the stove which caught fire, causing fire/smoke damage to the residence. The origin and cause investigation determined that the fire was intentionally set. After SIU requested interviews, the insured withdrew the claim. The claim was reported to DIF. Miami/Dropped Object: This claim involved damages to floor tile of the insured risk, allegedly caused while moving a piece of furniture and damages to kitchen cabinets caused by water loss due to dishwasher leak. SIU located the claim files with the previous carrier which confirmed that the insured was previously indemnified for the alleged damaged areas and failed to perform the necessary repairs. SIU conducted an interview with the insured who denied the existence of the previous floor tile damage claim. The claim, was voluntarily withdrawn by the insured following her interview with SIU. Miami/Water Plumbing Leak: The public adjuster submitted a plumbing bill to Citizens to substantiate the plumbing repair following a water loss at the insured s s home. The adjuster submitted the claim to SIU after she discovered the current damages were identical to damages claimed by the previous owner who had submitted a claim in 2006 to Citizens. SIU determined that the house was purchased by the insured thru foreclosure sale and that some damages preexisted the policy inception. In addition, the insured claimed loss of rents alleging the house was tenant occupied, however, could not provide documentation to substantiate this aspect of the claim. After the investigator obtained a recorded interview from the insured, the insured withdrew their claim. A referral was made to DIF. Miami/Cooking Fire: The insured alleged fire damage to the kitchen due to an unattended cooking fire. Cause and origin inspection revealed burn patterns appeared inconsistent with a typical cooking fire. SIU Investigation determined that the insured purchased the risk as a foreclosure from a bank. After conducting an EUO, the claim was denied when the insured failed to provided documents repeatedly requested by defense counsel in support of their loss. The claim, was subsequently denied. 22
SIU Investigations of Interest Miami / Fire Loss: This claim involves a residential loss caused by fire. Citizens retained an independent origin and cause investigator who confirmed the fire was intentionally set and that the property had been vacant for several years. While owner involvement in the fire was not proven, the SIU investigation revealed that the person filing the claim did not own the property and the property owner was deceased. The individual making the claim did not have an insurable interest in the property. The claim, was closed without payment. Miami/Roof Leak: The insured alleged damages to property as a result of a roof leak. An ISO search revealed existence of a prior roof leak claim from 2008. SIU obtained documents from the prior carrier which proved insured was claiming duplicate damages to Citizens. The claim, was denied. A DIF referral was submitted. Tampa/Theft VMM: The insured s burglary claim was initially denied by Citizens in July 2008 for vacancy issues, which were supported by initial statements of the insured and Citizens inspection of the loss. The insureds retained an attorney and reopened their claim, alleging that the house was in fact occupied. SIU conducted interviews and due to conflicting statements surrounding the timeline, the insureds appeared for an EUO. The claim, was denied based upon vacancy and material misrepresentations made by the insured in the application and during presentation of the claim. The claim was referred to DIF. False Insurance Policy Scheme : This case involved a CSR working in a Citizens appointed agent s office who attempted to divert Citizens mail in 2010. The subject pled guilty in February 2011 on the original charges of Fraud/False Statements in regards to the mail fraud issue. Her sentence hearing was held in May and involved testimony by Citizens SIU regarding our investigation. She was sentenced to 18 months in federal prison, followed by three years probation, barred from working in the insurance industry, required to undergo mental health counseling and required to pay restitution to Citizens. When she is released, the State may pursue charges of false and fraudulent check cashing. Insurance Agent Miami, Florida: This involves a complaint received by Agency Compliance wherein they had numerous infractions by a Miami insurance agency. The agent diverted premium refund checks, to his personal address and then forged the insured s signatures. When interviewed by SIU, the agent of record claimed this was an error on his secretary s part. SIU interviewed the secretary who stated that the agent was the only person in control of the checks and who had access to the bank account where the checks were deposited. The agent s appointment was terminated. A DIF referral was completed. Roofing Contractor: An SIU investigation was initiated after it was determined that a roofer who performed wind mitigation inspections had utilized Citizens logo in his advertising material. We researched with Underwriting and found no instances where this inspector was utilized on a Citizens policy. A referral was made to DIF. Upon contact by DIF, the contractor agreed to remove the Citizens logo from all forms of his advertising. 23
Subrogation Cases of Interest Defective Product: This case involves a faulty ignition switch in a Ford vehicle, which set the vehicle, the garage and the insured s home on fire. After overcomming the issue of several recall notices that were ignored by the insured, we recovered $65,000.00. Fire: This claim involved a large fire loss caused by the guest of a unit owner who fell asleep with a candle still lit. Our investigation revealed the guest carried liability insurance. Recovered full replacement cost value of the claim of $211,841.54. Water: The risk sustained damages when the A/C contractor working in a unit above the risk activated the sprinkler system in that unit. The contractor acknowledged his responsibility for the water intrusion, hired a company to conduct water mitigation services and reported the claim to his carrier. The contractor s carrier advised him they weren t sure if he had coverage with them and maintained that position causing the contractor to hire an attorney. The contractor and his attorney worked with our Recovery Specialist and the claim was resolved for a 90% recovery of $18,466.48. Water: A plumber cut a sprinkler line while doing remodeling in our insured s condo, which also caused water damage to other condo units. Full replacement cost recovery of $23,278.60 was made. Water: An installer hooked up the insured s new refrigerator to an old, existing water line. Within a year of the installation, the water line leaked causing extensive water damage. Throughout the risk Recovered $30,000.00 of the replacement cost claim of $53,641.64 36 6 in a compromise settlement. 24