kitchen cabinets as a result of a water supply line burst. Repairs to the supply line were made prior to the Citizens inspection. SIU obtained a recorded interview from the insureds and found inconsistencies in the timeline of the claim and their statements on how the loss occurred. SIU recommended a plumbing engineer be used in this case. The engineer concluded that the actual damage to the kitchen cabinetry existed prior to the reported supply line failure and was consistent with long-term moisture exposure. The claim was subsequently denied. A Division of Insurance Fraud (DIF) referral was submitted. Miami-Dade / Water-Plumbing Leakage or Break: The insured reported damage to the ceiling as a result of a sudden roof leak. SIU obtained a recorded interview from the insureds and found inconsistencies in their statements with the timeline regarding how the loss occurred. An engineer concluded that the long-term leaking roof was the result of the roof s age and deteriorated condition and not from an impact or wind damage. The claim was subsequently denied. A DIF referral was submitted. upstairs bathroom due to a pressurized copper pipe leak. During the interview, the insured claimed that on the day of the loss, she noticed water coming from a broken pipe through the wall to the downstairs ceiling and throughout other areas of the house. Contrary to the insured s statement, inspection revealed no evidence of water damage in the area of the pressurized water pipe within the bathroom wall. An expert concurred with SIU s findings as well as not finding any evidence for the need to repair the pressure pipe. The claim was denied, as there was no water damage to trigger coverage. A DIF referral was submitted. Miami-Dade / Water-Plumbing Leakage or Break: The insured reported a ruptured supply line under the kitchen sink that caused damage to the cabinets. The SIU investigation revealed a prior water loss claim submitted under the spouse s name, in which Citizens had paid to replace the kitchen cabinets. Photographs confirmed the insured did not replace the kitchen cabinets and presented the current loss with the same damage. The insured refused to meet with SIU and subsequently withdrew the claim. A referral to DIF was submitted. interior of the property resulting from a broken copper supply line in the kitchen. The insured had a prior water loss with Citizens for which he was indemnified and included the replacement of the kitchen cabinets. Although the damage in the current claim appeared to be identical, the insured provided an invoice of repairs; however, it was dated after the date of loss. SIU requested an interview with the insured, which was declined. The claim was closed without any payment after the insured withdrew the claim. SIU submitted a referral to DIF. interior of the property resulting from a broken supply line in the kitchen. The insured had a prior kitchen water loss with Citizens for which he was indemnified and included the replacement of the kitchen cabinets. During the EUO, the insured recalled several other claims, but did not disclose the prior loss for which he was indemnified for the kitchen cabinets. The claim was denied due to damage pre-existing the policy. SIU submitted a referral to DIF. 1 of 6
Miami-Dade / Water-Plumbing Leakage or Break: The insured reported a plumbing loss in the bathroom that caused water damage to the kitchen and master bedroom. The insured had two prior claims with Citizens in which the insured received payment for damage to master bedroom laminate wood flooring and kitchen flooring. The SIU investigation revealed that the damages presently claimed were never repaired or replaced from the prior loss. The claim was denied for pre-existing damages. SIU submitted a referral to DIF. Miami-Dade / Water-Plumbing Leakage or Break: The insured reported a plumbing leak in the laundry room that caused damage to the laminate flooring in the living areas and laundry room. The insured had a previous claim with Citizens in which similar damages were claimed and paid. SIU discovered that the prior payment included the replacement of the laminate flooring throughout the home. The SIU investigation confirmed that the laminate flooring was never repaired or replaced after the prior loss. The claim was denied for pre-existing damage. SIU submitted a referral to DIF. Miami Dade / Water-Plumbing Leakage or Break: The insured s public adjuster reported water damage to the property as a result of an alleged break in the toilet supply line in the upstairs master bedroom of the residence. Citizens received an invoice and Assignment of Benefits (AOB) from the water mitigation service provider for $6,770. The claim was referred to SIU with a demand of $65,054. Photographs from a prior loss depicted identical unrepaired damage. At the EUO, the insured did not provide any proof of repairs after the previous loss. The insured s attorney submitted a withdrawal of representation letter. The claim was subsequently withdrawn by the insured. SIU submitted a referral to DIF. Miami-Dade / Water-Roof Leak: The insured s attorney reported a roof leak to the rental property as a result of Tropical Storm Isaac. The SIU investigation revealed that the insured had submitted a previous claim that appeared to have similar damages to the current claim. The insured failed to attend all scheduled EUOs. The insured s attorney formally withdrew representation. The claim was denied based on the insured s failure to comply with policy conditions. A DIF referral was submitted. Miami-Dade / Theft, Burglary, Vandalism: The insured claimed that an unknown suspect gained entry into her home removing more than $22,000 in personal property in addition to causing cosmetic damage. During the SIU investigation, it was discovered that the insured claimed the theft of the same laptop in 2011. Further investigation proved that three other items that were claimed stolen were actually returned to their respective stores more than four years prior to the alleged theft. The claim was denied due to the evidence of fraud and misrepresentation. SIU submitted a referral to DIF and the case has been assigned. Miami-Dade / Theft, Burglary, Vandalism: The insured reported cosmetic damage and theft of personal property resulting from a burglary to their rental property. Citizens tendered initial indemnity payments totaling $40,711. During the SIU investigation, it was discovered the insured provided false rental payments, which were over stated by more than $3,640/month, in support of her loss of rents claim. SIU obtained claim records from the insured s prior carrier in which the insured was paid $18,900 for damage that overlaps with this claim and was not disclosed on the application with Citizens. The claim for additional damage and loss of contents 2 of 6
CLAIMS COMMITTEE was denied based upon lack of cooperation and for concealment and fraud. SIU submitted a referral to DIF. Miami-Dade / Dropped Object: The insured reported a framed picture fell and caused damage to the tile floor. The insured stated that the picture frame was damaged, discarded, and another picture was hung. The SIU investigation compared the photographs from the prior and current losses. It was confirmed that the same framed picture had been in place for years. SIU requested an additional statement, which the insured declined. The claim was withdrawn by the insured. SIU submitted a referral to DIF. Miami-Dade / Dropped Object: The insured claimed that her son accidentally dropped a planter and damaged a single tile in the dining room of the residence; claim was reported 30 days after the loss occurred. During her interview with SIU, the insured was vague regarding details of the claim as well as the timeframe of the loss. She further admitted that she submitted the claim at the direction of her public adjuster. After Citizens hired an expert to locate a matching tile, the claim was withdrawn by the public adjuster representing the insured. The claim was closed without payment. Miami-Dade / Lightning Loss: The Insured reported damage to personal property and appliances as a result of a lightning strike. The insured had no proof of ownership for any of the items listed on the property inventory form, which had been discarded prior to inspection. The SIU investigation into the weather events revealed and confirmed that there were no reported lightning occurrences on or around the immediate date of the reported date of loss. The insured refused to cooperate and provide proof of purchase and ownership for the alleged damaged electronics. The claim was denied, as there was no proof of lightening damage and the insured failed to present damaged items or proof of ownership of items claimed. A DIF referral was submitted. Broward / Roof Leak: The insured reported interior water damage caused by a roof leak seven months post loss. At the time the loss was reported, the Citizens policy was no longer in force. An inspection of the property revealed that the interior ceiling damage being claimed appeared to have been applied by hand and was not consistent with a roof leak. SIU identified three prior claims involving water and windstorm damage at this property, including a prior claim reported to another carrier by the same Public Adjuster. SIU left several unanswered messages for the Public Adjuster and the named insured to schedule a recorded statement. The Public Adjuster withdrew their representation. The insured continued to refuse to cooperate. The claim was closed without payment. SIU submitted a referral to DIF. Broward / Roof Leak A claim for interior water damage allegedly caused by a roof leak was reported after heavy rain in May of 2012. SIU obtained the file materials from a 2005 windstorm and a 2006 water damage claim filed with a prior carrier. The prior carrier paid the insured over $10,000 in 2005, and an additional amount over $10,000 in 2011. These payments covered the replacement of the roof, which contradicted the insured s recorded statement where she told SIU that she was not paid for a roof replacement. The insured also elected only to paint over existing ceiling stains, despite being paid to replace the ceiling drywall, insulation & popcorn texture in the prior claim. SIU researched the weather on the reported date of loss and was able 3 of 6
CLAIMS COMMITTEE to confirm minimal rain and wind activity, not consistent with a storm strong enough to damage the roof. The claim was denied. A DIF referral was submitted. Palm Beach / Water - Roof Leak: This claim was reported for interior water damage allegedly caused by a roof leak, which was reported nearly a month after the loss. The insured provided a recorded statement indicating that there were no prior claims filed involving this property, and that there was no damage to the home prior to this loss. SIU investigation established there was minimal wind speed and only 1.35 inches of precipitation on the date of loss. SIU identified three prior claims involving water or windstorm damage at the risk property since 2005, and damages seen in a 2011 roof leak claim filed with Citizens was consistent with the damages currently being claimed. This claim was denied, and a referral to DIF was completed. Palm Beach / Water Back Up: This claim involved interior water damage reportedly caused after the back up of an upstairs toilet, which was reported over three months after the loss occurred. SIU obtained claim file photographs and estimates from the insured s previous carrier that depicted identical damage being claimed to Citizens. The insured provided a recorded statement confirming that the damages were the same in both claims, but claimed to have made repairs after the prior loss. Proof of said repairs was requested on several occasions, but was never submitted. This claim was scheduled for an Examination Under Oath on three different dates, but the insured failed to appear each time. This claim was denied based on the insured s refusal to comply with post loss obligations and a referral to DIF was completed. Broward / Water - Plumbing Leakage or Break: The insured reported water damage to the interior of the property resulting from a broken supply line. During the inspection, there was no evidence of a water related loss. SIU confirmed that the EXIF analysis of the photos furnished by the water mitigation service provider and alleged to have been taken at the time of the loss had been taken weeks after the water mitigation was completed. An expert inspected and opined there was no water damage to the property. During the EUO, the insured claimed that the water loss occurred and claimed that the restoration company took photos weeks after the work was completed because they had forgotten to take the photos at the time they performed the work. Additionally, it was discovered the insured had an on-going plumbing problem in the property. The claim was denied due to no sudden and accidental direct damage to the property to trigger coverage. Broward / Water - Plumbing Leakage or Break: The insured reported a plumbing leak that caused damage to the cabinets and flooring. The SIU investigation confirmed the insured had submitted a previous claim and had been paid for the same cabinets and flooring being claimed in the current claim. The insured provided a cabinet repair receipt documenting the cabinets had been replaced as a result of the prior loss. An SIU interview with the contractor confirmed the invoice was false. The claim was denied. SIU submitted a referral to DIF. St Lucie / Water - Plumbing Leakage or Break: The insured reported a plumbing failure that caused damage to several rooms and personal property. Citizens initially tendered indemnity payments of $8,738.87 for damage to contents and for water mitigation expenses. The insured filed suit after presenting a bill for mold remediation which was received after the claim was closed. SIU conducted interviews with the plumber that revealed that the loss occurred prior to 4 of 6
the inception of the policy and that the insured misrepresented the damages on the application of insurance. The suit was dismissed. As the result of a referral to DIF, the insured was arrested and pled guilty to insurance fraud and was placed on 5 years probation. In late July, Citizens received restitution in the amount of $8,783.87. Pasco / Wind - Roof: The insured risk sustained property damage from a tornado. The claim was referred to SIU as the documentation for Additional Living Expenses submitted by the insured appeared questionable. SIU secured a statement from the insured s landlord confirming the rental, but denied signing a lease or providing receipts to the insured. The lease was found on the internet and did not represent the terms of the actual agreement with the landlord. During the EUO, the insured admitted he had misrepresented the amount paid to the landlord, but claimed he had an agreement to pay the balance to the landlord upon settlement of his claim. The insured failed to respond to requests for additional documents material to the investigation. The claim was closed without further payment. A DIF referral was submitted. Pasco / Theft, Burglary, Vandalism: The insured alleged that their residence sustained property damage due to vandalism by an unknown party. The claim was submitted by a third party vendor hired by the bank that was in the process of foreclosing on the subject property. SIU obtained records from the Sheriff s office that confirmed that the neighbor of subject property reported seeing the insured and relatives removing the items claimed as stolen out of the property. The claim made by the third party vendor was denied as the items removed and the resulting property damage was committed by the name insured who still had an insurable interest in the property at the time of the occurrence. Hillsborough / Wind - Roof: The insured reported roof damage resulting from storm activity. Citizens inspected the loss and tendered an initial indemnity payment to the roofing contractor of $1,100 who had executed an AOB with the insured. SIU became involved after the insured notified Citizens that she was being coerced by the roofing contractor to file for mediation against Citizens or pay 20% of their estimated cost of repairs. SIU interviewed the insured who confirmed that she was not aware of any damage to her roof prior to being advised by a roofing company representative who came to her home after a solicitation call. No roof inspection was conducted at the time of the visit by the representative. She confirmed a date of loss was provided to her by the roofing company and it was her understanding that the documents signed by her on the date of the representative s visit only allowed the roofing company to contact her insurer. The roofing contractor subsequently voluntarily withdrew mediation, which had been filed without the insured s consent. Based on the information obtained during the course of this investigation, SIU submitted a referral to DIF. Palm Beach / Application Misrepresentation - SIU received a referral from Commercial Underwriting regarding the policy for a Condo Association. A letter was received from a unit owner alleging issues with the roof and mentioned two claims; one for the 2004 Hurricane Frances damage with a prior carrier and one for the 2005 Hurricane Wilma damage paid by Citizens. When underwriting reviewed the file, it was noted that when the application was written in 2005 the insured and agent failed to disclose the existing damage and the prior claim in 2004. A review of the permit history and various claim payments provided no evidence to support that the roofs were fully repaired prior to the application being submitted to Citizens, or prior to the 5 of 6
claim for Hurricane Wilma damage reported to Citizens in October of 2005. SIU was able to identify application misrepresentation. A DIF referral was not submitted as the statute of limitations had exceeded 5 years. The information pertaining to the agent was shared with Agency Compliance who has an open investigation on the agency for unrelated violations of the agency appointment. Volusia / Application Misrepresentation: SIU received a referral from Personal Lines Underwriting involving a property that was previously cancelled for not meeting the 4-point inspection underwriting requirements. A request for reinstatement was submitted but the agent was advised that the policy was not eligible for reinstatement due to electrical deficiencies. The policy was bound by the same agent without any corrections and using the same 4-point inspection. Within hours of the binding the agent contacted Citizens to advise that the insured had a burglary. The investigation revealed that the burglary occurred hours prior to the submission of the bound policy. During the SIU interview, the customer service representative at the agency admitted that she bound the policy with the knowledge of the break-in and that there were still deficiencies making the property ineligible for Citizens. Citizens paid the claim because a binder was issued effective 12:01 am on the date of coverage. Subrogation and DIF referrals were submitted. 6 of 6