Jan 102015
 

InsuranceBusters.net Final EDDM Complete Front 6x8.75

 

InsuranceBusters.net Final EDDM Complete Back 6x8.75

 

When filing an insurance claim, everyone in the world wants you to believe your insurance company not only knows best, but that they have your best interest in mind. Sorry…There is no Tooth Fairy, and your insurance company is NEVER going to pay claims correctly, when they are the only ones looking at your claim that they owe…. Let that sink in…. Then Read this BEAutiful saying out loud.

InsuranceBusters.net Legalities

 

Now, for some actual proof. (Would never want to be the “Boy Who Cried Wolf”)

This is a complaint that will be filed on Monday at 1:00 pm. Why? Because the insurer has absolutely no knowledge of the laws, nor any want to learn. Every day they hold YOUR money, they make money. Every Dollar they owe, but do not pay, is profit!

The is the email sent to their Oblivious adjuster:

Mr. Adjuster, (Name Redacted for Obvious Reasons)

Unfortunately, you have exceeded the amount of time allotted to issue payment for the additional items that were clearly damaged, yet not addressed prior to our involvement. Monday, at 1:00pm, our office will file the following complaint. We have attempted to allow a natural process, without taking an adversarial position, even though Redacted adjusters attempted this from the onset. We are now past that point, and as my experiment has proven, no one really cares what happens to the insured, or what the statutes say. We do. The insured does. You should. What your license dictates. To #ProtectTheInsured, not your employers wallet.

 

Melanie, if you have not received confirmation of an issued check by 1:00 pm, exactly five business days from our appointment, and Mr. Hooper’s subsequent agreement that additional items were damaged, submit to all parties. (As usual, I suspect Mr. Hooper will attempt to deny this, it makes no difference, without issuance of payment, the complaint is to be filed. Photographs and time stamps prove everything needed, there is a massive amount of damage to the entire property.) Also, add the statute about licensing, and who can and cannot adjust claim on behalf of an insured. Redacted has engaged in BLATANT claim negotiations with a contractor who does not even have a contract with the insured and is NOT licensed as a Public Adjuster. The contractor is forbidden, by law, to attempt and adjust claims without a license just like an insurer is required to only negotiate an insured’s claim with either the insured, their Licensed Public Adjuster, or their Licensed Attorney. This is done to allow the insurer to be superior in the negotiation, thereby nullifying any opportunity the insured had at indemnification, which is one of the reasons it is prohibited. Again, very profitable for an insurer to ALWAYS be in control.

 

Cal Spoon 432-349-6631

Licensed Public Adjuster

InsuranceBusters.net

 

As Promised, this will be the complaint that is filed when he does not comply.

Begin Formal Complaint:

 

InsuranceBusters.net

­­Corporate Office                                                      Document Center    

902 51ST Street                                                         5756 N Dixie

Galveston, TX 77551                                              Odessa, TX 79762

877-41-2BUST Toll Free

409-539-5188  Phone

409-539-5184  Fax

Email calspoon@insurancebusters.net

Website www.insurancebusters.net

 

 

January 10, 2015

Formal Complaint

To:      Texas Department of Insurance

 

Re:      Insured:

Redacted

Redacted

Abilene, TX 79601

Claim # Redacted

Policy # Redacted

DOL June 12, 2014

 

 

Carrier:

Redacted

Redacted

Redacted

Redacted

Redacted

Redacted

Redacted Cell

Redacted Fax

Redacted Email Address

 

 

We represent the named insured above in this formal complaint, please advise our office of any actions taken on this complaint.

 

InsuranceBusters.net submitted a Notice to Insurance Company for the above referenced insured on 12-18-14. Inspection was set for January 5, 2015. InsuranceBusters.net via Cal Spoon and Redacted inspected insured location. Redacted stated that he had not had time to review the claim, so he was looking with “new” eyes. I stated Notice had been there since the 12/18 and there was a lot of info. He said he had reviewed my estimate briefly. Redacted was shown extensive, irrefutable damage. He photographed the areas, and claimed after a 40 minute inspection that he had seen all he needed. I attempted to show him further damage, to the metal awnings… (He photographed these from the main roof, stating he did not want to block traffic.) and the interior. He stated that he had to make a 4:30 p.m. flight and was cutting it close. Upon our departure, he stated that he would “send me an email” telling me when he “respond”. I stated at that time, that the luxury of responding at whim was not to be had here. There was obvious extensive damage that was conveniently overlooked, statutes were pretty clear about time limits.

 

I treated this claim somewhat differently, to see if it would illicit a different response. Even though all communication, as is posted below from our internal log, has been like pulling teeth, the adjusters have attempted to tie us to another Public Adjuster, simply by name, even after being told on numerous occasions we were of no association, then the shuffle of adjusters, only to still meet with an adjuster who claimed originally that he was there as a “large loss” adjuster, only to tell me at the end of the meeting, that this claim was over his limit as well. They had our valuation from the beginning, the number did not change. Normally, I would have given a very aggressive approach, however, as I stated above, I wanted to make sure that it was merited. After too many claims to name, we are very clear on how an insurance company is going to act when faced with actually being asked to pay what they owe. Seems like it should be a simple thing, “yes, that is damaged, and covered, and we are sorry we missed it, and thank you for bringing it to our attention.” That is not at all what happens….here is the internal log, exactly as it is in our file:

 

12/16 MS received documents from Cal….@ 1:18 MS called Redacted for declarations page so I can verify and send notice to IA. Redacted did not answer, MS left him a vm for declarations page12/17 Redacted contacted MS back for fax number….he faxed declarations page over….MS to file 12/18 and notify Redacted of our involvement.12/18 @ 8:15 MS called Redacted claim center.  Spoke with Grace in the call center..she said the adjuster on the claim is Redacted phone 940-808-8986 fax 508-926-5660 email Redacted…@ 8:21 MS faxed notice directly to Brad and as always requested all documents to be sent asap12/19 @ 9:08 MS called Brad, he said the insureds roofer sent roof sample to Rooftech and they did not find any hail damage.  He said why would a company pay any amount like that when there is no damage.  He is sending us the report and said Redacted sent samples and he doesn’t understand why the Insured would pay over $600000 when there is no hail damage.  MS said we fell differently and can prove that to him.  I need to setup a reinspection.  He said he will send all documents and has already dropped them off this morning at UPS to go to our document center.  Aside from Redacted he said Redacted is on the claim and he handled many with him in Amarillo, so is he related.  I said no.  Redacted is to be nowhere around my files or my company. He said are we related and I stated NO.  He asked who PA on this claim was and MS said my husband, Cal Spoon and he asked again what the relation was…Stated they share the same Redacted but definitely no relations.  He said he handled claims with him and crushed him in Amarillo…MS said he is a fraud and he said he must agree.  Have Cal call him and they will review together to make sure all is okay but he has proof from Rooftech and we are welcome to call.  MS said I already requested all reports and previous docs so we could review. He said he has sent. MS asked for via email as I am in the office and need to proceed on this claim he said he will try but have Cal call him…MS said I will pass the message so we can schedule inspection….@ 9:18 MS sent estimate via email to Brad again stating: Attached is our estimate of damages per the Insured.  Please do review and reply with a time and date so we may re-inspect the property and called Cal….discussed with Cal and he is in the field and will call Brad after he sees the reports….MS said okay…@ 9:27 MS called Brad again for appt and to see when he can send reports…he said he is out of the office until tomorrow and MS said I work on Saturdays as well so just as soon as he can send them in that would be helpful however lets go ahead and look at the schedule so we can set all up…Brad said since we sent a claim estimate of over half a million it will be reassigned to large loss…MS agreed and said yes we are aware so I will call Redacted and get that adjuster..he said again when he gets estimate then he will have to fill out form to large loss to be assigned and he will form a property large loss report and then they will assign…MS said alright, we are aware so again I will no longer contact him I will call Redacted to get assigned, he said you, Melanie, Cannot just call Redacted to get large loss assigned…MS said okay Brad just send the documents requested just as soon as you can he said again they are in the mail to ya…MS said TY….@ 9:32 MS called Redacted, spoke with Molly and explained Redacted is not capable or equipped for this loss so I need the large loss supervisor…she said she is sending me to Brads Supervisor, Redacted 225-791-0800, she transferred me to her line….MS discussed the claim with her to state this claim exceeds his credentials and amounts so need to get in touch with large loss claims so we can proceed….she took claim number then stated she will review and said Brad does handle large losses just depends on his availability but she will have to contact him then call me back so we can all proceed but she will review and call us back….MS faxed estimate to Darcys attn at following information…@ 9:40 MS called Redacted again spoke with Redacted 508-926-5660….@ 9:46 MS sent Darcy the estimate via email stating: Per our discussion, attached is our estimate of damages.  I have already discussed this claim and estimate with Redacted as he advised this will be out of his hands and he will file the large loss report when he can.  We need to proceed with the handling of this claim so please review and reply with the adjusters information so I may schedule and inspection for both parties as soon as possible…..@ 9:50 Darcy replied to my email stating: Thank you for your email.  Once the file has been reviewed with the new documentation, we will contact you to communicate how Redacted will proceed.  Thank you so much for the documentation and have a wonderful Christmas….MS sent to Cal for FYI….@ 10:20 am Darcy replied stating: Thank you again for the draft that you sent over for our review.  Can you please forward your photo documentation and any core samples that you have received regarding the damage to the insured location?  I appreciate your assistance and look forward to receiving the additional necessary documentation to review the file for further action. Thank you again, Redacted, CIC Property Unit Manager Southern Region office 225-791-0800 cell 225-324-1557 fax 508-635-0361 Redacted@ 1:05 Brad Taylor replied to MS also stating: Please see the attached. I’ve included two reports from Roof Technical, as I pointed out that their first report had photos of another project in it.  I asked that they remove the photos of the other project.  Roof Technical’s invoice is to be taken care of by the insd’s. roofer Barr Roofing – Griffin Hess. I’ve faxed the Dec. to you. Please call or e-mail with any questions. Thanks Redacted, CPCU Outside Property Adjuster The Redacted Insurance Group P.O. Box 738 Denton, TX 76202 Phone (940) 808-8986 Fax (508) 635-5906  Redacted….MS sent to Cal and SS for Onedrive….@ 3:26 MS shared IBN Initial photos with Redacted (North) stating: Attached are our damage photos for the property. Do reply with adjusters information and availability so we may mutually re-inspect….@ 3:41 Darcy replied stating: Thank you for the update.  So there are no other pictures (south side or any close up pictures of damage to the roof)?  I will forward these to the file as well for review….@ 3:44 MS replied stating: There are 100 photos, up close and entire property.  Those are all photos…@ 4:54 MS received an email from the new assigned adjuster Redacted, EGA Office:  281.547.8721 Cell:  832.752.5754 Redacted  P.O. Box 133306 Spring, TX  77393.  His email stated: Please be advised that the above claim has been reassigned to the undersigned for handling, going forward.  I just received this assignment this afternoon.  I am in the process of reviewing file notes, docs, estimates, etc. Please also note that while I will be working Monday and Tuesday, I am already obligated on those dates.  Further, I will be on vacation starting Christmas Eve through New Year Day. I am available to meet for a reinspection after Jan 1st on any date convenient to you.  However, please keep in mind that this location is in Abilene and we will have to pay attention to the weather forecast for the date we agree to meet, as you are probably aware, Abilene/North Texas can have some pretty inclement winter weather this time of year. Please revert with your available dates the first week of January.  You can reach me in my office or on my cell phone on Monday or Tuesday….@ 5:34 MS sent to Cal…@ 5:56 Cal replied stating: 1st or the second at the latest. Preferably 1st. Start the clock…..@ 6:10 pm MS replied to Redacted stating: We have availability at 10 am on January 1st. Please do reply so I may notify all parties….@ 6:15 pm Robert replied stating: Melanie, January 1 is New Year’s Day. It’s a holiday. I’m off on that date. Did you mean to type another date?12/20 @ 9:25 am MS replied to Robert stating: No. I did not. You said January 1st. I do not consider New Year a Holiday.12/31 @ 1:38 MS contacted Redacted as the weather did not look good for our scheduled appt on Friday the 2nd….tried rescheduling for Saturday the 3rd as the weather clears up according to the Weather Channel then….he said he is looking at accu weather and weather looks fine…high in 50’s and he already has itenerary for flight but it is going through Dallas…..MS told him I was reviewing the weather channel and it said rain with high of 37….he rechecked his app and said MS is right….it doesn’t look good, he is unavailable for Saturday but he can move to Monday….MS verified that would be okay and he said he will check and change his itenerary to Monday the 5th and if MS will send him email as he is still off and not returning until Friday anyway…MS resent appt to all parties at 1:46….@ 1:50 MS sent email to Redacted stating: Per our discussion, I am sending you an email for the changed appointment.  We have agreed that due to the weather on Friday the 2nd we both will not be able to inspect the property.  As agreed we have changed the appointment to Monday the 5th at the same scheduled time, 1 pm.  I have notified all parties and we will see you there….@ 2:03 pm MS called Mr. Redacted to notify of APPT CHANGE TO MONDAY JANUARY 5th @ 1 pm….he said that is fine and he will probably not be there….MS said that is okay we just need access to entire inside and outside…he said okay….he also said all solar panels belong the retail strip and if damaged they should be covered as well….MS im Cal to let him know…@ 2:04 Redacted replied stating: I will revise my itinerary tomorrow and will re-confirm once that has been done. Happy New Year to you as well,1/2 @ 11:15 Redacted emailed MS again stating: Per our conversation on Weds and per your email below: I have successfully rescheduled my trip to Abilene for Monday, Jan 5th.  I am scheduled to arrive in Abilene via DFW at 11:28 a.m., so the 1:00 p.m. meeting time should be fine. If for some reason I have travel delays, I will call your office number as per our discussion.1/5 @ 1:06 Cal contacted MS to notify and confirm appt was at 1…MS confirmed….@ 1:13 MS called Robert…he stated he was just pulling in….MS confirmed again appt WAS at 1. He said yes…he is there now….it’s the Radio Shack building…MS told him to look for our van, he said okay, he saw it**

End Internal Log:

 

 

As you can clearly see, there is an adversarial position, no matter how we conduct ourselves. In my opinion, armed with these facts, I feel the normal procedure of aggressiveness is not only merited, it is the only thing an insurance company actually understands.

 

We are supposed to be on the “same side”. The insureds side. We are not….that’s a problem. The insurer has ALREADY been paid to do what we are having to do, and the insured has to pay for again. From the log above, there is an example of how an insurer should handle claim. Receive it, document it, investigate it, valuate it correctly, and submit all info necessary to close it, within the allotted time frames. It shows clearly, that this not only can be done in this time frame, but much quicker, with much more efficiency. Below is a statute, which from my untrained eye, appears to state that this is a fundamental part of the insurance resolution process, and the guidelines provided within that statute were not merely suggestions, but rules to operate by. Unfortunately, no one in the insurance industry appears to see it that way. This is evidenced by the massive amount of insurers and their licensed employees who have no clue that these RULES EVEN EXIST.

 

How and why does this happen? Money… as insureds, we have paid money in good faith to an insurance company, any insurance company, in hopes of them doing what they promised when we paid them…for all those years. Reality, and what this firm has proven, they have absolutely no want or reason to pay a claim as it is owed, or under the time limits it is in owed in. This costs them money, they are a business, and without repercussions, they will do whatever necessary to make the most amount possible. This is VERY EASY when YOUR people are the only ones working on the claim that you owe on. It allows them to write their own profit.

 

As of today, Monday January 12, 2015, the insurer has missed their statutory time line to issue payment on any additional items that were proven, and agreed to, even though I, Cal Spoon, personally advised Mr. Hooper of said timeline verbally. Please note on the log, there has been absolutely no correspondence, and no activity whatsoever from them since inspection.

 

 

We have included a copy of the Statutes as we understand them:

 

 

  • 542.003. UNFAIR CLAIM SETTLEMENT PRACTICES

PROHIBITED. 

 

(a) An insurer engaging in business in this state may

not engage in an unfair claim settlement practice.

(b)  Any of the following acts by an insurer constitutes

unfair claim settlement practices:

(1)  knowingly misrepresenting to a claimant pertinent

facts or policy provisions relating to coverage at issue;

(2)  failing to acknowledge with reasonable promptness

pertinent communications relating to a claim arising under the

insurer’s policy;

(3)  failing to adopt and implement reasonable

standards for the prompt investigation of claims arising under the

insurer’s policies;

(4)  not attempting in good faith to effect a prompt,

fair, and equitable settlement of a claim submitted in which

liability has become reasonably clear;

(5)  compelling a policyholder to institute a suit to

recover an amount due under a policy by offering substantially less

than the amount ultimately recovered in a suit brought by the

policyholder;

(6)  failing to maintain the information required by

Section 542.005;  or

(7)  committing another act the commissioner

determines by rule constitutes an unfair claim settlement practice.

 

Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

 

And,

 

  • 542.054. LIBERAL CONSTRUCTION.

 

This subchapter shall be liberally construed to promote the prompt payment of insurance

claims.

 

Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

 

 

  • 542.055. RECEIPT OF NOTICE OF CLAIM.

 

(a) Not later than the 15th day or, if the insurer is an eligible surplus lines

insurer, the 30th business day after the date an insurer receives

notice of a claim, the insurer shall:

(1)  acknowledge receipt of the claim;

(2)  commence any investigation of the claim;  and

(3)  request from the claimant all items, statements,

and forms that the insurer reasonably believes, at that time, will

be required from the claimant.

(b)  An insurer may make additional requests for information

if during the investigation of the claim the additional requests

are necessary.

(c)  If the acknowledgment of receipt of a claim is not made

in writing, the insurer shall make a record of the date, manner, and

content of the acknowledgment.

 

Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

 

 

  • 542.056. NOTICE OF ACCEPTANCE OR REJECTION OF

CLAIM. 

 

(a) Except as provided by Subsection (b) or (d), an insurer

shall notify a claimant in writing of the acceptance or rejection of

a claim not later than the 15th business day after the date the

insurer receives all items, statements, and forms required by the

insurer to secure final proof of loss.

(b)  If an insurer has a reasonable basis to believe that a

loss resulted from arson, the insurer shall notify the claimant in

writing of the acceptance or rejection of the claim not later than

the 30th day after the date the insurer receives all items,

statements, and forms required by the insurer.

(c)  If the insurer rejects the claim, the notice required by

Subsection (a) or (b) must state the reasons for the rejection.

(d)  If the insurer is unable to accept or reject the claim

within the period specified by Subsection (a) or (b), the insurer,

within that same period, shall notify the claimant of the reasons

that the insurer needs additional time.  The insurer shall accept or

reject the claim not later than the 45th day after the date the

insurer notifies a claimant under this subsection.

 

Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

 

 

\§ 542.057. PAYMENT OF CLAIM. 

 

(a) Except as otherwise

provided by this section, if an insurer notifies a claimant under

Section 542.056 that the insurer will pay a claim or part of a

claim, the insurer shall pay the claim not later than the fifth

business day after the date notice is made.

(b)  If payment of the claim or part of the claim is

conditioned on the performance of an act by the claimant, the

insurer shall pay the claim not later than the fifth business day

after the date the act is performed.

(c)  If the insurer is an eligible surplus lines insurer, the

insurer shall pay the claim not later than the 20th business day

after the notice or the date the act is performed, as applicable.

 

Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

 

 

  • 542.058. DELAY IN PAYMENT OF CLAIM.

 

(a) Except as otherwise provided, if an insurer, after receiving all items,

statements, and forms reasonably requested and required under

Section 542.055, delays payment of the claim for a period exceeding

the period specified by other applicable statutes or, if other

statutes do not specify a period, for more than 60 days, the insurer

shall pay damages and other items as provided by Section 542.060.

(b)  This section does not apply in a case in which it is

found as a result of arbitration or litigation that a claim received

by an insurer is invalid and should not be paid by the insurer.

 

Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

 

 

  • 542.059. EXTENSION OF DEADLINES.

 

(a) A court may grant

a request by a guaranty association for an extension of the periods

under this subchapter on a showing of good cause and after

reasonable notice to policyholders.

(b)  In the event of a weather-related catastrophe or major

natural disaster, as defined by the commissioner, the

claim-handling deadlines imposed under this subchapter are

extended for an additional 15 days.

 

Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

 

 

  • 542.060. LIABILITY FOR VIOLATION OF SUBCHAPTER.

 

(a) If an insurer that is liable for a claim under an insurance policy is

not in compliance with this subchapter, the insurer is liable to pay

the holder of the policy or the beneficiary making the claim under

the policy, in addition to the amount of the claim, interest on the

amount of the claim at the rate of 18 percent a year as damages,

together with reasonable attorney’s fees.

(b)  If a suit is filed, the attorney’s fees shall be taxed as

part of the costs in the case.

 

Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

 

 

  • 542.061. REMEDIES NOT EXCLUSIVE.

 

The remedies provided

by this subchapter are in addition to any other remedy or procedure

provided by law or at common law.

 

Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

 

 

 

 

 

 

 

End Statute Excerpt

InsuranceBusters.net Fox in the Hen House

 

InsuranceBusters.net is committed to fair claims handling, we file these complaints in order to bring the attention of the Department to the horrific deeds done on a daily basis. At this point, we can state, with proof, that only a handful of people are following your rules. We are not asking you to determine coverage, we are asking that you hold insurers responsible for clearly violating the statutes over and over. They are not being taught the rules because the rules eat away at their profits, and there is no punishment for doing it.

 

Respectfully,

Cal Spoon,

InsuranceBusters.net

432-349-6631

InsuranceBusters.net Free Claim Review

 

 

Check Our License Here: Texas Department of Insurance License Verification

Other resources for the insured:

www.C3ADJUSTERS.com

www.cornerstonepac.net

www.socspa.com

www.papublicadjuster.org

www.DickLawFirm.com

www.MerlinLawGroup.com

www.nlmus.com

www.benchmarkclaims.com

www.apiadjusters.com

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