Sep 152019
 

It is long, but it has to be. The “Senior Claims Manager” is that “Gertrude” many of you have heard me speak of, long winded, self righteous, and full of shit, all rolled into one.

The following is a copy and paste of “Senior Claims Manager” last correspondence.

My responses are italicized and in larger bold:

Dear Mr. Spoon:

As you know, we serve as the third party administrator on this insurance claim for “The Insured”’s insurer, “The Insurance Carrier”. This letter will provide an update on “The Insured”’s referenced March 2019 wind claim, including addressing the recent estimate prepared by “The Building Consultant” (““THE BUILDING CONSULTANT””). The August 2019 “THE BUILDING CONSULTANT” estimate is based upon the July 2019 engineering report from engineer “The Second Engineer” of “The Second Engineer”. We previously provided you with the engineer’s report are enclosing the “THE BUILDING CONSULTANT” Report with this letter.

As you will see, the August 2019 “THE BUILDING CONSULTANT” estimate is for $264,489 ACV ($376,482 RCV), which is higher than the April 2019 “THE BUILDING CONSULTANT” estimate for $112,838 ACV ($135,870 RCV). The August 2019 “THE BUILDING CONSULTANT” estimate, however, includes repairs of damage from multiple occurrences, including a wind event at the property that occurred after “THE BUILDING CONSULTANT”’ April 8, 2019 inspection. At a minimum, the “THE BUILDING CONSULTANT” estimate includes repairs of damage from (1) one or more storms before May 16, 2018, (2) a windstorm on or about March 12, 2019, and (3) the June 9, 2019 windstorm.

While “CARRIER” has paid all that is owed in response to Claim No. 13336 for March 2019 windstorm damage, engineer “The Second Engineer”’s report indicates that there was significant

Claim “Generic IA Claim Number”

Page 2

additional damage to the property from the June 9, 2019 wind event. That cost to repair this new damage is the difference between the two “THE BUILDING CONSULTANT” estimates—i.e., approximately

$152,000 on an ACV basis.

“The Insured” should note that the June 9, 2019 storm occurred during “Generic Policy Number” that began on April 1, 2019—the policy that follows Policy No. “GENERIC POLICY NUMBER” under which “The Insured” has made its other three claims. As we previously advised, if “The Insured” wishes to make a claim for such June 9, 2019 wind damage under Policy No. “GENERIC POLICY NUMBER”, “The Insured”’s agent should promptly report the claim to “Generic IA Firm Name” Claims. We will then be able to set up the claim for the June 9 storm damage, assign it a claim number, apply the policy’s $100,000 wind deductible, and issue the ACV payment in exchange for the signed proof of loss required by the policy. If you need a copy of “CARRIER” Policy No. “GENERIC POLICY NUMBER”, please advise and we can provide.

As for Claim No. 13336 for the March 2019 windstorm damage, after an extensive investigation by the Engle Martin adjuster, the “THE BUILDING CONSULTANT” building consultant and professional engineer “The Second Engineer”, “CARRIER” has paid all that is owed in response to the claim. “The Insured” has not offered any consulting reports or other information that contradicts our findings as to the cause, scope or timing of the damage, and still has not provided the historical roof information that we requested to assist our investigation. As a result, our previous claim decision is unchanged—the ACV amount of $62,838.62 is all that is owed under the “CARRIER” Policy No. “GENERIC POLICY NUMBER” for Claim No. 13336.

Often, when folks are trying to convince you of something that is provably false, they will ramble about the same thing, over and over, like “Senior Claims Manager” has done here.

The truth of the entire matter, categorized by Dates of Loss or …Deductibles. The below numbered items do not transfer to large print, but is inclusive of our response.

  1. You owed a full replacement for the hail claim that originated prior to our involvement. You were able to successfully avoid current litigation when the insured unknowingly filed the wind claim, allowing you to pay the minimal on the new, and defeat the lawsuit by doing so. Amazingly, a long list of the denials used there were used in this one, and the next… and you guessed it, the next.
  2. You factually owed a minimum of $199,000.00 on the fire loss, that began our journey together. After multiple, factual, documented attempts to pay the insured absolute least minimum possible, finally settling on a number just shy of $70,000.00, forcing them to seek our help. Luckily, they did, after all those same people you claim set the loss on the wind that occurred prior to our involvement set the fire loss.
  3. We proved them wrong on site, after a single visit and less than two weeks, including the three-day rescission period, for the entire process. How many had been there before us, and how long did they take? The answer is in the files. Minimum four different people attempted over a period of over 3 months, finally coming up with the disrespectfully low figure of less than 70,000.00, only to pay the majority of our valuation after proving all involved wrong on site. Payment defeats any argument that could even be attempted.
  4. For the record, at this point, it is four for Cal, zero for “Your Side”. (Actually, five including the proof of loss fiasco, but whose counting. Unfortunately, we are. You have left no choice.
  5. Back to the wind. After securing the payment on the fire, we were obviously retained on the wind claim, after all, it was the bad, incompetent actors. Our contract was signed on 05-03-19. We submitted our valuation for full roof replacement on 06-04-19, five days before the alleged second wind event. Take very careful notice of a few of the things I am fixing to tell you. a.) Our Notice Demanded that you send any and all pertinent information on this claim. We received response stating work product would not be forwarded, ergo, no other claim information could be used to deduct anything. This is the purpose of the demand. You cannot decline to send, then cite the absence… wait, it is what you are used to. Attempting to create an impossible path to indemnity. b.) My valuation is very specific and includes all the damages missed by all the same experts that missed the damages on the fire, by roughly 300%. Your claim that your folks provided a comprehensive loss assessment holds zero water. Here, or in a courtroom. We have proven beyond a shadow of a doubt, we are superior. Truth be told on the fire, and it will before I am done, you still owe the remainder of the insured’s demand plus the additional cost for hidden lightweight concrete on that was the subfloor. c.) My valuation includes and opening statement, and a closing statement, specifying that the carrier is to remove the deductions as they believe they apply to the policy. It is no less amazing than the rest that this is the only time they are attempting this. d.) It is fact, demand for full replacement of the roofs and all of the photographs I took in May depict the property in the same shape as it was when the next alleged wind event occurred. Time stamp and date do not lie.
  6. When trying to respond to her ramblings, it is akin to attempting to follow an Xactimate estimate that has 700-line items, and never hit the re-sequencing line items button. She jumps from event to event, and is so absolutely with rhyme, nor reason, that it is hard to follow exactly what she is saying. This is what happens when you must start covering up lies and misdeeds, it gets confusing, and simply takes someone to point out the fact that the person who authored has the appearance of credibility, due to the shear size of the ramblings. After a perfunctory review, it becomes apparent. They are nothing but ramblings from someone attempting to save what has been reasonably demanded and should have been paid for several times over the last several years, just like the engineer who received three roofs since 2014. A little north of 1.2 million dollars.
  7. One of the most amazing things of the whole process on “Generic IA Firm Name”’s part, after an admitted multiple catastrophic weather events, Wind we are hearing about now, hail events dating back to 2009… In all that time, and after all of those catastrophic events, that property never warranted a full roof replacement, or anything even close. That is truly amazing, especially after the second “engineer” claimed to live close by, and have had three brand new roofs since 2014, yet claimed this one was anything but. We will get to him later, now that we have a narrative not skewed by the dribble, we will move forward to specifics.

Claim Background

Claim No. 13336 was submitted under “CARRIER” Policy No. “GENERIC POLICY NUMBER”, effective April 1, 2018 to April 1, 2019. Following our investigation, including work by a field adjuster and building consultant, on May 3, 2019, we provided “The Insured” our claim decision along with the April 25, 2019 report and estimate from the building consultant, “THE BUILDING CONSULTANT”.

As you will recall, “THE BUILDING CONSULTANT” found wind damage to roofs, a chimney chase, an HVAC platform, HVAC railings, and some resulting interior water damage to 3 units. “THE BUILDING CONSULTANT” determined that the shingles on some slopes could be spot repaired, other slopes should be replaced in their entirety, the roofs were more than 15 years old, and that the wind damage and related interior damage could be repaired for $135,870.71 RCV. Please see the April 25 report for further details of “THE BUILDING CONSULTANT”’ findings. The ACV payment for

$62,838.62—issued on May 22, 2019—was calculated as follows:

$135,870.71

Undisputed RCV loss (based on “THE BUILDING CONSULTANT” report/estimate)

-$9,368.85

Less Non-Recoverable Depreciation

-$13,663.24

Less Recoverable Depreciation

$112,838.62

ACV Loss or Damage

-$50,000.00

Less deductible

$62,838.62

Net ACV Payment

Claim “Generic IA Claim Number”

Page 3

After payment was issued, in early June you submitted a repair estimate, but no materials that addressed “THE BUILDING CONSULTANT”’ findings as to the cause or scope of damage at the property. On June 26, 2019, I again wrote to you in response to the estimate you provided in early June. In that letter, as before, I explained that the damage and loss caused by the March 13, 2019 storm was determined to be $135,870.71, and that after applying the policy’s deductible and depreciation provisions, the amount owed is

$62,838.62, which “CARRIER” had previously paid to “The Insured”.

Your explanations have been proven to be invalid, from the notarized proof of loss, to the prompt payment statute, to the valuations of the fire. There is not a single time “Generic IA Firm Name” had won, been right, or done anything successfully, save denying the owed benefits the policy promised. There is a not a single time that your rambling below can be claimed valid.

My June 26, 2019 letter also explained that the InsuranceBusters.net estimate for $1,273,783 did not alter “CARRIER”’s position on the claim because the estimate does not respond to the “THE BUILDING CONSULTANT” findings or scope, but instead provides for repairs / renovations without regard to whether the items were damaged by the March 2019 storm.

As we have proven to date, our valuations are far superior to anything produced by “Generic IA Firm Name”, or any of the people they claim to be professionals. Factually, financially proven.

In an effort to reach an agreement on this claim, we retained a professional engineer, “The Second Engineer”., P.E., of “The Second Engineer”, LLC, to investigate the property and determine the extent of wind damage from the March 13, 2019 storm and provide repair recommendations. Following his inspections of the “The Insured” property in mid-June, Mr. “Second Engineer” issued his report on Wednesday, July 3, 2019. I provided you a copy on July 9 and explained those findings in detail, and their impact on this claim, in my July 23, 2019 letter.

The incompetence, whether it be financial greed or outright incompetence will be addressed before this is over. This specific character will get a chance to present his credentials, and those three claims he had on his house. The full files, so we may see what constituted damage on his own. Would be best for him to not run around telling the folks he is trying to harm that he received what he is denying them… three times.

As “The Insured” is well aware, there is no question that wind damaged some shingles on this property well before March 2019, but that such wind damage did not necessitate replacement of the roofs. Indeed, on April 25, 2018, “The Insured” made a claim for wind and hail damage under “CARRIER” Policy No. “GENERIC POLICY NUMBER”. Claim No. 12590 was assigned to that claim. The engineer retained for that claim, “Hail Engineer”, found no hail damage to the roofs, but did find some wind damage. As “The Insured” knows, “Hail Engineer”’ May 28, 2018 report detailed his wind damage findings—328 wind-damaged field shingles and 15 wind-damaged ridge cap shingles, all of which could be spot-repaired. We provided “The Insured” our claim decision on June 13, 2018. We explained that the isolated wind damage could be repaired for approximately $12,000, far less than the policy’s $50,000 wind deductible.

“Generic IA Firm Name” was able to successfully deny legitimate damage while continuing to take premiums.

It is also clear that the June 9, 2019 storm did additional damage to the property after the March 2019 storm. Nevertheless, neither your $1.2 million estimate nor any other communication from you or “The Insured” has ever made any distinction between wind damage from the March 2019 storm versus other wind events. The dates of loss are important in light of the fact that the wind events occurred in multiple policy periods and each requires the application of a separate wind deductible

July 2019 Findings of Engineer “The Second Engineer”

As explained in the “Second Engineer” engineering report, Mr. “Second Engineer” determined that the property was damaged by wind, including wind on the March 13, 2019 date of loss, as well as

Claim “Generic IA Claim Number”

Page 4

wind on June 9, 2019 (after the date of loss) and wind events dating back several years before the March 13, 2019 date of loss.

Mr. “Second Engineer” found that the south and west slopes of the apartment buildings generally had the most wind damage and require replacement, the north and east slopes generally had less wind damage and can be spot repaired (with the exception of the east slope on building 9 that requires replacement), and the carport roofs with heavier (i.e., laminated) shingles had no wind damage. He also found conditions unrelated to wind, such as deteriorated shingles, mechanical damage, raised nails, installation defects, improper sealing, and unadhered corners of shingle tabs.

It is fact, demand for full replacement of the roofs and all of the photographs I took in May depict the property in the same shape as it was when the next alleged wind event occurred. Time stamp and date do not lie.

While I encourage you and “The Insured” to read the entire report, the engineer’s specific observations, findings and recommendations included the following, among others:

· the property has been damaged by wind, but historical aerial and street view imagery indicates that damage to the roofs was present prior to the March 13, 2019 date of loss consistent with the previous windstorm events as far back as 2009

· the most significant wind event estimated to have occurred at the site according to CoreLogic was on June 9, 2019

· multiple wind events dating back to 2009 have, in combination with the deteriorated conditions at the shingles, caused distress to shingle tabs at Buildings 1 through 13, including a contribution from the storms on March 13, 2019 and June 9, 2019

Composition Shingle Roofs on Apartment Buildings

· shingles on south and west roof slopes exhibited more deteriorated conditions

· south and west roof slopes typically exhibited varying degrees of wind damage in the form of creased and torn shingle tabs (0-25 creased/torn/missing shingles per test square; 5-33 unadhered shingle tabs per test square)

· similar distress at the east and north slopes was more isolated (0-4 creased/torn/missing shingles per test square; 4-23 unadhered shingle tabs per test square)

· replacement of all roof shingles at Buildings 1 through 13 with a south or west exposure is required

· for shingles with an east exposure, “The Insured” should spot replace torn and creased shingles (approximately 2.5% of the shingles on each slope) and 100% of the shingles with an east exposure at Building 9

Claim “Generic IA Claim Number”

Page 5

· for shingles with a north exposure, “The Insured” should spot replace isolated torn and creased shingles (approximately 1% of the shingles on each slope)

· “The Insured” should hand seal unadhered shingle tabs as follows:

o east slopes of roofs – up to 5% of the shingle tabs, except at Building 9

o north slopes of roofs – up to 10% of the shingle tabs

· “Second Engineer” disagrees that all shingles require replacement due to wind

· “Second Engineer” sees no basis for replacing all wood decking on roofs

· only isolated repairs to water damaged decking will be required, such as the damage observed in the attic of unit 503

· the unadhered and creased shingles typically exhibited varying degrees of adhesive transfer at all exposures and the failed adhesive typically displayed a lustrous appearance consistent with recent separation

· high concentration of granule loss and gouges in shingles surrounding HVAC platforms

· isolated displacement / distress to roof appurtenances (e.g., loose chimney cover and flue caps, uplifted base and stucco-to-roof flashing, detached chimney at building 6, displaced HVAC platform at building 2)

· evidence of previous shingle repairs (spot repairs) and tarping (face nails)

· multiple failed shingles due to installation defects throughout the roofing systems including, but not limited to, raised nails causing perforations in the shingles above, and unadhered shingle tabs due to improper sealing of the tabs after original installation

· the three-tab shingles are at least 15-20 years old, nearing the end of their useful life and in need of replacement due to normal aging and degradation unrelated to any storm event

Architectural Shingles on Carport Roofs

· aged and deteriorated shingles with delamination of architectural shingle overlays, granule loss and embrittlement

· no missing, torn, or creased shingles

Claim “Generic IA Claim Number”

Page 6

· the architectural shingles at the carports are in excess of 20 years old, nearing the end of their useful life and in need of replacement due to normal aging and degradation unrelated to any storm event

Apartment Building Exteriors

· exterior brick veneer, stucco, siding, and fascia were typically weathered but in generally good condition

· isolated displacement of exterior finish materials and roof guttering and downspouts (e.g., missing and displaced downspouts and gutters, uplifted flashing, separated soffit panels, displaced fascia)

· displaced metal chimney covers and flue caps at multiple locations, the displaced chimney enclosure and flue piping at Building 6, the leaning chimney at Building 8, and the displaced deteriorated wood HVAC platform at Building 3 are related to wind from the March 13, 2019 storm

· observed isolated displaced flashing and roof vent penetrations are attributable to wind from multiple windstorm events dating back to 2009, including a contribution from March 13, 2019 and June 9, 2019 storm events

· observed isolated damage to exterior siding and fascia boards is attributable to wind from multiple windstorm events dating back to 2009, including a contribution from March 13, 2019 and June 9, 2019 storm events

Interior Damage Issues

· Unit 503: No apparent wind-related distress to the shingles at the roof above the water damage in the attic and at the ceiling, but cannot rule out wind- driven rain at unadhered shingle tabs

· Unit 902: Water damage to kitchen area originated from roof area, but wind damage at roof appears to pre-date March 2019 date of loss and is long-term based on aerial imagery and street view imagery

· Unit 901: Water damage to ceiling appears to have migrated from unit 902 above

· Unit 1204: Previous shingle repairs surrounding the HVAC platform and chimney above unit 1204

· Unit 1301: Multiple generations of previous repairs at the stucco rise wall to roof interface

Claim “Generic IA Claim Number”

Page 7

· Unit 1304: Water damage to previously repaired ceiling not related to wind damage at the roof or exterior. Damage at interior was long-term and related to water intrusion through flashing deficiencies at the rise wall to roof interface above. Multiple generations of sealant repairs were observed at the rise wall to roof interface

· Units 905, 1201: not wind related

· Units 908, 1301: not assessible

Dates of Loss Issues

· CoreLogic reported 61 mph wind around the March 13, 2019 date of loss

· the highest windspeed at the property indicated by CoreLogic was 73 mph on June 9, 2019

· CoreLogic indicated multiple reports of windspeeds of 58 mph or greater prior to March 13, 2019 and since January 1, 2009

· before March 2019, the highest windspeeds at the property indicated by CoreLogic were 62 mph on May 2, 2009 and June 10, 2009

· Google Earth street view images from June 2018 reveal blue and white tarps at Buildings 8 (south slope) and Building 9 (west slope) long before the March 13, 2019 date of loss:

Claim “Generic IA Claim Number”

Page 8

Repair Recommendations / Opinions (Non-Shingle Exterior Items)

· “Second Engineer” generally disagrees with the scope of repair included in InsuranceBusters.Net’s estimate related to items not required as part of the “Second Engineer” scope of repair in its report

· the scope included in InsuranceBusters.Net’s estimate for interior repairs appears excessive relative to on-site conditions observed

I find this comment, from any person on your side, to be of particular humor. Especially when one factors that I have already proven your entire group wrong. One by one, time after time.

· repair all wind damaged items at the roofs of Buildings 1 through 13 presented in Table 2 of its report

· repair all wind damaged items at the exteriors of Buildings 1 through 13 presented in Table 3 of its report

August 2019 “THE BUILDING CONSULTANT” Estimate Based Upon “The Second Engineer” Findings

In our July 23, 2019 letter we advised that “THE BUILDING CONSULTANT” was preparing an estimate based upon “The Second Engineer”’s engineering report following his June 10-11, 2019 inspection. The amount of the attached “THE BUILDING CONSULTANT” estimate is $376,481.98 RCV and $264,489.34 ACV, which includes $194,782.21 for replacement of all roof slopes on Buildings 1-13.

You will note that, although Mr. “Second Engineer” provided for spot repair of the minor wind damage to many east slopes and all north slopes, as well as some hand sealing of unadhered tabs on east and north slopes, “THE BUILDING CONSULTANT” has nevertheless estimated the full replacement of all roof slopes. In measuring the loss at the property from the multiple wind events, we are agreeable to allowing for the cost of the full replacement of all the roof slopes. We are agreeable to full replacement even though full replacement is not required to restore the property and even though the policy does not require payment of full replacement when spot repair will correct the wind damage. This is a benefit of approximately

$10,000 to “The Insured”, which we are agreeable to in the spirit of cooperation and an effort to resolve the disputed March 2019 wind claim, as well as the June 2019 wind claim we anticipate that “The Insured” will soon submit.

Historical Storm Events and Claims at Property

In light of the “Second Engineer” findings about wind-damage at the property pre-existing the March 13, 2019 date of loss (e.g., see the June 2018 photograph above), wind damage as the result of the June 9, 2019 storm, as well as indications in the underwriting file that “The Insured” View made claims for May 10, 2011 hail damage to the roofs and April 3, 2012 wind and hail damage to the roofs, we previously requested but have never received the following items to assist our investigation of the scope of damage from the March 2019 storm, the age of the roofs, and the timing of various storm damage to the property:

Claim “Generic IA Claim Number”

Page 9

· “The Insured”’s May 2011 Hail Claim: What buildings and items were included in the claim? Who determined that the property was damaged by May 10, 2011 hail? Loss runs indicate more than $66,000 was paid to “The Insured” in response to the hail claim. What repairs were made as a result of the storm damage? Who made the repairs? Please provide documentation of the claim and any repairs.

· “The Insured”’s April 2012 Wind/Hail Claim: What buildings and items were included in the claim? Who determined that the property was damaged by an April 3, 2012 storm? Was any amount paid to “The Insured” in response to the claim? What repairs were made as a result of the storm damage? Who made the repairs? Please provide documentation of the claim and any repairs.

· Roof Records: Please provide all records of roof damage, inspections, maintenance and repairs concerning the roofs since 2009. This requests includes photographs, incident reports, resident complaints, estimates, invoices, checks, and leak logs or other records concerning the roofs, whether the records are maintained by residents, the HOA, the management company or their representatives. Your response should include documentation of the installation of the tarps on Buildings 8 and 9 that are shown in the June 2018 photograph above. Your response should also include documentation of any repairs to wind damage to shingles that was observed at the property in April/May 2018.

“CARRIER” Policy NO. “GENERIC POLICY NUMBER”

In light of observed deterioration of property components, installation defects, and normal wear and tear at the property, “The Insured” should be aware of the provisions below setting forth what causes of loss are covered, limited and excluded under the “CARRIER” policy. The policy excludes coverage for wear and tear, deterioration, and defective construction, repairs and maintenance. The cost to repair damage caused by leaks in the building interiors is not covered unless the building or structure first sustains damage by a Covered Cause of Loss, such as wind or hail, to its roof or walls through which the rain enters.

The policy’s Property Coverage Form (NC R1 00 03 17), among other things, provides the following insuring language, exclusions and limitations to coverage:

A. INSURING AGREEMENT: The Company will pay for direct physical loss or damage to Covered Property at an Insured Location as described in the most recent Statement of Values caused by or resulting from a Covered Cause of Loss. Notwithstanding any other provision in this Policy, the Company will not pay for loss to Covered Property due to any “Diminution in Value”, whether the Covered Property is repaired, partially repaired or not repaired.

….

Claim “Generic IA Claim Number”

Page 10

D. EXCLUSIONS

2. The Company will not pay for loss or damage caused by or resulting from any of the following:

a. Artificially generated electric current, including electric arcing, that disturbs electrical devices, equipment, appliances or wires. However, in the event artificially generated electric current results in fire or explosion, the Company will be liable only for such resulting loss or damage.

b. Indirect or remote loss or damage; delay, loss of use or loss of market; or interruption of business.

c. (1) Wear and tear or depletion;

(2) Rust, corrosion, erosion, decay, deterioration, hidden or latent defect or any quality in the property that causes it to damage or destroy itself;

(3) Settling, cracking, shrinking, bulging or expansion;

….

3. The Company will not pay for loss or damage caused by or resulting from any of the following:

….

c. Faulty, inadequate or defective:

(1) Planning, zoning, development, surveying, siting;

(2) Design, specifications, workmanship, repair, construction, renovation, remodeling, grading, compaction;

(3) Materials used in repair, construction, renovation…; or

(4) Maintenance;

of part or all of any property on or off an Insured Location.

….

E. LIMITATIONS

1. The Company will not pay for loss of or damage to property, as described and limited in this section. In addition, the Company will not pay for any loss that is a consequence of loss or damage as described and limited in this section.

….

c. The interior of any building or structure, or to personal property in the building or structure, caused by or resulting from rain, snow, s”Second Engineer”t, ice, sand or dust, whether driven by wind or not, unless:

Claim “Generic IA Claim Number”

Page 11

(1) The building or structure first sustains damage by a Covered Cause of Loss to its roof or walls through which the rain, snow, s”Second Engineer”t, ice, sand or dust enters; or

(2) The loss or damage is caused by or results from thawing of snow, s”Second Engineer”t or ice on the building or structure.

….

G. DEFINITIONS

The following definitions apply to the defined terms wherever they appear in any form included in the Policy, unless the term is otherwise specifically defined in an endorsement to the Policy.

1. “Actual Cash Value” means the cost to repair, rebuild or replace the lost or damaged property, at the time and place of the loss, with other property of comparable size, material and quality, less allowance for physical deterioration, depreciation, obsolescence and depletion….

“The Insured” should note the following policy provisions in the General Conditions form (NC R5 02 03 17) of the “CARRIER” policy, including duties imposed on “The Insured” in the event of a loss. Such duties include the duty to report the claim promptly and provide a description of the loss, protect the property from further damage, provide written records, make the property available for inspection, provide a proof of loss when requested, and cooperate with its insurer, as follows:

S. NOTICE OF LOSS AND DUTIES IN THE EVENT OF LOSS OR DAMAGE

1. The Named Insured must see that the following are done in the event of loss or damage:

a. Notify the police if a law may have been broken.

b. Give the Company prompt written notice of the loss or damage. For losses caused by fire, Windstorm (including hail), notice must be given no later than 365 days after this Policy expires, terminates, or is cancelled. Notice should include a description of the property involved, and a description of how, when, and where the loss or damage occurred.

c. Promptly make claim in writing against any other party that had custody of the Covered Property at the time of loss.

d. Take all reasonable steps to protect the Covered Property from further damage, and keep a record of expenses necessary to protect the Covered Property, for consideration in the settlement of the claim.

This will not increase the Limit of Insurance. However, the Company will not pay for any s”The Building Consultant”equent loss or damage resulting from a cause

Claim “Generic IA Claim Number”

Page 12

of loss that is not a Covered Cause of Loss. Also, if feasible, set the damaged property aside and in the best possible order for examination.

e. At the request of the Company, give the Company complete inventories of the damaged and undamaged property, including quantities, costs, values and amount of loss claimed.

f. As often as may be reasonably required, permit the Company to inspect the property and records proving the loss or damage and examine the Named lnsured’s books and records.

g. Permit the Company to take samples of damaged and undamaged property for inspection, testing and analysis and permit the Company to make copies from the Named lnsured’s books and records.

h. Send the Company a signed, sworn proof of loss containing the information that the Company requests to investigate the claim. The Named Insured must do this within sixty (60) days after the Company’s request. The Company will supply the Named Insured with the necessary forms.

I. Cooperate with the Company in the investigation or settlement of the claim.

2. The Company may examine any Named Insured under oath, while not in the presence of any other Named Insured and at such times as may be reasonably required, about any matter relating to this insurance or the claim, including a Named lnsured’s books and records. In the event of an examination, a Named lnsured’s answers must be signed….

In light of “Second Engineer”’s findings as to the dates of the wind events that damaged the property, “The Insured” should also be aware that the “CARRIER” policy, as set forth below, only covers loss or damage that commences during the policy period—April 1, 2018 to April 1, 2019:

U. POLICY PERIOD AND TERRITORY: Under this Policy, the Company will cover loss or damage that commences during the Policy period as specified in the Declarations [4/1/18 – 4/1/19] and, except as otherwise specifically provided, within the Policy Territory. The Policy Territory is the United States of America (including its territories and possessions)….

Further, in light of the state of repairs at the property and the age of the roofs, “The Insured” should be aware that the “CARRIER” policy provides that any recovery thereunder is limited to Actual Cash Value, instead of Replacement Cost Value, where repairs are not made within 365 days after the loss or damage occurs. In addition, composition roof coverings that are more than 15 years and 1 day old are valued at Actual Cash Value for wind damage. The policy’s Replacement Cost Form provides in part as follows:

This modifies the Property Coverage Form.

Claim “Generic IA Claim Number”

Page 13

The following Valuation Provisions are added:

A. REPLACEMENT COST: In the event of a covered loss or damage, the Company will determine the value of Covered Property at replacement cost as of the time and place of loss, without deduction for physical deterioration, depreciation, obsolescence and depletion, except as otherwise provided in this form or as stipulated by any other endorsement(s) to this Policy. This replacement cost valuation is subject to the following conditions:

1. The Company will not pay more on a replacement cost basis than the least of:

a. The cost to repair, rebuild or replace, at the same site, the lost, damaged or destroyed property, with other property of comparable size, material and quality; or

b. The actual amount spent by the Named Insured that is necessary for it to repair, rebuild or replace the lost, damaged or destroyed property; or

c. Any Limit of Insurance or Sublimit of Insurance applicable to the lost, damaged or destroyed property.

2. The Company will not pay for any loss or damage on a replacement cost basis until the property is repaired, rebuilt or replaced by the Named Insured, and then only if such repair, rebuilding or replacement is made within 365 days after the loss or damage occurs. If the property is not repaired, rebuilt or replaced by the Named Insured within 365 days after the loss or damage occurs, the value of the property will be determined at Actual Cash Value.

3. For property to which this replacement cost valuation applies, the Named Insured may make a claim for loss or damage on an Actual Cash Value basis instead of on a replacement cost basis. In the event the Named Insured elects to have loss or damage settled on an Actual Cash Value basis, the Named Insured may still make a claim on a replacement cost basis if the Named Insured notifies the Company within 180 days after the loss or damage occurs and requests additional time in writing to complete the required repairs, but such repairs by the Named Insured must be completed no more than 365 days after the loss or damage occurs.

….

B. REPLACEMENT COST EXCEPTIONS

….

13. Any damage to existing composition roof coverings that have been in place on a building or structure of an Insured Location for more than

Claim “Generic IA Claim Number”

Page 14

fifteen (15) years and one (1) day will be valued at “Actual Cash Value” for the perils of Windstorm (including hail) and Named Storms….

Conclusion

As explained above, our investigation has determined that the ACV amount of

$62,838.62 is all that is owed under the “CARRIER” Policy No. “GENERIC POLICY NUMBER” for Claim No. 13336. “CARRIER” has already paid that amount. Our investigation has also determined that the June 9, 2019 wind event caused significant wind damage to the property. We have determined that all the wind damage from the various wind events can be repaired for

$376,482 RCV. The ACV for such repairs is $264,489.

If any repairs of non-roof items damaged by wind have been made, please provide documentation required to support a claim for the depreciation holdback, so that we can consider same. Also, if “The Insured” has any information that bears on the scope or timing of the wind damage at the property, please provide that information to “Generic IA Firm Name” Claims in addition those items previously requested.

Because “CARRIER” Policy No. “GENERIC POLICY NUMBER” ended on April 1, 2019, the wind damage from the June 9, 2019 storm is a separate occurrence under a different “CARRIER” Policy that began on April 1, 2019. If “The Insured” intends to make a claim for June 9, 2019 wind damage, please have “The Insured”’s agent submit the claim to “Generic IA Firm Name” Claims.

“The Insured” should be aware that the mere fact that “CARRIER” has investigated and obtained information about the claim does not mean that “The Insured”’s entire claim or any particular portion thereof is covered by the “CARRIER” policy. Please be advised that “CARRIER”’ efforts to consider, investigate and determine “The Insured”’s claimed damage or loss has been performed under a complete reservation of rights. In the investigation and assessment of the claim, “CARRIER” has not assumed or undertaken any liability under the “CARRIER” policy beyond the Policy’s specific terms. All rights under the policy and Texas law are reserved.

Should you have questions or concerns regarding the content of this letter, feel free to contact me at 469-283-1707.

Sincerely,

“Senior Claims Manager”

Senior Claims Manager “Generic IA Firm Name” Claims Management

Enclosure:

1) August 2019 “THE BUILDING CONSULTANT” Estimate

Claim “Generic IA Claim Number”

Page 15

cc:

My closing statement, and final demand on the policy will address the ramblings of the policy language, or what “Senior Claims Manager”’s erroneous interpretation of anything may be. As to any records that may be present for the early years… You are aware that 5 years is the standard for records. The fact that you allude to all the items, then talk succinctly about the underwriting files, tells me that you already have these files and are attempting to yet again install additional hurdles for the insured… that are anything but reasonable.

So that we are all clear. “Generic IA Firm Name” has managed to successfully deny valid, legitimate claims, on multiple occasions, charging multiple deductibles for the same damage that should have been covered under the original claim, long before we were retained. They got very lucky. This same group of folks have been involved, writing bogus, even nefarious reports to appease a Senior Claims Manager named “Senior Claims Manager”. All the while, the insured’s complying with ridiculous demands, outrageous premiums, and incompetence at the highest level. This is what a true travesty looks like. To me, it is what I see every day. To the individual insured… this is a deathblow, over and over. They have fought with the city, with adjuster after adjuster, engineer after engineer, consultants, even filed a lawsuit with a previous attorney and PIA. Never to receive indemnification, or anything close, until we entered the picture on the fire. Everything changed then. You can ask the insured after this is all over with, what it actually felt like to have someone fulfill their contractual promise.

Best part, we don’t get paid until and unless, we perform. What a novel idea.

As for claiming any exclusions due to the age or condition of the roof, I will advise you of this. That is an invalid denial/argument on it’s face, same as the notary issue.

Wear and tear is actually called…ACV. Read that again. Then take a long hard thought on this process, then read it again. Wear and tear is absolutely built into the policy via ACV and depreciated to that value unless the insured paid an additional premium called RCV…

In my entire career as a Licensed Public Insurance Adjuster, I have never witnessed an insured who filed an insurance claim based off the covered cause of loss being “wear and tear”. There is a covered Peril such as wind or hail, and the claim is filed. The carrier then inspects with THEIR ADJUSTER, who then denies based upon the wear and tear exclusion we spoke of above. The same one they already charged the depreciation on. The same one that is a natural occurrence and factored into the entire process, then removed it as a matter of course. That is right. All these years, all these claims. Denying them based on the known factor of depreciation, after deducting that same known depreciation from the RCV.

Simple items that were demanded, such as OSHA regulatory compliance for working over 6’ off of the ground, which, like the permit, are not suggestive. They are the law. They were demanded, yet still, even after all this, not paid.

Then you have the nerve to attempt and state, emphatically, erratically… that you are correct on every single thing I have factual proven you wrong on, up to, but certainly not limited to, a scope you claim adequate… that the above items were not paid on, you know, those items that are not suggestive, and are not tied to your whim. Like the Sworn Statement of Loss thingy…

Shame. Shame on you, and shame on every single one of you who do this, in this, or any other manner, against insured’s just like yourself. That is right, you too, are an insured. Shame.

You have 72 hours to pay the valid, legitimate “Reasonable Demand” that was sent to your office, minus any legitimate deductions for prior payments, and of course, depreciation. Not fifteen years’ worth either, much closer to anything under 15 years, since we know the occurrence happened less than 90 days into the new year.

The insured has had enough, and despite your ramblings claiming the contrary, we have, again, handed you the most thorough valuation you, or any of the underlings you hired have ever seen.

At this point, I am done. There is nothing else I can do as a Public Insurance Adjuster, hence the 72 hours. If no response, or anymore ramblings, I will arrange the meeting for the folks that can prove up all these instances of bad faith that have been specifically laid out. I do not see how anyone could see it as any different than what it has been for the entire association, a nightmare.

Sincerely,

Cal Spoon

InsuranceBusters

[suffusion-the-author]

[suffusion-the-author display='description']

Sorry, the comment form is closed at this time.

%d bloggers like this: