No Defense Because of Six Month Delay

Immediate Notice Requirement Defeats Claim

See the full video at https://rumble.com/v34covs-no-defense-because-of-six-month-delay.html and at https://youtu.be/1SfYXPmDF2c

IHC Construction Companies, LLC (“IHC”) and MA Rebar Services, Inc. (“MA Rebar”), appealed a final summary judgment entered in favor of Westfield Insurance Company (“Westfield”) in Westfield’s declaratory judgment action against IHC, MA Rebar, and Wayne McClure.   In  Westfield Insurance Company v. MA Rebar Services, Inc., IHC Construction Companies, LLC, and Wayne Kelly McClure, No. 1-23-0161, 2023 IL App (1st) 230161-U, Court of Appeals of Illinois, First District, Fourth Division (July 27, 2023) the Court of Appeals resolved the dispute.

FACTS

In 2016 IHC was the general contractor for a municipal construction project (“the Project”) and that IHC had hired MA Rebar as a subcontractor on the Project. As a condition of its subcontract, MA Rebar was required to obtain liability insurance. In accordance with the subcontract, MA Rebar obtained the required insurance from Westfield and provided IHC with a certificate of insurance confirming such compliance.

Wayne McClure filed a complaint against IHC alleging that he was injured as a result of IHC’s negligence while working on the Project as an employee of MA Rebar. IHC promptly notified its insurance carrier, Hartford Insurance Company, of the suit, but it did not provide any notice to Westfield at that time. In July 2018, IHC filed a motion to dismiss McClure’s complaint. After the circuit court denied the motion in October 2018, IHC filed a third-party complaint against MA Rebar seeking indemnification and contribution.

Approximately three months later MA Rebar notified Westfield of IHC’s third-party complaint against it. Westfield then sued for declaratory judgment  seeking declarations (1) that it has no duty to defend and indemnify MA Rebar and (2) that it owed no coverage obligation to IHC due to the six-month delay between the time that IHC learned of the McClure lawsuit and the time that Westfield received notice of the suit.

The circuit court issued a final order granting Westfield’s motion for summary judgment and denying IHC and MA Rebar’s cross-motion.

The focus of the present dispute is IHC’s compliance with a notice requirement in MA Rebar’s insurance policy with Westfield, for which IHC was listed an additional insured. The relevant policy language in this case provides that an insured is required to “[immediately send [Westfield] copies of any demands, notices, summonses or legal papers received in connection with [a] claim or ‘suit.'” ” ‘Immediate’ in this context ‘has been uniformly interpreted to mean within a reasonable time, taking into consideration all the facts and circumstances.'” Zurich Insurance Co. v. Walsh Construction Co. of Illinois, Inc., 352 Ill.App.3d 504, 512 (2004)

The circuit court below determined that IHC’s notice to Westfield was untimely because IHC had not provided a justifiable excuse for its three- to six-month delay in notifying Westfield of McClure’s claim.

IHC failed to provide Westfield with notice of the suit for six months after it received service of the complaint. IHC’s only justification for the delay in providing notice is that it was attempting to negate the need for insurance coverage by seeking dismissal of the case, but that does not justify the delay.

Westfield was entitled to be informed of the suit “immediately,” precisely to allow it to participate in defense actions like motions to dismiss.  IHC denied Westfield that contractual right by withholding notice while pursuing the motion to dismiss.

The court concluded that the Insured failed to comply with the terms of an insurance policy notice provision requiring “immediate” notice of any claims when the insurer did not receive notice of a lawsuit against the insured until six months after service of the complaint on the insured.

ZALMA OPINION

The insured tried to reduce its premium, by moving to dismiss without reporting a claim, found itself to be its own worst enemy. Its scheme to save future premium increases resulted only to eliminate its insurance for McClure’s claimed injury and lost over $10 million in available coverage and the unlimited defense costs. Ignorance can be cured but stupid attempts to save insurance premiums is not curable.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Lawyer Paying For Clients Guilty

Experienced Lawyer Claiming Ignorance of Law Is No Defense

PHOTOCOPY COMPANY ACTED AS A PASS THROUGH TO PAY THE CAPPER

See the full video at https://rumble.com/v343yd7-lawyer-paying-for-clients-guilty.html?mref=22lbp&mrefc=2 and at https://youtu.be/-WZtSI7oBuc

Robert Irving Slater was a practicing worker’s compensation attorney when he entered into an agreement with the owner of USA Photocopy who paid a third party to perform intake interviews with clients of defendant’s practice, saving a significant amount of his the lawyer’s own employees time and money. In exchange, defendant used USA Photocopy’s services during all workers’ compensation proceedings on those cases.

The law prohibits referring workers’ compensation clients for remuneration. Defendant was ultimately convicted of conspiracy, submitting false and fraudulent claims against insurers, and 21 counts of insurance fraud. He was sentenced to probation for two years in The People v. Robert Irving Slater, G061331, California Court of Appeals, Fourth District, Third Division (July 17, 2023) and appealed his conviction.

FACTS

USA Photocopy provided attorney services, including photocopying and sending subpoenas for records for workers’ compensation cases. The company would then bill insurance carriers for its services

Peter Ayala worked as a “legal investigator performing intake services.” Ayala’s role was to meet with the potential “workers’ compensation client to fill out the intake retainer . . . and also get the retainer signed for the claim.”

Ayala was told by the lawyer to send an invoice for his services every two weeks to USA Photocopy, which paid him for his services. Ayala had done similar work in the past for approximately 13 attorneys, and this was the first time he would be paid by a party other than an attorney. Over the six years his relationship with USA Photocopy and defendant lasted, Ayala estimated he performed intake services for about 2,000 clients for defendant, and USA Photocopy was the only copy service used for those clients. Ayala did not perform any service for USA Photocopy other than the services he performed for the lawyer defendant.

Employees from USA Photocopy went to defendant’s offices once or twice a month to obtain records. As the injured worker’s attorney, defendant would authorize all subpoenas that were issued. Each entity would respond to the subpoena with records or by stating they had no responsive records. USA Photocopy would separately bill the cost for each subpoena to the workers’ compensation insurance carrier, regardless of whether the subpoena resulted in the production of documents.

Defendant was convicted of conspiracy submitting a false and fraudulent claim; and 21 counts of insurance fraud based on concealing or failing to disclose information that affects a person’s right to an insurance benefit.

Verdict and Sentencing

The jury convicted defendant on all 23 counts. The jury also found the enhancement regarding the pattern of fraudulent conduct true. The court sentenced defendant to serve a total of 183 days, with 182 of those days suspended on the successful completion of two years of supervised probation. Six months of the probation term was to be served with an ankle bracelet. The court also ordered defendant to pay $356,175.24 in victim restitution in addition to statutory fines and fees.

DISCUSSION

In reviewing the sufficiency of the evidence to support a conviction, the Court of Appeal applied the test whether substantial evidence, of credible and solid value, supported the jury’s conclusions. Appellate courts simply consider whether any rational trier of fact could have found the essential elements of the charged offenses beyond a reasonable doubt.  The standard of review is the same even when the case relies on circumstantial evidence and the appellate court must accept logical inferences that the jury might have drawn from that evidence.

To prove defendant guilty of conspiracy and insurance fraud, the prosecution was required to prove defendant conspired to refer clients for compensation in violation of section 3215. Defendant’s only argument is that the evidence did not support that he knew the referral scheme at issue in this case was a crime.

Based on defendant’s level of knowledge and experience, the jury could infer that defendant knew the laws involving what kinds of referrals were lawful and which ones were not in the context of workers’ compensation law. A defendant cannot remain willfully ignorant and then claim a lack of knowledge about the specific law he was violating as a defense to a specific intent requirement.

Further, the very oddness of the scheme involved here – where Ayala was paid by USA Photocopy, rather than by defendant himself – a type of scheme the experienced workers’ compensation attorney and retired Judge Hernandez had never heard of – suggested that something was not aboveboard. The jury was entitled to infer from the oddity of the scheme that defendant, as an experienced attorney, was aware it was illegal.

The lack of a written agreement – something a reasonable jury might consider routine for a lawyer – also suggests knowledge of illegality.

Taken together, and given the substantial evidence standard, the evidence was sufficient for a reasonable jury to infer that defendant was aware that the referral scheme violated the law.

ZALMA OPINION

Slater, an experienced lawyer, should have known – and the jury found he did – that the scheme with the photocopy service and Mr. Ayala, was an attempt to hide capping – causing insurers to pay for the illegal referrals to a lawyer of clients – a crime  in California and most states. He received a kind sentence with no jail time and payment of restitution and yet, he appealed. If he doesn’t pay it he will go to jail. Creativity in hiding the scheme did not work and his conviction properly stands.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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NY Applies Policy as Written

Construction and Development Activities Exclusion Unambiguous

See the full video at https://rumble.com/v33ummx-ny-applies-policy-as-written.html and at https://youtu.be/Uc-SoKFEgBM

In Grenadier Realty Corp., et al. v. RLI Insurance Company, appellant, et al., No. 2020-06795, Index No. 502159/18, 2023 NY Slip Op 03910, Supreme Court of New York, Second Department (July 26, 2023) a New York Supreme Court (trial court) order requiring RLI Insurance Company to defend its insured was appealed by RLI.

The trial court order granted the plaintiffs’ motion for summary judgment declaring that certain losses were covered under a general liability insurance policy issued by RLI Insurance Company and that RLI Insurance Company was obligated to indemnify the plaintiffs in connection with the underlying action entitled Gargiso v Howland Hook Housing Co., Inc.

UNDERLYING ACTION AND INSURANCE CLAIM

In July 2012, Michael Gargiso allegedly was injured when he stepped in a trench which was dug as part of a construction project that had been left unfinished. Gargiso sued the  property owner, Howland Hook Housing Co., and the property manager, Grenadier Realty Corp.

Grenadier, which had purchased a general liability insurance policy from the defendant RLI effective March 1, 2012 (the subject policy), sought to obtain coverage from RLI. RLI denied coverage based upon an exclusion in an endorsement to the subject policy for “bodily injury” arising out of “Construction and Development Activities.”

Thereafter, the plaintiffs sued RLI to recover damages for breach of the subject policy and for a judgment declaring that RLI is obligated to provide coverage under the policy and to indemnify the plaintiffs in connection with the underlying action.

The plaintiffs moved for summary judgment on their causes of action against RLI alleging breach of contract and for a judgment declaring that RLI was obligated to provide insurance coverage to them under the policy and to indemnify them. RLI cross-moved for summary judgment dismissing the complaint insofar as asserted against it and for a judgment declaring that it has no duty to indemnify the plaintiffs.

ANALYSIS

In determining a dispute over insurance coverage, the appellate court first looks to the language of the policy. As with any contract, unambiguous provisions of an insurance contract must be given their plain and ordinary meaning. The insurer has the burden of proving the applicability of an exclusion. If the language is doubtful or uncertain in its meaning, any ambiguity will be construed in favor of the insured and against the insurer. However, the plain meaning of a policy’s language may not be disregarded to find an ambiguity where none exists.

The RLI policy provided coverage for, among other things, damages because of “bodily injury.” The policy, however, includes a construction and development exclusion, which, as is relevant, excludes from coverage “bodily injury” resulting from “Construction and Development Activities.” Gargiso was injured when he stepped into a trench which had been dug as part of the construction activities in a parking lot on the property. RLI demonstrated that the construction and development exclusion unambiguously excluded from coverage bodily injury arising out of such construction and development activities. Therefore, RLI established that it did not have a duty to indemnify the plaintiffs in connection with the underlying action.

CONCLUSION

The Supreme Court should have denied plaintiffs’ motion for summary judgment and should have granted RLI’s cross-motion for summary judgment dismissing the complaint insofar as asserted against it and for a judgment declaring that RLI is not obligated to indemnify the plaintiffs in connection with the subject underlying action

The appellate court reversed, with costs. RLI Insurance Company’s cross-motion for summary judgment dismissing the complaint insofar as asserted against it and for a judgment declaring that it has no duty to indemnify the plaintiffs was granted.

The appellate court then remitted the matter to the Supreme Court, Kings County, for the entry of a judgment, inter alia, declaring that RLI is not obligated to indemnify the plaintiffs in the underlying action entitled Gargiso v Howland Hook Housing Co., Inc.

ZALMA OPINION

Clear and unambiguous exclusions must, as did the appellate court, be affirmed and enforced.  When you fall into a construction trench, as did Mr. Gargiso, you are the victim of construction activities that were clearly and unambiguously excluded.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg;  Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library\

 

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Zalma’s Insurance Fraud Letter – August 1, 2023

ZIFL – 08/01/2023

See the full video at https://rumble.com/v33m0oj-zalmas-insurance-fraud-letter-august-1-2023.html and at https://youtu.be/RMtbucUFg2E

Man Bites Dog Story

State Farm Sues Fraudster Doctor to Stop False No-Fault Accident Claims

In State Farm Mutual Automobile Insurance Company, State Farm Fire and Casualty Company v. Herschel Kotkes, M.D., P.C., Herschel Kotkes, M.D., No. 22-cv-03611-NRM-RER, United States District Court, E.D. New York (July 13, 2023) Plaintiffs, various State Farm insurers sued Herschel Kotkes and Herschel Kotkes, M.D., P.C. (“Kotkes”), alleging that Dr. Kotkes defrauded State Farm by submitting hundreds of fraudulent bills for no-fault insurance charges on behalf of insured patients who were involved in automobile accidents.

Read the full article at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

More McClenny Moseley & Associates Issues

This is ZIFL’s eleventh installment of the saga of McClenny, Moseley & Associates and its problems with the federal courts in the State of Louisiana and what appears to be an effort to profit from what some Magistrate and District judges indicate may be criminal conduct to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana.

Read the full article at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

Lie to Your Insurer and You Will Lose

Plaintiffs Richard Converse and Stephanie Converse own a dwelling that was damaged by fire. Defendant State Farm Fire and Casualty Company (“State Farm”) insured the property at the relevant time. After a fire on December 8, 2019, Plaintiffs sought coverage under the insurance policy. Plaintiffs brought this action when Defendant denied coverage for much of the claim. In Richard Converse, and Stephanie Converse v. State Farm Fire and Casualty Company, No. 5:21-CV-457 (TJM/ATB), United States District Court, N.D. New York (July 12, 2023) the USDC was asked to rule on cross-motions for summary judgment.

Read the full article at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

Alex Murdaugh & Insurance Fraud

After being convicted of murder investigators and lawyers turned to the financial frauds alleged to have been committed by Murdaugh and how those served as a motive for the murders. There is a civil lawsuit against Murdaugh related to a fatal boat wreck involving the same son that Murdaugh was convicted of killing.

Read the full article at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

Good News From the

A British man tried to pass off as the son of a dead man, stealing thousands of pounds from his real family. Jack Reece, from the Welsh city of Flint, appeared at Chester Crown Court on Thursday for sentence after previously pleading guilty to two counts of fraud, one of theft and one of providing false information. The crimes he is admitting to: Between January and February of 2020, Reece claimed he was the son of the late David Hughes and intended to gain a life insurance policy to the value of over £3K. He also tried illegally accessing the deceased’s bank account, stealing almost £1K. Reece also pleaded guilty to claiming he was the stepson, illegally registering the death of David Hughes at Flintshire Registrar Office, and stealing a £500 motor car belonging to Mr. Hughes.

Read the full article and many more convictions at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

How to Add to the Professionalism of The Insurance Claims Profession

The insurance industry has been less than effective in training its personnel. Their employees, whether in claims, underwriting or sales, are hungry for education and training to improve their work in the industry.

Read the full article at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

8 Years in Prison for Firefighter’s Fraud Joined in Major Health Insurance Fraud Conspiracy

Tom Sher and another firefighter were sentenced to prison Wednesday, July 12, for their respective roles in a multimillion-dollar health care fraud conspiracy, U.S. Attorney Vikas Khanna announced.

Sher, 50, was sentenced to 96 months in prison. The former Margate, New Jersey firefighter was found guilty Sept. 8, 2022, of one count of conspiracy to commit health care fraud and three counts of health care fraud following a 12-day trial before U.S. District Judge Robert B. Kugler in Camden federal court.

Read the full article at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

Health Insurance Fraud Convictions

3 Years for $7M Auto Fraud Scheme

Gyulnara Bayryshova, a 57-year-old owner of the Brighton Physical Therapy Center, was one of four people who were indicted in February 2021 by the US Attorney’s Office in Boston on felony insurance fraud charges. All four pleaded guilty to a single count of fraud and three have been sentenced.

Read the full article and many more convictions at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

Other Insurance Fraud Convictions

Four Years in Federal Prison for Insurance Fraud

Michael Stuart Smith, also known as Black Mike, 36, pleaded guilty in federal court in Jefferson City, Missouri, to participating in wire and mail fraud conspiracies.

Smith, a Kansas City man was sentenced to four years in federal prison for his role in a $1.1 million insurance fraud scheme with a former Columbia, Missouri man. In addition to jail Smith was also ordered by U.S. District Judge Roeseann Ketchmark to pay $40,836 in restitution.

Read the full article and many more convictions at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

Funeral Services Owner Sentenced to Three Years in Prison for Insurance Fraud

Whitt Pleads Guilty to Multiple Charges, Receives Sentence, Behind Bars

Jeremiah Randall “J.R.” Whitt, former owner of Harrelson Funeral Services in Yanceyville, North Carolina pleaded guilty to numerous charges in Caswell County and will serve a minimum of three years in the North Carolina prison system. Upon his release, he will be on supervised probation for five years and owes $51,011.86 restitution.

Read the full article at https://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-08-01-2023.pdf

Barry Zalma

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 54 years in the insurance business. He is available at http://www.zalma.com and zalma@zalma.com

Over the last 55 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.

Barry Zalma, Inc., 4441 Sepulveda Boulevard, CULVER CITY CA 90230-4847, 310-390-4455; Subscribe to Zalma on Insurance at locals.com https://zalmaoninsurance.local.com/subscribe. Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; I publish daily articles at https://zalma.substack.com, Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ to consider more than 50 volumes written by Barry Zalma on insurance and insurance claims handling.

Go to Zalma’s Insurance Fraud Letter at https://zalma.com/zalmas-insurance-fraud-letter-2/

Follow Mr. Zalma on Twitter at https://twitter.com/bzalma

Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921

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Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/

and GTTR at https://gettr.com/@zalma

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No Sprinklers No Coverage

Negligent Broker Saved by Exclusion

See the full video at https://rumble.com/v32xyji-no-sprinklers-no-coverage.html and at https://youtu.be/u0OAqTVcW4k

Boulevard RE Holdings, LLC, (Boulevard) sued Mixon Insurance Agency, Inc., (Mixon), alleging breach of contract and negligent procurement of insurance only to find that if the policy had been issued protecting Boulevard there would be no coverage because of a clear and unambiguous exclusion requiring operative fire sprinkler systems.

In Boulevard RE Holdings, LLC v. Mixon Insurance Agency, Inc., No. 22-1895, United States Court of Appeals, Eighth Circuit (July 20, 2023) the Eighth Circuit applied Missouri law to resolve the dispute.

FACTUAL HISTORY

Boulevard owned commercial property in which BMG Service Group, LLC, (BMG) operated a bar (Property). Boulevard entered into a contract for deed with BMG for the sale of the Property for $1,275,000. Under the contract, Boulevard retained the Property’s legal title until BMG paid the purchase price in full. The contract also obligated BMG to obtain, at its own expense, fire insurance in the amount of the purchase price. The insurance was to be issued in Boulevard’s name.

BMG asked its broker, Mixon, to have Boulevard listed as a “named insured, loss payee, additional insured, and mortgagee” on the insurance policy. Mixon procured the policy from Berkley Assurance Co. The policy was issued and contained an endorsement called the Fire Protective Safeguard Endorsement (Endorsement). The Endorsement required the insured to maintain a working automatic sprinkler system on the Property. The Endorsement also excluded all coverage for loss or damage by fire if the sprinkler system was inoperative.

The policy, as issued, did not list Boulevard as a “named insured, loss payee, additional insured, and mortgagee.”

Approximately one year later, the Property was destroyed by fire. At the time of the fire, the sprinkler system was inoperative.

Boulevard submitted a proof of loss to Berkley Assurance, claiming to have an interest in the property as a “lender.” The district court held that Boulevard was not entitled to recover as a mortgagee because sellers in a contract for deed are not mortgagees under Missouri law. The district court also concluded that even if Boulevard was an insured or a mortgagee, noncompliance with the Endorsement barred recovery.

BOULEVARD’S COMPLAINT AGAINST MIXON

The operative complaint raises two causes of action against Mixon: negligent failure to procure insurance and breach of contract. Under Missouri law, both causes of action require showing that the defendant caused the plaintiff to suffer damages.

The Eighth Circuit noted that on the record facts, even if Boulevard had been named as a mortgagee, coverage would still be barred because of the Endorsement.

The Endorsement required the Property to have a working sprinkler system. The Property was destroyed by a fire that occurred while the Property lacked a working sprinkler system. Indeed, had Mixon procured the Policy in precisely the manner requested by BMG, and had the Policy issued with Boulevard listed as a mortgagee or other additional insured, Boulevard would nonetheless be in the same position in which it found itself.

If the policy had issued listing Boulevard as requested, the Endorsement would still have barred coverage.

ZALMA OPINION

It is usual for insurers of restaurant and bar risks to require the presence of fire sprinkler systems. The bar that burned had no operative fire sprinkler systems and, as a result, had no available coverage for damage by fire. Boulevard, who sold the property under contract tried to avoid the condition precedent and its own negligence by failing to review the policy or insist on the fire sprinklers, by suing the broker for not naming it as an insured. The Eighth Circuit found the arguments sufficient to consider and then avoided all the arguments by concluding that if the broker did everything requested there would still be no coverage. In essence it concluded as did the great basketball announcer Chick Hearn: “No harm, no foul.”

(c) 2023 Barry Zalma & ClaimSchool, Inc.

Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos.

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Daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg;  Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library\

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Is a Covid-19 Lawsuit Frivolous?

Ninth Circuit Is Exhausted by Covid Insurance Claims Suit

See the full video at https://rumble.com/v32i30k-is-a-covid-19-lawsuit-frivolous.html   and at https://youtu.be/FPrAUy2fzG8

Khatchik Hairabedian d/b/a Kris Mobil (“Khatchik”) appealed from the district court’s order granting Defendant Security National Insurance Company’s (“Security”) motion to dismiss this action for insurance coverage in Khatchik Hairabedian, Dba Kris Mobil v. Security National Insurance Company, a Texas Corporation, No. 22-55355, United States Court of Appeals, Ninth Circuit (July 21, 2023) applied its precedent.

THE CLAIM

Khatchik sought coverage from its insurer, Security, for COVID-19 related economic losses. However, the policy had a virus exclusion that provides: Security “will not pay for loss or damage caused by or resulting from any virus, bacterium or other microorganism that induces or is capable of inducing physical distress, illness or disease.” The virus exclusion “applies to all coverage under all forms and endorsements,” in the policy, including “forms or endorsements that cover business income, extra expense or action of civil authority.”

Khatchik argued that the virus exclusion does not apply because government orders, not COVID-19, caused the losses. Here COVID-19 is the efficient proximate cause of Khatchik’s alleged losses.

Khatchik also contended that the virus exclusion does not apply to pandemics because Security chose not to use a publicly available “pandemic exclusion” in its policy. The Ninth Circuit disagreed. Arguing that the Virus Exclusion does not apply to bar coverage for losses stemming from the COVID-19 pandemic defies the plain and unambiguous text of the Policy and is akin to arguing that a coverage exclusion for damage caused by fire does not apply to damage caused by a very large fire.

ZALMA OPINION

It is time that courts stop dealing with lawsuits seeking insurance coverage resulting from Covid-19. They continue to fill the trial and appellate courts and they continue to lose. They are causing unnecessary expense to the plaintiffs, the insurers and the courts. Considering the volume of precedent it is beginning to be considered a frivolous law suit that would subject the parties and their lawyers to sanctions.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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No Coverage After Expiration of Policy

Insurers Should Avoid Suing Each Other

See the full video at https://rumble.com/v32hkwc-no-coverage-after-expiration-of-policy.html  and at https://youtu.be/mahjJagMZnw

The United StatesCourt of Appeals for the Ninth Circuit certified to the California Supreme Court, the following question for our review: “Under California’s Motor Carriers of Property Permit Act (Veh. Code, § 34600 et seq.; the Act), does a commercial automobile insurance policy continue in full force and effect until the insurer cancels the corresponding Certificate of Insurance on file with the Department of Motor Vehicles (DMV or Department), regardless of the insurance policy’s stated expiration date?”

The Supreme Court in Allied Premier Insurance v. United Financial Casualty Company, S267746, Supreme Court of California (July 24, 2023) the California Supreme Court logically advised the court of its opinion based on the statute and California precedent.

The certified question arose only in the context of claims for equitable contribution and subrogation between two insurance companies. It bears repeating that the plaintiffs in the underlying lawsuit were compensated to the full limits of Allied’s policy under the terms of their settlement and that, at all relevant times, Porras, the trucker, properly maintained an active operating permit.

BACKGROUND

Commercial trucker Jose Porras is a “motor carrier of property” (motor carrier or carrier). Under the Act, a motor carrier cannot operate on public highways without securing a DMV permit, which requires proof of the carrier’s financial responsibility. A carrier can satisfy that requirement by obtaining a policy of insurance. If a carrier does so, the insurer must submit a certificate of insurance to the Department as evidence that the “protection required under [section 34631.5,] subdivision (a)” is provided.

The Act requires that proof of financial responsibility be continued in effect during the active life of the permit issued to the motor carrier. This requirement prohibits cancellation of a certificate of insurance without notice to the DMV by the insurer. When an insurer gives notice that a certificate will be cancelled because the policy will lapse or be terminated, the DMV must suspend the carrier’s permit effective on the date of lapse or termination unless the carrier provides evidence of valid insurance coverage pursuant to section 34630.

United appealed to the Ninth Circuit, which certified the question of law to the Supreme Court. If the Act requires a commercial auto insurance policy to remain in effect indefinitely until the insurer cancels the certificate of insurance on file with the DMV, then Allied must prevail. If not, United must prevail.

DISCUSSION

Equitable contribution assumes the existence of two or more valid contracts of insurance covering the particular risk of loss and the particular casualty in question. This assumption lies at the heart of the Ninth Circuit’s question. Allied’s entitlement to equitable contribution depends on whether United was obligated to indemnify Porras for any damages due to the accident. Allied is entitled to equitable contribution only if it can show that United was a “coobligor who shares . . . liability” with Allied for the loss resulting from that event. That is, did both insurers have a policy in effect because of the statute.

The Act Does Not Extend the Policy Beyond the Term Contained in the Contract

As to cancellation of a policy, the HCA provided that protection against liability shall be continued in effect during the active life of the trucker’s permit, and that the policy of insurance or surety bond shall not be cancelable on less than 30 days’ written notice to the PUC, except in the event of cessation of operations as a highway carrier as approved by the PUC.

An uncancelled certificate of insurance that remains on file with the DMV does not cause the corresponding insurance policy to remain in effect in perpetuity. But that is not to say that an uncancelled certificate of insurance imposes no obligation of any kind on the responsible insurer.

It is true that commercial trucking is a business affecting the public interest and that one goal of the regulating legislation is to ensure that truckers do not improperly seek to reduce costs by carrying inadequate insurance. The Act’s legislative history indicates that it was also intended to “enhance public safety.”

CONCLUSION

Under the Act, a commercial automobile insurance policy does not continue in full force and effect until the insurer cancels a corresponding certificate of insurance on file with the DMV. The duration of the policy’s coverage is regulated by its terms and those of any endorsement or amendment to the policy itself. The terms of an insurance contract generally determine the duration of the policy’s coverage.

Although an endorsement can amend the policy, neither the Act nor the specific endorsement requires extending coverage beyond the underlying policy’s expiration date.

ZALMA OPINION

The California Supreme Court, in a Solomon-like decision, read an insurance policy as written. Although the statute requires proof of insurance for a trucker to be able to operate on the road it does not intend to, nor can it, change the wording of the policy. If the Legislature wished to change the wording of the policy, eliminate the expiration date to a date to be determined by notice to the DMV, it could have done so. It did not. The expiration date stood and only the insurer with a policy in effect at the time of the accident was responsible and it could not force an insurer whose policy had expired to take on a portion of the liability owed.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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No Right to Subrogation

Mutual Benefit Insurance Defeats Subrogation Effort

See the full video at https://rumble.com/v329nl0-no-right-to-subrogation.html and at https://youtu.be/wanpCpre6eQ

Typically, an insurer that pays a claim to an insured as a result of the negligent acts of a third party an insurer has the right, in the name of its insured, to sue the responsible party in the name of its insured. The right to sue in the name of the insured results from the equitable remedy of subrogation and is effective as long as the insured has not waived the right of its insurer to subrogate.

In Delaware there is an exception to the equitable remedy because landlords and tenants are presumed to be co-insureds under the landlord’s fire insurance policy unless a tenant’s lease clearly expresses an intent to the contrary. If the rule applies, the fact that the landlord’s insurance is presumed to be for the mutual benefit of the landlord and the tenant, and the insurer cannot pursue the tenant for the landlord’s damages by way of subrogation.

The Superior Court ruled in the tenants’ favor at summary judgment that the rule applied because the lease did not clearly express an intent to hold the tenants liable for the landlord’s damages.

In Donegal Mutual Insurance Company A/S/O Seaford Apartment Ventures LLC T/A The Villages Of Stoney Brook Apartments v.Thangavel and Muthusamy, No. 379, 2022, Supreme Court of Delaware  (July 18, 2023) the apartment’s insurer sued the tenants for the $77,704.06 to repair the water damage they caused.

The Superior Court ruled in the tenants’ favor at summary judgment that the rule applied because the lease did not clearly express an intent to hold the tenants liable for the landlord’s damages.

ANALYSIS

In Delaware landlords and tenants are presumed to be co-insureds under the landlord’s fire insurance policy unless a tenant’s lease clearly expresses an intent to the contrary. If the rule applies, the landlord’s insurer cannot pursue the tenant for the landlord’s damages by way of subrogation.

The tenants who leased an apartment from Seaford Apartment Ventures, LLC, Donegal’s insured, were considered to be coinsueds since the lease did not express an intent to the contrary. The complaint alleged that the tenants hit a sprinkler head while they flew a drone inside the apartment. Water sprayed from the damaged sprinkler head and caused damage to the apartment building.

The Superior Court granted the tenants’ summary judgment motion. It concluded that the lease in this case was substantially similar to the leases in three other Delaware all of which found that the leases did not clearly express an intent to the contrary.

CONCLUSION

The Supreme Court concluded that the Superior Court correctly found that the apartment lease did not clearly express an intent that the tenants were responsible for the water damage in this case. Since the Seaford Apartment lease did not specifically address liability for fire or water damage caused by the tenant’s negligence the policy issued by Donegal was issued for the mutual benefit of the insured and the tenant and Donegal had no right to subrogate..

Also, the Superior Court correctly observed that the policy considerations recognizing the one-sided nature of residential leasing and protecting the parties’ typical expectations regarding the assignment of risk of loss – are served by applying the rule in this case because residential landlords control the lease terms. If they want, they can clearly express a requirement that the tenants obtain fire insurance or notify them that they would not benefit from the landlord’s fire insurance policy.

ZALMA OPINION

Most commercial fire insurance policies, like the Donegal policy in this case, allow the insured to waive the insurer’s right of subrogation. Apparently, the landlord did not specifically waive its insurer’s right to subrogation but, Delaware precedent, accomplished the same effect by, as a mater of law, made the landlord’s policy a policy for the benefit of both the insured and the tenant, effectively acting as a waiver of subrogation.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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A Threat of Litigation is not a Claim

There Must be a Claim for Coverage Under a Claims Made Policy

See the full video at https://rumble.com/v31to7m-a-threat-of-litigation-is-not-a-claim.html  and at https://youtu.be/KsTik44pB_k

Homeland Insurance Company of New York (Homeland) issued Plaintiff a claims made  liability insurance policy covering errors and omissions, effective January 16, 2019 to January 16, 2020.  Plaintiff eQHealth AdviseWell, Inc., f/k/a eQHealth Solutions, Inc., a Louisiana corporation that provides health care management services to Medicaid agencies, commercial healthcare payers, third-party administrators, and self-insured employer groups.

In Eqhealth Advisewell, Inc. v. Homeland Ins. Co. Of N.Y., Civil Action No. 22-00050-BAJ-EWD, United States District Court, M.D. Louisiana (July 15, 2023) the USDC resolved the dispute over coverage.

BACKGROUND

Homeland issued a Managed Care Organizations Errors and Omissions Liability Policy (“the Policy”) to Plaintiff. The Policy covered “Damages and Claim Expenses in excess of the Retention that [Plaintiff is] legally obligated to pay as a result of a Claim …” A “Claim,” as defined by the Policy, “means any written demand from any person or entity seeking money or services or civil, injunctive, or administrative relief from [Plaintiff].”

Plaintiff Authorizes Treatment For B.N., A Florida Resident, In Oklahoma

One of Plaintiff’s contracts was to provide Medicaid management services to the State of Florida. Under this contract, Plaintiff’s primary operational contact was Florida’s Agency for Health Care Administration (“AHCA”), which is the state agency responsible for administering Florida’s Medicaid program. As part of its contract, Plaintiff reviewed requests for patients-Medicaid recipients-to receive medical services outside of Florida.

One such request for out-of-state services was a Medicaid claim by B.N. a Florida resident. B.N. was admitted on an emergency basis into non-party Brookhaven Hospital (“Brookhaven”), a licensed psychiatric hospital located in Tulsa, Oklahoma. At the end of B.N.’s initial 180-day period neared, Brookhaven submitted a continued stay authorization request to Plaintiff, requesting an additional 180 days of inpatient services for B.N. Plaintiff denied Brookhaven’s request based on Plaintiff’s determination that B.N. no longer met the medical necessity criteria for the level of neurological rehabilitation provided at Brookhaven.

Plaintiff’s Communications To Defendant Regarding B.N.’S Treatment At Brookhaven

Plaintiff’s April 30 Notice of Circumstances email also contained a written timeline of events for B.N.’s treatment at Brookhaven. On June 10, 2019, a lawyer with the Jones Law Firm, representing Brookhaven, sent a letter to Florida’s Governor, multiple Florida AHCA officials, and a Medicare/Medicaid official. Brookhaven’s June 10 letter discussed Brookhaven’s disagreements with how Florida AHCA handled B.N.’s case.

The lawyer stated that “[n]o lawsuit has been filed, at least as yet.”  (emphasis added) The lawyer recommended to Plaintiff that it review its E&O insurance policy “to determine whether th[e] letter triggers a reporting requirement.” He concluded that “[t]his letter reasonably constitutes threatened litigation. Depending on the language of the policy, it may need to be reported.”

Plaintiff and Florida AHCA’s Settlement with Brookhaven

Six months later, on December 12, 2019, Plaintiff “formally tender[ed]” the matter for coverage. To do so, Plaintiff wrote a letter to Defendant, discussing the history of the B.N. matter and informing Defendant that Plaintiff had participated in settlement negotiations with Florida AHCA and Brookhaven and, ultimately, settled the matter in September 2019.

At the point of a settlement eQHealth had virtually no choice but to settle on the terms agreed by AHCA and Brookhaven. Had eQHealth refused, then the likely alternative would have been a suit by Brookhaven in federal court against AHCA and eQHealth, with eQHealth not only having to indemnify AHCA for any judgments but for all defense fees and costs. In order to mitigate the total exposure to all parties involved, eQHealth agreed. The settlement agreement was signed by the last parties on September 20, 2019, and pursuant to it, eQHealth paid Brookhaven $262,500.

Defendant denied coverage on February 3, 2020, stating that: “[n]o Claim against eQHealth was reported to Homeland, eQHealth did not ask for consent to settle any Claim, and Homeland did not provide prior written consent for the settlement, or for any expense, payment, liability, or obligation eQHealth may have had in relation to this matter. Therefore, no coverage is available for the settlement payment eQHealth made to Brookhaven.”

DISCUSSION

Homeland expressly conditioned coverage of all claims under the Policy on the filing of notice of a “Claim” against Plaintiff. When considering what constitutes a “claim” to trigger coverage under a “claims-made” insurance policy, the court relied on the Fifth Circuit that instructs trial courts to differentiate the “mere threat of a claim” from an “actual claim.”

The USDC concluded that despite the numerous communications between the parties and relevant third parties, no communication rose to the definitional level of a “Claim” such that coverage under the Policy was triggered.

Because the Court found that none of the relevant communications prior to the September 2019 settlement between Brookhaven, Florida AHCA, and Plaintiff constituted “Claims” as defined by the Policy, coverage under the Policy was never triggered since none of the communications sought “money or services or civil, injunctive, or administrative relief.”

ZALMA OPINION

Homeland included in its policy wording a definition of the word “claim.” For the insured to obtain defense or indemnity it must establish that a claims, as defined, happened. Without question threats were made. A settlement was reached and the insured paid money to fund the settlement. Yet, no one made a “claim” as defined, the insurer was not advised of the settlement nor was it advised of the insured’s intent to pay until after it paid although the decision to pay was a “business” decision since no one made a demand in writing that they pay for a cause of loss insured against, there could not be coverage for a claim or loss triggered under the policy’s clear and unambiguous definition of the word “claim.”

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Torch Down Roofing Exclusion Unambiguous

Exclusion Defeats Claim for Defense and Indemnity

See full video at https://rumble.com/v31de7m-torch-down-roofing-exclusion-unambiguous.html?mref=22lbp&mrefc=2 and at https://youtu.be/daXw5_ZpbzE

Duckworth roofing, while repairing a roof for LGO Properties, caused a fire at the Tulane Building while using hot torches to repair the roof. In Certain Underwriters At Lloyd’s Of London As Subrogee Of L.G.O. Properties, LLC  v.  Duxworth Roofing And Sheetmetal, Inc., No. 2022-CA-0821, Court of Appeals of Louisiana, Fourth Circuit (July 18, 2023) the defendant sought coverage when the  defendant’s insurer denied coverage because of an exclusion called the Torch Down Roofing Exclusion.

FACTS

L.G.O. Properties, L.L.C. entered into a contract with Duxworth to perform roofing work at 4033 Tulane Avenue (hereinafter “the Tulane Building”). Duxworth’s roofing work included the use of hot tools and the installation of a process called “torch down roofing” to repair a leak on the roof of the Tulane Building. On December 9, 2016, the Tulane Building was damaged in a fire (hereinafter “the December 2016 fire”).

On October 12, 2017, Certain Underwriters at Lloyd’s, as a subrogee of L.G.O. Properties, L.L.C. (hereinafter collectively “Lloyd’s of London”) filed a suit for damages naming Duxworth as a defendant. Lloyd’s of London’s petition alleges that Duxworth negligently used hot torches to perform roofing work on the Tulane Building thus causing the December 2016 fire. The petition also asserted that Duxworth failed to train its employees and take reasonable precautions to prevent damage to the Tulane Building.

James River, Duckworth’s insurer, filed a motion for summary judgment arguing that the Commercial General Liability insurance policy precludes Duxworth from receiving coverage. Specifically, James River maintained that the CGL policy excludes coverage for damages resulting from the use of torches to perform roofing work (hereinafter “the Torch Down Roofing Exclusion”).

Duxworth opposed James River’s motion for summary judgment arguing that the CGL policy and Lloyd’s of London’s petition contains language that does not entitle James River to summary judgment. The trial court granted James Rivers’ motion for summary judgment dismissing James River, without prejudice and before Duckworth could amend James Rivers appealed.

DISCUSSION

Duxworth asserts multiple assignments of error challenging the trial court’s ruling on the motion for summary judgment.

The Language Of The Torch Down Roofing Exclusion Is Not Ambiguous

The extent of coverage is determined by the parties’ intent as reflected by the words in the policy. In order to resolve ambiguous language within an insurance policy, the policy must be construed as a whole.  If the policy wording at issue is clear and unambiguously expresses the parties’ intent, the insurance contract must be enforced as written.

The Louisiana Court of Appeals found that the Torch Down Roofing Exclusion precludes Duxworth from receiving coverage from James River. A Court must give words and phrases their general meaning. Mr. Duxworth’s deposition revealed that he was a part of the crew that was present and performing torch down roofing repairs to the Tulane Building on the day of the December 2016 fire.

Since Mr. Duxworth testified that his team was instructed to repair a leak to the Tulane Building’s roof which required the use of hot tools and torches, also known as “torch down” roofing, and since Mr. Duxworth concedes that hot tools and torches were used to install a flat torch down roof to the Tulane Building the exclusion applies.

Given the plain, ordinary, and generally prevailing meaning of the words “arise out of,” it was clear to the Court of Appeals that Lloyd’s of London’s claims against Duxworth arose out of and are derived from the property damage caused by the fire that occurred during the time Duxworth was performing ongoing torch down roofing installation.

Duxworth’s contention that the James River’s CGL policy fails to define “Torch Down Roofing” is unpersuasive. Although the Torch Down Roofing Exclusion does not define the term “Torch Down Roofing Operations” it is undisputed that hot tools and torches were used on the date of the December 2016 fire. A plain reading of the CGL policy between James River and Duxworth provides that the damages caused by the use of hot tools to perform roofing repairs, triggers the Torch Down Roofing Exclusion, and precludes coverage.

Duty to Defend

A duty to defend is determined solely from the plaintiff’s pleadings and on the face of the policy. James River’s CGL policy provides: “we will have no duty to defend the insured against any ‘suit’ seeking damages for ‘bodily injury’ or ‘property damage’ to which this insurance does not apply.” Lloyd’s of London’s petition alleges that Duxworth failed to safely use hot torches to perform roofing work on the Tulane Building.

The Torch Down Roofing Exclusion unambiguously excluded the claims against Duckworth. The trial court properly sustained James River’s motion for summary judgment and determining that the Torch Down Roofing Exclusion prevents coverage from the use of torch down roofing operations.

ZALMA OPINION

Everyone who is sued wants to use other people’s money to defend the suit. Duckworth bought a policy with a “Torch Down Roofing Exclusion” that obviously applied after the insured testified he and his staff were using torches to repair the building at the time it caught fire. Using that type of roofing with a policy that excludes it accepted the full risk of loss and will have to use his own funds to pay off the Lloyd’s Underwriters’ subrogation action.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg;  Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library

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Creative Pleading Does not Avoid Sloth

Suing for Unfair Competition and an Injunction to Avoid Private Limitation of Action Provision Dismissed

See the full video at https://rumble.com/v315xh6-creative-pleading-does-not-avoid-sloth.html and at https://youtu.be/QdHITyiIGpQ

Katherine Rosenberg-Wohl had a homeowners insurance policy with State Farm Fire and Casualty Company (State Farm), providing coverage on her home in San Francisco. The policy has a limitation provision that requires lawsuits to be “started within one year after the date of loss or damage.”

In Katherine Rosenberg-Wohl v. State Farm Fire And Casualty Company, A163848, California Court of Appeals, First District, Second Division (July 11, 2023) she sought indemnity to remedy a defect in the home. State Farm refused to pay because there was no insurable event and because the suit was filed more than a year after the alleged loss.

FACTS

In late 2018 or early 2019, plaintiff noticed that on two occasions an elderly neighbor stumbled and fell as she descended plaintiff’s outside staircase and learned that the pitch of the stairs had changed and that to make the stairs safe the staircase needed to be replaced. In late April 2019, plaintiff authorized the work and contacted State Farm, and on August 9, she submitted a claim for the money she had spent.

The denial was based on the investigation findings and concluded there was no evidence of a covered cause for accidental direct physical damage to the property. The denial also stated that the policy does not provide coverage for preventative nor safety measures to the property. Maintenance would be the responsibility of the property owner to properly maintain the property to keep it safe.

Plaintiff submitted a claim to State Farm for her construction expenses, which by then were approximately $52,600, with another $16,800 in anticipated expenses for additional work. By letter dated August 26-plaintiff alleged, without any investigation-State Farm denied the claim. The letter also specifically referenced “the suit limitation period” as a “policy defense.”

Plaintiff filed two lawsuits against State Farm in San Francisco Superior Court. One alleged two causes of action for breach of the policy and for bad faith. That lawsuit was removed to federal court and was resolved against plaintiff on a motion to dismiss based on the one-year limitation provision. It is currently on appeal in the Ninth Circuit.

The second suit before the the Superior Court purports to allege a claim for violation of California’s unfair competition law. This case was also resolved against plaintiff, also based on the limitation provision, when the trial court sustained a demurrer to the second amended complaint without leave to amend. Plaintiff appealed.

On October 22, 2020-some 18 months after she had replaced the staircase, 14 months after State Farm had denied her claim the first time, and nearly six months after the one-year limitation period of the policy had expired-plaintiff filed two lawsuits in San Francisco County Superior Court.

On April 20, 2021, Judge Massullo sustained the demurrer with leave to amend to add additional facts supporting waiver. On May 21, plaintiff filed a second amended complaint (SAC), adding, apparently without leave of court, a claim for false advertising. The SAC then states, again in capitalized boldface, that “This Is Not A Lawsuit For Damages For Breach Of Contract; Rather It Is A Challenge To How State Farm Does Business.”

State Farm filed a demurrer and a motion to strike the SAC. On July 29, Judge Massullo entered her order sustaining the demurrer without leave to amend, a comprehensive order indeed, eight pages of thoughtful analysis. She held that “the Court is persuaded that Plaintiff’s claims are nonetheless ‘on the policy’ because they are ‘grounded upon [State Farm’s] failure to pay policy benefits.’”  She also concluded that “[a]ll of the alleged acts which form the basis of Plaintiff’s claims occurred during the claim handling process.” Finally, Judge Massullo held that State Farm had not waived the limitation provision.

DISCUSSION

The one-year limitation provision in the State Farm policy is there because it was required by statute. [Califonria Insurance Code section 2071] The one-year limitation provisions have long been held valid as mandated by statute.

The One-Year Policy Limitation Provision Applies

State Farm asserted that “the Legislature has expressly endorsed the provision under Insurance Code section 2071” and argued that because the allegations here all concern how it handled plaintiff’s claim, the suit is subject to the policy limitation period under applicable law. In sum, the crux of plaintiff’s claim is grounded upon a failure to pay policy benefits.

An insured cannot plead around the one-year limitations provision by labeling her cause of action something different than breach of contract which, of course, includes claims for bad faith. Conduct by the insurer after the limitation period has run cannot, as a matter of law, amount to a waiver or estoppel.

The policy requires any waiver to be in writing. Plaintiff does not allege State Farm agreed to waive anything in writing. Therefore, the judgment was affirmed and State Farm was allowed to recover its costs on appeal.

ZALMA OPINION

The Court of Appeal spent many pages resolving this fairly simple dispute. The plaintiff sued to collect benefits she believed were owed under a policy of insurance only to find that the suit was filed to late. To avoid that problem she amended the suit to allege unfair business practices and sought an injunction, all of which were seen to be an alternative way to obtain policy benefits and failed again. For more than 120 years the California Supreme Court and Courts of Appeal have upheld the private limitation of action provision required by statute and no amount of creative pleading can avoid its effect.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Man Bites Dog

State Farm Obtains Injunction Against Doctor to Stop Fraudulent No Fault Accident Claims

See the full video at https://rumble.com/v30ycns-man-bites-dog.html and at https://youtu.be/g6-DjjMkw3Y

In State Farm Mutual Automobile Insurance Company, State Farm Fire and Casualty Company v. Herschel Kotkes, M.D., P.C., Herschel Kotkes, M.D., No. 22-cv-03611-NRM-RER, United States District Court, E.D. New York (July 13, 2023) Plaintiffs, various State Farm insurers sued Herschel Kotkes and Herschel Kotkes, M.D., P.C. (“Kotkes”), alleging that Dr. Kotkes defrauded State Farm by submitting hundreds of fraudulent bills for no-fault insurance charges on behalf of insured patients who were involved in automobile accidents.

State Farm alleged common law fraud and unjust enrichment, seeking damages for benefits paid under no-fault insurance policies to Kotkes. State Farm also sought a declaratory judgment establishing that, among other things, it is not obligated to pay unpaid, pending claims submitted by Kotkes.

BACKGROUND

Under New York Law, an automobile insurer must provide no-fault insurance benefits to the individuals they insure (“insureds”) for necessary healthcare expenses resulting from automobile injuries, for up to $50,000. No-fault insurers like State Farm may reimburse patients without requiring proof of negligence. An insured may assign their claim to their provider, who then bills the insurers directly.

Factual Allegations

Defendants are Dr. Herschel Kotkes (“Kotkes”) and his medical practice, Herschel Kotkes, M.D., P.C. Kotkes is a pain management specialist, whose practice includes treating insureds who have been involved in automobile accidents. The insureds assign their policies to Kotkes, who bills State Farm for the treatment purportedly rendered.

State Farm alleged that Kotkes, since at least 2017, has been systematically submitting fraudulent and misleading claims to State Farm. Kotkes almost always described patient complaints in the same way (as non-specific neck and/or low back pain), diagnosed 99% of patients with radiculopathy in either the lumbar or cervical region, or both, along with “intervertebral disc displacement” in the corresponding region, but without specifying the particular location on the spine. The random sample of eighty-six patients also reveals that Kotkes provided the same prognosis for 98% of those he treated and recommended the same combination of treatment methods for nearly all patients.

State Farm asserted three causes of action: for common law fraud and unjust enrichment, under which it seeks damages for claims already paid to Kotkes, and for a declaratory judgment, under which State Farm seeks a judgment declaring that Kotkes is not entitled to reimbursement for claims submitted to State Farm that have not been paid to date and are unpaid through the pendency of this litigation.

COMMON LAW FRAUD

Under New York law, to state a claim for fraud, a plaintiff must demonstrate

  1. a material misrepresentation or omission of fact;
  2. which the defendant knew to be false;
  3. which the defendant made with the intent to defraud;
  4. upon which the plaintiff reasonably relied; and
  5. which caused injury to the plaintiff.

State Farm points to Kotkes’s own testimony, from an examination under oath in a state court collection action, where he testified, for one, that he does not believe that certain procedures are medically valuable, but that he performs them as a matter of course. Kotkes also testified that it is his practice to perform a percutaneous discectomy and an IDET-two mutually exclusive procedures-at the same time and using the same needle.

State Farm adequately alleged that Kotkes had motive to commit fraud: to gain a financial benefit of hundreds of thousands of dollars in insurance payments by submitting claims to State Farm. State Farm also adequately alleges that Kotkes had opportunity to commit fraud, specifically that Kotkes could submit claims to State Farm that allegedly misrepresented the necessity of certain treatments or inflated the bills for certain treatments.

State Farm adequately pled that it reasonably relied on Kotkes’s misrepresentation and was injured as a result. State Farm has alleged the elements of common law fraud. State Farm has adequately and plausibly alleged that Kotkes made fraudulent statements in submitting the claims at issue. State Farm alleges fraudulent knowledge and intent by showing Kotkes’s motive and opportunity to submit fraudulent claims to take advantage of New York’s no-fault insurance scheme. Common law fraud is sufficiently pled and Kotkes’s motion to dismiss the common law fraud count was denied.

DECLARATORY JUDGMENT

State Farm has established a substantial controversy between the parties: whether Kotkes is entitled to payment on pending claims presented to State Farm, or whether, due to Kotkes’s allegedly fraudulent scheme, State Farm is under no obligation to pay.

MOTION FOR A PRELIMINARY INJUNCTION

State Farm alleges that, as of March 23, Kotkes initiated 103 arbitrations and 95 state court lawsuits seeking payment on claims that State Farm has refused to pay since uncovering the alleged fraudulent scheme and initiating the instant federal lawsuit. As of March 24, 2023, approximately $1,188,841.32 in unpaid claims was at issue in pending state court litigation and arbitrations, and $1,787,989.98 of Kotkes’s billed-unpaid amount was not yet the subject of pending collections litigation or arbitration.

New York courts routinely stay collection actions pending declaratory judgment proceedings. Accordingly, State Farm’s request that the USDC stay pending no-fault collection actions in state court was granted.

State Farm’s motion for a preliminary injunction was granted in full. Specifically, the Court granted State Farm’s request to stay pending state civil court proceedings and no-fault arbitrations against State Farm by Kotkes, and enjoined Kotkes from filing any new collection actions against Kotkes seeking no-fault insurance benefits, whether in state court or in arbitration proceedings, pending resolution of the declaratory judgment action, absent further order of the Court. State Farm’s obligation to post security was waived.

ZALMA OPINION

Because insurance fraud – especially with regard to individual small amounts – the only means of deterring or defeating insurance fraud relating to no-fault insurance claims assigned to less than scrupulous health care providers is to sue the providers for fraud. State Farm should be commended for its proactive work against Dr. Kotkes and was properly provided an injunction stopping further claims while litigating the declaratory relief and fraud suit. The evidence appears overwhelming and I look forward to reading about the results at trial.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg;  Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Denying Letter Seeking an Arson Fire is Fraud

Lie to Your Insurer and You Will Lose

See the full video at https://rumble.com/v30qt52-denying-letter-seeking-an-arson-fire-is-fraud.html  and at https://youtu.be/lPWdEj-UElk

Plaintiffs Richard Converse and Stephanie Converse own the property. Defendant State Farm Fire and Casualty Company (“State Farm”) insured the property at the relevant time. After a fire on December 8, 2019, Plaintiffs sought coverage under the insurance policy. Plaintiffs brought this action when Defendant denied coverage for much of the claim. In Richard Converse, and Stephanie Converse v. State Farm Fire And Casualty Company, No. 5:21-CV-457 (TJM/ATB), United States District Court, N.D. New York (July 12, 2023) the USDC was asked to rule on cross-motions for summary judgment.

BACKGROUND

State Farm insured the Converses against the risk of loss to a rental property under a homeowners policy.

The parties agree that Plaintiff Stephanie Converse sent a letter to Joseph Pelton on or about November 8, 2019 that stated: “Joe, … Having issues with my house again. Need help this time! I will pay $5,000 cash when I get the insurance. The back door will be unlocked and open to the basement. That’s where the access to utilities are. Make look like electrical. I will come up after it happens so I will meet up with you. … It’s a mint green house with garage. Love you, See you soon.  Stephanie.”

While Plaintiffs admit that Stephanie Converse mailed the letter, they “deny any implication or allegation that Stephanie Converse committed insurance fraud, paid anyone to commit arson on the property, or was in any way involved in the fire that caused the loss on the property.”

Stephanie Converse filed a claim on December 8, 2019 for the loss caused by the fire. State Farm mailed Stephanie Converse a blank Sworn Statement in Proof of Loss and a return envelope. The cover letter stated that the Sworn Statement should be returned by February 17, 2020. State Farm Counsel Roy Mura reminded Stephanie Converse that she had to return the sworn statement. That letter warned that “a failure . . . to timely complete and return the Sworn Statement in Proof of Loss form for the reported loss may result in loss [of] your rights under the . . . policy.”

Stephanie Converse appeared for an examination under oath (“EUO”) in connection with her insurance claim on March 13, 2020. Stephanie Converse affirmed during the examination that “everything as far as you can recall [was] truthful about what you told Mr. Loarca[.]” Converse further testified that she could not “recall asking anybody to burn . . . I mean I can’t remember. I don’t know if I did, or I didn’t.” She further testified that she could not “recall” whether she had offered “to pay anybody money to” burn the property down.

Defendant denied Stephanie Converse’s claim on October 7, 2020 and Plaintiffs sued.

ANALYSIS

Defendant first argues that State Farm has no obligation to provide coverage under the policy because Stephanie Converse breached the insurance contract by making material misrepresentations in reference to her claim. The materiality requirement is satisfied if the false statement concerns a subject relevant and germane to the insurer’s investigation as it was then proceeding.

Plaintiffs deny that Stephanie Converse willfully made any material misrepresentations. Plaintiffs do not seriously dispute that Stephanie Converse made misrepresentations to State Farm during the course of the investigation. They could not. The undisputed evidence before the Court indicated, Stephanie Converse told an investigator that she had made no such request.

Defendant does not argue that Plaintiff dissembled about the cause of the fire at the home, committed arson herself, or paid Joseph Pelton to set the home on fire. The Court found that as a matter of law Plaintiff made these misrepresentations willfully. Taken as a whole, the Court concluded that Plaintiff Stephanie Converse’s statements represented a continuing attempt to conceal from State Farm that she had contacted Pelton and offered him money to burn down the insured property. The Court concluded that a reasonable juror could not find that such contradictory statements were the result of mistake or misunderstanding, but that the differences between what Plaintiff told various investigators were intentional.

“The purpose” of procedures like examinations under oath and other investigative measures is to enable the insurance company to acquire knowledge or information that may aid it in its further investigation or that may otherwise be significant to the company in determining its liability under the policy and the position it should take with respect to the claim. A reasonable juror could only find that her misleading conduct was material.

Stephanie Converse made material misrepresentations to insurance investigators as a matter of law and breached the insurance contract and Defendant is entitled to summary judgment in this respect.

Failure to Cooperate

Testifying falsely can also breach the condition of cooperation.  Stephanie Converse admitted to Lee County Sheriff’s Office investigators that she had written the letter she had denied to State Farm. Converse thus made misrepresentations about facts material to State Farm’s investigation.

Given the inconsistencies in Stephanie Converse’s stories to various parties and her clear misrepresentation to State Farm about her knowledge of the letter to Pelton, no reasonable juror could find that Converse’s misrepresentations were not willful.

 Proof of Loss

When an insurer gives its insured written notice of its desire that proof of loss under a policy of fire insurance be furnished and provides a suitable form for such proof, failure of the insured to file proof of loss within 60 days after receipt of such notice, or within any longer period specified in the notice, is an absolute defense to an action on the policy.

There is no dispute that the Plaintiff did not return a sworn statement of proof of loss until March 12, 2020, well after the date specified by State Farm in correspondence to Stephanie Converse. Defendant has an absolute defense to Plaintiffs’ claims.

Defendant’s motion for summary judgment, was granted and Plaintiffs’ motion for summary judgment was denied.

ZALMA OPINION

An insured who seeks to hire a person to set fire to her house for a fee paid from insurance proceeds is offering to pay for a felonious act. If the person refuses to set the fire, has an alibi when an arson fire actually occurred, performed by a person unknown, and the insured lies about her offer to burn her house, the lie is sufficient to deny the claim in accordance with the terms and conditions of the policy. This case proved the old saw that “liars never prosper.”

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Jail-House Lawyer Fails

Arsonist-Killer Not Eligible for Elderly House Confinement Program

See the full video at https://rumble.com/v30jifa-jail-house-lawyer-fails.html and at https://youtu.be/nE_6BsIp0aU

Jack Ferranti, acting as his own attorney, appealed the District Court’s orders denying his petition for habeas relief under 28 U.S.C. § 2241 and his motion to reconsider.

FACTS

Ferranti was responsible for causing a fire at his business that resulted in the death of a firefighter. The trial judge sentenced him to 435 months’ imprisonment. See United States v. Ferranti, 928 F.Supp. 206, 21316 (E.D.N.Y. 1996). His conviction and sentence were affirmed on appeal. See United States v. Tocco, 135 F.3d 116 (2d Cir. 1998).

In Jack Ferranti v. Warden Allenwood LSCI, No. 22-1892, United States Court of Appeals, Third Circuit (June 30, 2023) noted that Ferranti was convicted in the United States District Court for the Eastern District of New York of arson homicide, arson conspiracy, 16 counts of mail fraud, and witness tampering, based on an insurance-fraud scheme. The Third Circuit resolved the request for release to the elderly home confinement program (EOHDP).

In 2020, Ferranti argued that he met the criteria for the EOHDP, and he asked for the District Court to order the BOP to process his application and place him in the program.

ANALYSIS

As the District Court explained, federal courts do not have the authority to grant the relief that Ferranti requested to order his placement in the EOHDP. The executive branch, not the courts, have control over an inmate’s placement. Moreover, even if the ability to challenge the BOP’s actions were available through habeas, Ferranti did not establish that he qualified for the program.

The statute disqualifies those whom “the Bureau of Prisons, on the basis of information the Bureau uses to make custody classifications, and in the sole discretion of the Bureau, [determines] to have a history of violence.”

Further, even if he did qualify, the BOP would not be required to place him in the EOHDP because, again, the statute leaves placement as a matter of discretion for the BOP. In any event, the BOP did not err by concluding that Ferranti’s history of violence-comprised of the underlying conduct for his convictions as well as disciplinary infractions in prison-disqualified him from participating in the EOHDP.

ZALMA OPINION

In an example of Chutzpah, Ferranti sought release from prison into the EOHDP in violation of the program’s requirement that only a non-violent prisoner is allowed into the program. Just being elderly, especially after the arson-for-profit scheme resulted in the death of a firefighter, was denied by the District Court and the Third Circuit without hesitation.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos.

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Daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

 

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Zalma’s Insurance Fraud Letter – July 15, 2023

ZIFL Volume 27, Issue 14

See the full video at https://rumble.com/v300apk-zalmas-insurance-fraud-letter-july-15-2023.html and at https://youtu.be/iLGxqTnVKGA

The Source For Insurance Fraud Professionals

This, the fourteenth issue of the 27th year of publication Zalma’s Insurance Fraud Letter provides multiple articles on how to deal with insurance fraud in the United States. The issue begins with:

No Coverage Under a False Name

Liars May Never Prosper

Cheryl Tisdale was injured in an automobile collision while she was driving her own vehicle containing passengers while logged into the Uber Technologies (“Uber”) application as a paid driver. Tisdale served Farmers Insurance Exchange with the complaint, seeking underinsured motorist (“UM”) coverage pursuant to an insurance policy Farmers issued to Raiser, LLC, a subsidiary of Uber. 

It takes a great deal of chutzpah (unmitigated gall) to be fired by Uber for cause, rejoining Uber under a false name, and then claim a right to benefits from the Uber policy. Tisdale was punished by her lies and was not allowed to profit from her fraud.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

More McClenny Moseley & Associates Issues

This is ZIFL’s tenth installment of the saga of McClenny, Moseley & Associates and its problems with the federal courts in the State of Louisiana and what appears to be an effort to profit from what some Magistrate and District judges indicate may be criminal conduct to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

Ethics for Independent Insurance Adjusters

Independent insurance adjusters serve insurance companies who do not have sufficient claims staff to handle insurance claims on behalf of those various insurers without staff in every jurisdiction where there is property the risk of loss of which was insured.

The professional insurance adjuster recognizes that the work of adjusting insurance claims is a profession of public trust. Independent insurance adjusters should maintain a standard of integrity that will promote the goal of building public confidence and trust in the insurance industry.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

Good News From the


This fraudster worked with a former school principal to scam healthcare benefits; now, he’s gotten schooled by a jury for his fraud. Matthew Puccio from Randolph, New Jersey, has been convicted of scheming to defraud public health benefits plans and has been sentenced to five years in federal prison. Working as a sales representative for several pharmacies between November 2014 and March 2016, Puccio conspired with others to induce two New Jersey doctors to write phony prescriptions for compounded medications on behalf of patients Puccio recruited. Puccio received kickbacks in a scheme targeting health plans that reimbursed for compound drugs at high rates. His brother-in-law, Peter Frazzano, former principal of the Sussex Avenue Elementary School in Morris Township, awaits sentencing for his role in the scam. Frazzano pleaded guilty in 2019 to conspiring to defraud the New Jersey School Employees’ Health Benefits Program, the New Jersey State Health Benefits Plan, and other plans, out of $2.7M over the same period from 2014 to 2016.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

How to Add to the Professionalism of The Insurance Claims Profession

The insurance industry has been less than effective in training its personnel. Their employees, whether in claims, underwriting or sales, are hungry for education and training to improve their work in the industry.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

California Commissioner Lara Announced Over $50.5 Million In Grants Awarded Statewide to Assist Law Enforcement in Fighting Fraud

Press release from the California Department of Insurance

Under Commissioner Lara’s leadership, these grants, funded through annual employer assessments, support law enforcement efforts in investigating and prosecuting fraud and increase outreach to our communities. Commissioner Lara also awarded an additional $400,000 in grants to protect consumers, the majority of whom are seniors, from abuse involving the sale of individual life and annuity products as part of the Life and Annuity Consumer Protection Program.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

Health Insurance Fraud Convictions

Diversicare and Two Occupational Therapy Assistants to Pay Over $1.3 Million

Diversicare Healthcare Services, LLC, with related subsidiary Diversicare entities (Diversicare), along with Certified Occupational Therapy Assistants Kellie S. Lemons and Charles M. James, have agreed to pay the United States $1,377,696.00 to resolve allegations that they violated the False Claims Act (FCA) by submitting claims to Medicare for occupational therapy services that they did not provide.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

New California Bar Rule

California Supreme Court Approves New Rule Requiring Attorneys to Report Professional Misconduct

New California Rule Compelling Attorneys to Report Misconduct by Other Attorneys to Circulate for Public Comment

In late June, the California Supreme Court approved a new Rule of Professional Conduct, rule 8.3, that will require California lawyers to report misconduct by other California attorneys. Specifically, the rule requires reporting when an attorney “has committed a criminal act or has engaged in conduct involving dishonesty, fraud, deceit, or reckless or intentional misrepresentation or misappropriation of funds or property that raises a substantial question as to that lawyer’s honesty, trustworthiness, or fitness as a lawyer in other respects.” The rule is operative August 1, 2023.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

Other Insurance Fraud Convictions

Former Santa Rosa Agent Sentenced to Prison After Stealing from Consumers

Christopher Ramos, 45, of Santa Rosa, was sentenced today to four years in prison after an investigation by the California Department of Insurance found he stole over $189,000 from consumers and left them uninsured. Ramos was convicted of multiple felony counts of grand theft, theft of fiduciary funds and additional enhancements for theft over $100,000.00.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

The Effect of the Tort of Bad Faith

It is indisputable that in the 1950’s, 1960’s and 1970’s the insurance industry abused some insureds to avoid paying legitimate claims. Without a factual basis, insureds were accused of arson or other variations on insurance fraud. Indemnity payments were refused on the flimsiest of excuses. People were found to have diseases that only horses could catch. Disability payments were refused because an insured was wheeled in her wheelchair to church one day and, therefore, was not totally house-confined. Insureds were driven into bankruptcy when reasonable demands within policy limits were refused.

Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf

Barry Zalma

Over the last 55 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.

Barry Zalma, Inc., 4441 Sepulveda Boulevard, CULVER CITY CA 90230-4847, 310-390-4455; Subscribe to Zalma on Insurance at locals.com https://zalmaoninsurance.local.com/subscribe. Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; I publish daily articles at https://zalma.substack.com, Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ to consider more than 50 volumes written by Barry Zalma on insurance and insurance claims handling.

Go to Zalma’s Insurance Fraud Letter at https://zalma.com/zalmas-insurance-fraud-letter-2/

Follow Mr. Zalma on Twitter at https://twitter.com/bzalma

Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921

Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg

Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ and GTTR at https://gettr.com/@zalma

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Mistake Not Grounds for Bad Faith

Bad Faith in Arkansas Requires Proof of Dishonest, Malicious, or Oppressive Conduct Including Hatred, Ill Will, a Spirit of Revenge

See the full video at https://rumble.com/v2zsgpm-mistake-not-grounds-for-bad-faith.html and at https://youtu.be/eb65ymfyTTk

Owners Insurance Company moved for summary judgment as to a claim of bad faith. Separately, Owners argued the Court should make a finding that there no evidence to support a punitive damages instruction.

In RMS Warehouse 1315, LLC v. Owners Insurance Company, No. 5:22-CV-5114, United States District Court, W.D. Arkansas, Fayetteville Division (July 7, 2023) the USDC resolved the bad faith issue.

BAD FAITH

The tort of bad faith is established in Arkansas when an insurance company affirmatively engages in dishonest, malicious, or oppressive conduct in order to avoid a just obligation to its insured. The tort requires evidence of a state of mind characterized by hatred, ill will, or a spirit of revenge. Importantly, bad faith does not arise from a mere denial of a claim; there must be affirmative misconduct.

Plaintiff RMS contends its two claims of loss should have been covered under the policy of insurance it had with Owners. The first loss occurred on May 4, 2020, following a hailstorm that caused damage to RMS’s warehouse. The second loss was in February 2021, after a winter storm event. RMS narrows its bad-faith claim to Owners’s treatment of the winter-storm claim and explicitly states that Owners did not act in bad faith with respect to the hailstorm claim.

The only evidence RMS cited in support of its bad-faith claim is the denial letter sent by insurance adjuster Brian Doherty. RMS believes Mr. Doherty “misrepresented” in the letter what the insurance policy actually provided and omitted reference to crucial portions of the policy that provided coverage.

The standard for establishing a claim for bad faith is, and always should be, rigorous and difficult to satisfy. RMS betrayed a fundamental misunderstanding about the tort when, at one point in its briefing, it characterizes Owners’ actions as “[a]t best… a mistake,” Neither a mistake nor a “refusal to pay a disputed claim” is tortious behavior according to Arkansas law.

Summary judgment on Count II, the tort of bad faith, was therefore granted. As a consequence, RMS is not entitled to a punitive damages instruction.

The Motion was granted as to Count II, and the claim of bad faith was dismissed with prejudice; as a result, RMS will not be entitled to an instruction on punitive damages.

ZALMA OPINION

Acting as its own worst enemy the insured’s brief admitted that the insurer erred. A mistake may be sufficient to establish a breach of contract but is insufficient to prove the tort of bad faith and the right to seek punitive damages.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Res Judicata – You Only Get to Bite Defendant Once

Condo Association are Birthplaces of Litigation

See the full video at https://rumble.com/v2zlpt2-res-judicata-you-only-get-to-bite-defendant-once.html and at https://youtu.be/ekxbg-kA3Zo

Plaintiff, Nationwide Mutual Insurance Company (Nationwide), brought a declaratory judgment action against insureds, Beverly Glen Homeowners’ Association (Association) and members of the board of directors asking the court to declare that Nationwide had no duty to defend or indemnify defendants against claims made by the Association residents in a derivative suit. The trial court granted Nationwide’s motion for judgment on the pleadings, finding that res judicata and collateral estoppel barred defendants from seeking a defense in the derivative suit where judgment rendered in a prior case determined that Nationwide had no duty to defend.

In Nationwide Mutual Insurance Company v. Beverly Glen Homeowners’ Association, et al, No. 3-22-0089, 2023 IL App (3d) 220089-U, Court of Appeals of Illinois, Third District (July 7, 2023)

BACKGROUND

This lawsuit arises out of an ongoing dispute between defendants and Teresa and Katarzyna Jagiello, two Association residents.

On April 14, 2020, the trial court granted Nationwide’s motion. It held that “There are no material issues of fact in dispute and it is clear, as a matter of law, that the lack of cooperation on the part of the insured and its counsel has relieved Nationwide of its duties under its policy …. Nationwide’s insured failed to cooperate with Nationwide, relieving Nationwide of its duties under the policy, and Nationwide owes nothing to its insured…  for any legal services. As such, Nationwide owes neither a duty to defend nor indemnify its insured in this matter.”

ANALYSIS

Res Judicata and Collateral Estoppel

The doctrine of res judicata serves to bar actions in which: (1) there was a final judgment on the merits rendered by a court of competent jurisdiction; (2) there is an identity of cause of action; and (3) there is an identity of parties or their privies in both actions. Res judicata prevents the relitigation of issues that could have been decided in the first action along with those issues that were actually decided.

The directors of a Condo Association act as the arms of the Association and for all intents and purposes are one and the same. In other words, there exists a legal relationship in which the directors, acting within their corporate authority, bind the Association.

When a valid and final judgment rendered in an action extinguishes the plaintiff’s clam the claim extinguished includes all rights of the plaintiff to remedies against the defendant with respect to all or any part of the transaction, or series of connected transactions, out of which the action arose.

Res judicata is an equitable doctrine that should be applied only as fairness and justice require. It is intended to be used as a shield, not a sword. Nationwide is asserting the doctrine in a declaratory judgment action to obtain a no-duty-to-defend ruling. It is, contrary to defendants’ argument, attempting to use the doctrine as a shield in the underlying derivative suit. Under the circumstances, applying the doctrine to deny defendants coverage in the derivative suit would not be unfair or unjust. Defendants have refused to produce documents, ignored settlement agreements and court orders requiring them to do so, and failed to cooperate with Nationwide counsel in defending their actions.

In continuing to dispute it should come as no surprise to defendants that Nationwide would have no duty to defend or indemnify their actions.

The trial court did not err in granting the motion for declaratory judgment on the pleadings in insurer’s favor based on doctrines of res judicata and collateral estoppel where order entered in the prior case, finding that the insurer had no duty to defend or indemnify insured, involved identical cause of action and parties were in privity with parties in the underlying dispute.

ZALMA OPINION

The basic covenant of good faith and fair dealing requires that neither party to the policy may do anything to deprive the other of the benefits of the policy. When the condo association failed or refused to cooperate in the investigation of a claim a court found the insurer owed neither defense nor indemnity to the association because of the breach by the association. When a new set of directors sought defense of the continuation of the same dispute res judicata applied because the association was the entity involved regardless of who sits on the Board of Directors.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Magistrate’s Report Affirmed

Multi-Unit Construction Exclusion Eliminates Coverage

See the full video at https://rumble.com/v2zeoly-magistrates-report-affirmed.html   and at https://youtu.be/d8BmNKPxK_g

Midvale Indemnity Company (“Midvale”) sued Arevalos Construction Corp. (“Arevalos”), Victor Siguenza Zuniga (“Zuniga”), 625 Halsey LLC (“Halsey”), D&G Construction NY Inc. (“D&G”), and RM Construction and Development Corp. (“RM”) seeking a declaratory judgment relating to a commercial general liability insurance policy Midvale issued to Arevalos and an underlying lawsuit in New York state court, captioned Victor Siguenza Zuniga v. 625 Halsey LLC, Index No. 525911/2018 (the “Underlying Action”).

In Midvale Indemnity Company v. Arevalos Construction Corp., et al, No. 22-CV-97 (FB) (RML), United States District Court, E.D. New York (July 5, 2023) was asked to overturn the report and recommendations of the Magistrate Judge to acknowledge the default and order no coverage for defense or indemnity of anyone named in the Underlying action.

FACTS

D&G and Zuniga timely objected to the report of the Magistrate judge. These objections triggered the US District Judge’s de novo review.

D&G, a subcontractor of Arevalos claiming coverage and a right to indemnification by Arevalos’ insurer Midvale, and Zuniga, the injured tort claimant in the Underlying Action, has been named as defendants in this declaratory action by Midvale. D&G and Zuniga object to the Magistrate’s finding that none of the named defendants was owed coverage under the policy.

DISCUSSION

D&G and Zuniga object to the conclusion that they lack standing to oppose Midvale’s motion, its finding that none of the named defendants were entitled to coverage, and the scope of its declaratory relief.

The Magistrate recommended finding that D&G’s subcontractor agreement with Arevalos imposed no duty on Midvale, a “stranger to that contract,” to D&G. He also found that “D&G does not claim to be a third-party beneficiary of the Policy,” that “the Policy does not indicate an intent to confer a benefit upon D&G or any other individual or entity other than Arevalos,” and that “Zuniga is not a named insured or third-party beneficiary under the Policy.”

In New York, a non-party to a contract generally lacks standing to enforce the agreement in the absence of terms that clearly evidence an intent to permit enforcement by the third party in question unless it establishes:

  • the existence of a valid and binding contract between other parties,
  • that the contract was intended for his benefit and
  • that the benefit to him is sufficiently immediate, rather than incidental, to indicate the assumption by the contracting parties of a duty to compensate him if the benefit is lost.

The US District Judge concluded that the Magistrate did not err. He found that Arevalos was not entitled to coverage because of the policy’s Multi-Unit and Tract Housing Residential Exclusion, which “excludes coverage for ‘[b]odily injury’ arising out of any ‘construction operations’ that involve a ‘housing tract’ or ‘multi-unit residential building.’”

Since the Underlying Action seeks damages for a construction project falling under this exclusion: specifically, one for a four-story building with ten residential units the exclusion clearly applied. This scope of relief is proper because it is what Midvale requested in its Complaint, and because the Magistrate rightly found Midvale entitled to a default judgment. The Court adopted the relief recommended by the Magistrate but noted that it is only binding against the defaulting parties.

The Court overrules D&G and Zuniga’s objections, adopts the Magistrate’s recommendation and directs the Clerk to enter a judgment granting Midvale’s motion for a default judgment against Arevalos and RM and declaring that Midvale has no duty to defend or indemnify any party with respect to the Underlying Action.

ZALMA OPINION

Every defendant in a law suit wants it resolved with other peoples’ money and even if they did not buy insurance to protect themselves will seek the benefits of insurance available to others. Claiming a benefit to an insurance contract as a result of a construction contract can be effective if the policy provided coverage. In this case there was no coverage because of a clear and unambiguous exclusion the insurer had no obligation to provide defense or indemnity to anyone. It pays to read the insurance policy before making a claim and filing a suit.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Residence Requires Presence

Homeowners Policy Requires Insured to Reside at Premises

See the full video at https://rumble.com/v2z7wce-residence-requires-presence.html and at https://youtu.be/Hhe6ZgieHEQ

Shanice Currie had a homeowners insurance policy with State Auto Property & Casualty Insurance Company (State Auto). After two fires severely damaged her duplex in Milwaukee, Currie sought payment from State Auto. State Auto denied the request for coverage, claiming that the duplex was not a “residence,” and therefore was not covered by the policy. Currie sued State Auto. The district court granted summary judgment to State Auto.

In Shanice Currie v. State Auto Property & Casualty Insurance Company, No. 22-2517, United States Court of Appeals, Seventh Circuit (July 5, 2023) the USCA for the Seventh Circuit explained the meaning of the terms “residence premises” and “reside.”

BACKGROUND

Currie purchased the previously abandoned duplex (the Property) from the City of Milwaukee in the spring of 2018. She proceeded to install electricity and fill the bedroom with a dresser, mirror, clothing, and a bed. Yet, at the time she acquired the policy the property had no running water, kitchen appliances, no chairs or sofas in the living room, or a front door. Where a door should be, there was a wooden board that Currie would have to unscrew to enter the Property. Strangers came and went, and Currie took no action to eject them.

Apart from sleeping at the Property two or three nights per month, Currie did not stay there. She bathed, prepared meals, kept personal belongings, and received mail at her two other addresses in Milwaukee.

THE POLICY

The homeowners policy Currie purchased from State Auto for the Property covered “residence premises,” which the policy defined as: “The two-, three-, or four-family dwelling where you reside in at least one of the family units . . . on the inception date of the policy period shown in the Declarations and which is shown as the ‘residence premises’ in the Declarations.

Because the policy’s inception date was September 15, 2018, Currie needed to reside in one of the units on the Property on that date for coverage to attach. She did not.

THE FIRES

On October 31 and on November 2, 2018, fires broke out at the Property, causing extensive damage. Currie informed State Auto that the Property was a total loss and sought full replacement value. State Auto denied Currie’s claim, explaining that the Property was never her residence.

DISCUSSION

Currie sued. The district court granted State Auto’s motion for summary judgment. The court held that, while the operative clause in the policy-“the dwelling where you reside”-was ambiguous, “[a] reasonable person would, nevertheless, understand the clause to require plaintiff to maintain and use the [Property] as a home, even if it was only one residence among many.” Given Currie’s lack of legal and practical ties to the Property, the district court found that a jury could not reasonably conclude that Currie resided there.

There is no statutory definition of “residence” or “dwelling” in Wisconsin with respect to homeowners insurance coverage. Because neither “occupied” nor “dwelling” are technical terms, an appellate court may ascertain their meanings by reference to recognized dictionaries. Because Currie did not use the Property as a home the court found that no reasonable jury could conclude that she resided there.

The Seventh Circuit concluded that the district court correctly concluded that Currie did not “actually live” at the Property, on the inception date or at any other time, thus it was not her residence. The address was not listed on her driver’s license and her mail was sent to a different location. Most telling, the Property was not secure. It had no door nor facilities to support normal life.

As a matter of law, Currie’s Property was not a residence on the policy’s inception date nor any time before or after. It was not covered by the insurance policy, and the district court’s grant of summary judgment to State Auto was proper.

ZALMA OPINION

Insurers will issue fire insurance on vacant property but will not do so on a homeowners policy form. To protect the insurer the homeowners policy requires the insured to reside on the property. Since the property was not sufficiently equipped for a person to reside in because it had no door, no water and no other facilities to support normal life, Currie failed to fulfill the basic requirement for coverage: residence. Had the insurer been told the truth about the condition of the property it would never have agreed to the coverage. Because of the residence condition there was no need for the insurer to accuse the insured of fraud although she probably obtained the coverage by fraud.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Potentially Compromised Embryos not a Direct Physical Loss

Failure to Prove Loss by a Named Peril Destroys Breach of Contract Suit

See the full video at https://rumble.com/v2yv3pc-potentially-compromised-embryos-not-a-direct-physical-loss.html  and at https://youtu.be/q-2HGCrpHIY

Modern science allows an embryo to be created outside the body of a woman and later implanted and grown to term. The in vitro fertilization process allows more than one viable embryo to be created and they can be stored for use later in a cryogenic tank.

Sherlene and Lawrence Wong (the Wongs) had stored some embryos at a facility that kept them in a cryogenic tank that failed to maintain the temperature necessary to store the embryos, following which the Wongs’s fertility doctor told them they should consider the embryos “compromised” and “no longer viable, and lost.”

In Sherlene Wong et al. v. Stillwater Insurance Company, A162893, California Court of Appeals, First District, Second Division (June 30, 2023) the Wongs attempted to recover the value of the embryo’s from a homeowners insurance policy they maintained with  Stillwater Insurance (Stillwater). The policy was a specified perils policy that only insured for “direct physical loss” that was “caused by any of the following perils,” going on to list 16 specified perils. The Wongs made a claim for property damage, which Stillwater denied.

The Wongs sued, and Stillwater moved for summary judgment, on two bases: the Wongs could not submit evidence of (1) “direct physical loss” or (2) that “one of the sixteen specified perils occurred.” The trial court granted summary judgment.

BACKGROUND

Beginning in 2014, the Wongs pursued in vitro fertilization, working with Aimee Eyvazzadeh, M.D., as their doctor. In 2015, the Wongs completed an in vitro fertilization (IVF) cycle, and obtained four viable embryos, one of which was implanted. As to the other three, as Dr. Eyvazzadeh put it, after discussion with the Wongs they determined to “bank the rest,” which they did at Pacific Fertility Center (Pacific Fertility or PFC), a facility in San Francisco that included several cryogenic storage tanks that used liquid nitrogen to store human embryos at very low temperatures. Specifically, the embryos were stored in Tank 4, which also contained embryos belonging to other people.

On or about March 4, 2018, Tank 4 failed to maintain the temperature necessary to store embryos, as a result at least some (and possibly all) of the embryos stored in that tank partially or totally thawed.

The Stillwater policy provided coverage for personal property the Wongs “owned or used” while “anywhere in the world,” with policy limits for personal property of $502,720. The policy was a “specified perils” policy, the significance of which is that in order to demonstrate a covered loss the insured has the threshold burden of proving the loss was caused by a specifically enumerated peril.

On August 3, attorney Michelle Burton outlined her coverage evaluation to Stillwater, which among other things concluded that she “cannot ascertain from the file whether the insured’s zygotes were compromised, whether they are still viable or whether there has been a determination either way.” And, she further concluded, there was no evidence the claimed damage resulted from any of the 16 perils that apply to personal property as set forth in the policy.  The claim was eventually denied and the Wongs sued the insurer.

The Proceedings Below

Stillwater filed a motion for summary judgment. The fundamental argument was that the Wongs “cannot establish essential elements” of the breach of contract claim because “the policy covers personal property only for ‘direct physical loss’ caused by one . . . of the [16] specified perils.” No proof of any specified peril was ever provided Stillwater with evidence of why Tank 4 failed to maintain proper temperature.

The opposition was accompanied by declarations of both of the Wongs, their attorney, Mr. Rosenberg-Wohl, and their fertility doctor, Dr. Eyvazzadeh who declared that as a result of this disaster, the Wongs’ embryos became worthless. “No responsible fertility physician would use them; I certainly would not.”

Eventually, the trial court filed its order granting the motion for summary judgment concluding that Stillwater met its burden of demonstrating that the causes of action alleged in the Wongs’ complaint cannot be established, and the Wongs have not raised a triable issue of material fact as to any of those causes of action.

Judgment was entered in favor of Stillwater, from which the Wongs filed an appeal.

DISCUSSION

The burden is on the insured to prove facts establishing the claimed loss falls within the coverage provided by the policy’s insuring clause.

The Wongs failed to demonstrate a direct “physical loss.” Dr. Eyvazzadeh testified that she had requested Pacific Fertility to conduct a test of one of the Wongs’s embryos, but that Pacific Fertility declined; and, she went on, there is “no way to know” whether the Wongs’s embryos actually sustained physical damage. That does not create a triable issue of material fact as to “physical loss.”

Dr. Eyvazzadeh’s concession there is “no way to know” whether the Wongs’s embryos had actual physical damage was devastating to the Wongs’s claim. And her conclusion that she deemed the embryos to be “worthless” was not a substitute for evidence that any of the embryos actually had undergone a physical change. The mere possibility that the embryos had suffered physical damage was insufficient to create a triable issue of fact to trigger coverage

No Evidence of Any Specified Peril

The Stillwater policy was, as noted, a “specified perils” policy. The Wongs presented no evidence that the cause of the alleged damage to the embryos was caused by one of the named perils and as a result the Court of Appeal concluded that the judgment was affirmed.

ZALMA OPINION

Stillwater conceded that the embryos were “personal property” that could be insured under the homeowners policy, although arguments could have been made that they were not property any more than a child born from the embryo would be property. Regardless, it effectively argued that there was no evidence that the embryos were damaged or destroyed when the temperature in the cryogenic chamber rose nor was there evidence that the embryos suffered direct physical damage only that they were “worthless” to an IVF doctor.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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To Stack or Not to Stack, That is the Question

Anti-Stacking Provision Clear & Unambiguous

No Extra Insurance for Fatal School Bus Accident.

See the video at https://rumble.com/v2ygzys-to-stack-or-not-to-stack-that-is-the-question.html  and at https://youtu.be/B9yDDMQjj6M

Plaintiffs, Mark and Karen Kuhn (the Kuhns) sued seeking a declaratory judgment of the available liability insurance covering an accident between a semitruck owned by Jason Farrell and a school bus driven by Mark.

In Mark Kuhn and Karen Kuhn v. Owners Insurance Company; et al, No. 4-22-0827, 2023 IL App (4th) 220827, Court of Appeals of Illinois, Fourth District (June 28, 2023) the semitruck was insured under a policy issued by Owners Insurance Company (Owners), and that policy also insured six other vehicles-two other semitrucks and four trailers- that were not involved in the accident. Each vehicle had a limit of $1 million per accident. The Kuhns sought a declaration that the coverage limits for all of the covered vehicles should be aggregated, or “stacked,” resulting in a total of available liability insurance of $7 million for the accident.

The trial court entered a written judgment in favor of the Kuhns, concluding that (1) the policy was ambiguous; (2) because the ambiguity should be construed against Owners, stacking of the policy’s coverage limits was permitted; and (3) the aggregate limit of insurance for liability coverage under the policy was $7 million. Accordingly, the court granted the Kuhns’ motion for summary judgment and entered judgment against Owners. Owners appealed

BACKGROUND

“Stacking” ordinarily involves combining or aggregating the policy limits applicable to more than one vehicle where the other vehicles are not involved in the accident.

The rationale behind not allowing stacking of liability coverage-that liability policies insure particular cars-is contrary to plaintiff’s position. Because the insurance attaches to a particular car.

The Illinois Supreme Court recently declined to consider adopting a per se rule barring stacking of automobile liability coverage as a matter of law because the antistacking provision in that case was unambiguous and enforceable as written. [Hess v. Estate of Klamm, 2020 IL 124649, ¶ 30, 161 N.E.3d 183.’

The Insurance Policy at Issue

The policy provided “Combined Liability” coverage on each of the seven vehicles of up to “$1 Million each accident.” The Kuhns argued that the wording of the policy and accompanying declarations were ambiguous pursuant to Illinois case law because the coverages and premiums set forth in the declarations were repeated for each insured vehicle.

Owners argued that the policy declarations were consistent with each other and not ambiguous. Owners argued the policy contained an unambiguous antistacking provision that cleared up any arguable ambiguity in the declarations and should be enforced as written. In particular, subsection 5 explicitly stated that the limits for the same or similar coverage applying to other vehicles could not be added to determine the amount of coverage for an accident.

ANALYSIS

In general, antistacking provisions in insurance policies are not contrary to public policy. In Illlinois, an unambiguous antistacking clause will be given effect by a reviewing court.

In this case, the “Limit of Insurance” provisions refer back to the declarations to define the policy limits and the declarations pages state seven separate times that the “combined liability” limit on each vehicle is $1 million for each accident.

Reading the policy as a whole and interpreting its plain language, the court concluded that the declarations are consistent, not ambiguous, and the antistacking clause set forth in the policy clarifies any possible ambiguity.

The coverages varied based on the vehicle insured; for example, the premiums for vehicle 1 and vehicle 2 (both semitrucks) were identical for liability, UIM/UM coverage, and medical payments, but only vehicle 1 had comprehensive and collision coverage.

The Antistacking Clause

Even if some ambiguity existed, the policy’s antistacking clause cleared up any possible confusion.

The explicit antistacking clause of the policy, is unambiguous and should be enforced as written.

Instead of applying the Policy’s clear anti-stacking provision, the trial court engaged in the very sort of tortured and strained reading of the Policy to find an ambiguity that this Court and the Illinois Supreme Court have repeatedly rejected. This was error, the trial court’s order was reversed and the case remanded with directions to enter summary judgment in favor of Owners.

ZALMA OPINION

It should be axiomatic that a trial court should never engage in tortured or strained reading of a policy to find an ambiguity that did not exist regardless of the need of the accident victims and their families. A clear and unambiguous policy wording that refuses to allow stacking of coverages that apply to more than one vehicle insured when only one vehicle is involved in an accident, should be enforced as written. The Illinois Court of Appeals read the entire policy and found no ambiguity and insisted on enforcing the contract of insurance as written.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Liars May Never Prosper

No Coverage Under a False Name

See the full video at https://rumble.com/v2ya42y-liars-may-never-prosper.html and at https://youtu.be/hqBFCZOd6U4

Cheryl Tisdale was injured in an automobile collision while she was driving her own vehicle containing passengers while logged into the Uber Technologies (“Uber”) application as a paid driver. Tisdale served Farmers Insurance Exchange with the complaint, seeking underinsured motorist (“UM”) coverage pursuant to an insurance policy Farmers issued to Raiser, LLC, a subsidiary of Uber.

In Tisdale v. Farmers Insurance Exchange, No. A23A0616, Court of Appeals of Georgia (June 27, 2023) Farmers moved for summary judgment, arguing that Tisdale did not qualify as an insured under the Uber policy, or, in the alternative, that she was barred from seeking coverage because she intentionally concealed or misrepresented material facts and committed fraud by using a false identity in her Uber driver application and while using the app. The trial court granted summary judgment to Farmers. Tisdale appealed.

FACTS

Tisdale was an Uber driver from 2015 to 2017. According to her deposition, at some point Uber “stopped [her] from driving because they did a background check [,] and something popped up on there . . . they didn’t agree with.” In 2019, because she did not believe that Uber would hire her under real name, Tisdale applied to work for Uber using the name “Annie Mollie.” Uber approved “Mollie’s” application, and Tisdale began driving for Uber as Annie Mollie.

In April 2020, Tisdale was involved in an automobile accident with Graves while driving her own car, which was registered under her legal name, and while logged into the driver version of the Uber app as Annie Mollie. Tisdale gave a recorded statement to Farmers as “Annie Mollie.”

In May 2020, Tisdale sued Graves for damages arising out of the accident, alleging that he rear-ended her, pushing her vehicle into the path of another vehicle, which struck her, and that she incurred in excess of $184,000 in medical expenses.

At the time of the accident, Tisdale had not entered into a contract to use the Uber app in her own name/capacity, and Uber had not authorized her to drive as an Uber driver; instead, Tisdale operated her vehicle while logged into the Uber app using a false identity. Under these circumstances, Tisdale did not qualify as an insured under the policy Farmer’s issued to Uber.

ANALYSIS

The hallmark of contract construction is to ascertain the intention of the parties, as set out in the language of the contract. As a result, when the language of an insurance policy defining the extent of an insurer’s liability is unambiguous and capable of but one reasonable construction, the courts must enforce the contract as written and agreed to by the parties.

Tisdale served her own UM carrier – State Farm Fire and Casualty Company – and Farmers with a copy of the complaint and discovery requests. Farmers, in response, alleged that coverage for Tisdale under Uber’s UM policy was void.

Farmers moved for summary judgment claiming Tisdale intentionally concealed or misrepresented material facts and committed fraud by using a false identity in her Uber application and while using the app, she did not qualify as an insured under the Uber policy, and she was barred from seeking coverage based on the fraud condition in the policy. The trial court granted summary judgment to Farmers.

Tisdale concedes that she intentionally misrepresented her identity and presented Uber with a false driver’s license and a false insurance registration card in order to become a driver. This misrepresentation and fraud provided her coverage under the Farmer’s policy, which clearly bars the payment of damages to a driver who commits fraud or intentionally misrepresents or conceals a material fact relating to coverage. Therefore, the trial court properly granted summary judgment to Farmers.

ZALMA OPINION

It takes a great deal of chutzpah (unmitigated gall) to be fired by Uber for cause, rejoining Uber under a false name, and then claim a right to benefits from the Uber policy. Tisdale was punished by her lies and was not allowed to profit from her fraud.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

 

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Arbitration May be used to Resolve Fraud

Arbitration and No Fault Fraud Claims

See the full video at https://rumble.com/v2y2u76-arbitration-may-be-used-to-resolve-fraud.html and at https://youtu.be/wG2KNhCkyMA

This case is about the relationship between New Jersey healthcare providers and the insurance companies that pay those providers for treating patients for injuries arising from automobile accidents.

In GEICO In v. Caring Pain Management PC a/k/A Careon Pain Management, Jinghui Xie, M.D., First Care Chiropractice Center, L.L.C., and Konstantine Fotiou, D.C., No. 2:22-cv-05017(BRM)(JSA), United States District Court, D. New Jersey (May 31, 2023) the insurer attempted to defeat fraudulent claims under the New Jersey no-fault law.

BACKGROUND

Multiple GEICO insurers (the “Plaintiffs) alleged a series of fraudulent schemes, including unlawful compensation in exchange for patient referrals, misrepresentation of the nature, extent, and results of patient examinations, and false representation regarding compliance with pertinent healthcare laws.

MOTION TO DISMISS

In deciding a motion to dismiss pursuant to Federal Rule of Civil Procedure 12(b)(6), a district court is required to accept as true all factual allegations in the complaint and draw all inferences from the facts alleged in the light most favorable to the non-moving party.

DECISION

The Insurance Fraud Prevention Act (“IFPA”), which was enacted roughly a decade after the No-Fault Law, provides that an “insurance company damaged as the result of a violation of any provision of this act may sue therefor in any court of competent jurisdiction.” In part, the New Jersey Legislature enacted the IFPA to address rising insurance rates resulting from widespread fraud with the clear objective to confront aggressively the problem of insurance fraud in New Jersey by facilitating the detection of insurance fraud and eliminating the occurrence of such fraud through the development of fraud prevention programs.

A person or practitioner violates the IFPA by presenting or preparing false or misleading statements in connection with an insurance claim, or by failing to disclose the occurrence of an event that affects an individual’s entitlement to insurance benefits or the amount of benefits

THE COMMON LAW FRAUD, UNJUST ENRICHMENT, AND RICO CLAIMS

The No-Fault Law’s language, legislative intent and application cover Plaintiffs’ claims for common law fraud, unjust enrichment and RICO. The plain language of the No-Fault statute provides that “[a]ny dispute regarding the recovery of . . . benefits provided under personal injury protection coverage . . . arising out of the operation, ownership, maintenance or use of an automobile may be submitted to dispute resolution on the initiative of any party to the dispute.” (emphasis added)

Plaintiffs’ claims involve:

  1. a dispute by [Plaintiffs]
  2. involving Defendants’ recovery of PIP Benefits that
  3. one party wishes to send to arbitration.

Consequently, Plaintiffs’ common law fraud, unjust enrichment, and RICO claims fall within the statute’s arbitration provision. Having reviewed the No-Fault Law’s language, legislative intent, application, and arbitrable claims with Plaintiffs’ claims for common law fraud, RICO and unjust enrichment, the USDC found there was nothing preventing an arbitrator from hearing the claims.

New Jersey IFPA Claim

The plain meaning of the New Jersey Insurance Fraud Prevention Act (IFPA) requires insurers’ claims for damages under the IFPA be judicially resolved. Although the statute states that insurers “may sue in any court of competent jurisdiction,” arbitration does not constitute a court of competent jurisdiction.

To the extent the IFPA may seem to contradict the No-Fault Law, state legislatures are presumed aware of prior enactments, including the pre-existing No-Fault Law. The state legislature could have provided a carve out for PIP Benefits disputes in the IFPA but did not.

The USDC concluded that to avoid duplicative findings, the Court, in its discretion, declined to separately entertain the IFPA claim under the Declaratory Judgment Act. To the extent Plaintiffs seek a declaration that Defendants violated RICO, committed common law fraud, or are liable for unjust enrichment, an arbitrator shall decide that issue.

ZALMA OPINION

Clearly, the health care providers who were accused by GEICO of fraud felt that they had a better chance of success with an arbitrator rather than a federal judge. The judge found the statutes allowed for arbitration and sent the fraud to an arbitrator. I would like to be that arbitrator and hope the parties get an arbitrator who dislikes insurance fraud as much as I do, and find they would have done better with a federal judge. GEICO should be honored for working to defeat fraud by attempting to take the profit out of the fraud.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Zalma’s Insurance Fraud Letter – July 1, 2023

ZIFL – Volume 27, Issue 13

See the full video at https://rumble.com/v2x0dna-zalmas-insurance-fraud-letter-july-1-2023.html  and at https://youtu.be/yiSwfKAB7GM

The Source For Insurance Fraud Professionals

From https://zalma.com/blog, this, the Thirteenth issue of the 27th year of publication Zalma’s Insurance Fraud Letter provides multiple articles on how to deal with insurance fraud in the United States. The issue begins with:

Fraud in Inception is Ground for Rescission

No Restitution from Defrauded Insurer

Esurance Property & Casualty Insurance Company (Esurance) appealed the trial court’s order granting summary disposition in favor of Nationwide Mutual Fire Insurance Company (Nationwide) and denying Esurance’s request for summary disposition. In Nationwide Mutual Fire Insurance Company v. Esurance Property & Casualty Insurance Company, and Derek Allen Gregory and Blair Gregory, No. 361298, Court of Appeals of Michigan (June 15, 2023) Esurance alleged its insured defrauded it when it acquired the policy, and it was entitled to rescind the policy regardless of the trial court’s balancing the equities.

Read the full text of ZIFL in Adobe .pdf format at ZIFL-07-01-2023

More McClenny Moseley & Associates Issues

This is ZIFL’s ninth installment of the saga of McClenny, Moseley & Associates and its problems with the federal courts in the State of Louisiana and what appears to be an effort to profit from what some Magistrate and District judges indicate may be criminal conduct to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana.

June 14, 2023

US Magistrate Judge Michael North held a hearing to advise insurers on how to handle thousands of Hurricane Ida claims affected by alleged fraud by Texas law firm McClenny Moseley & Associates. It’s standing room only, more than 200 lawyers in court. One fainted.

Read the full text of ZIFL in Adobe .pdf format at ZIFL-07-01-2023

Ethics And the Public Insurance Adjuster

An example of a public insurance adjuster and the lawyer who failed to follow the requirements set out by National Association of Public Insurance Adjusters (NAPIA). Both represented the same client, involved in a claim that resulted from the 1994 Northridge, California earthquake. The earthquake caused billions of dollars in damage across Southern California. It drew lawyers and public adjusters seeking large fees like vultures flying over a dead antelope. As a result of the disaster, investigation by insurers was limited because of the extent of losses caused by the earthquake and the need to rapidly serve their needs. Many unnecessary and spurious suits were filed. Insurance fraud was rampant, and insurers paid rather than fight because there were inadequate staff available to deal with fraud and governmental agencies threatened insurers with major fines if they did not pay quickly.

Read the full text of ZIFL in Adobe .pdf format at ZIFL-07-01-2023

Good News From the Coalition Against Insurance Fraud

When faced with a fraud conviction, this woman couldn’t stop herself from doing it again. Tanea Bouma, who had been court-ordered not to obtain employment or a volunteer role involving financial authority.

Read the full text of ZIFL and many more reports of convictions in Adobe .pdf format at ZIFL-07-01-2023

Order Limiting Cross-Examination Fair and Appropriate

In The People v. Renae Louise Witt, G061305, California Court of Appeals, Fourth District, Third Division (June 5, 2023) a jury had convicted Renae Louise Witt of committing seven counts of medical insurance fraud in violation of Penal Code section 550, subdivision (a)(6). The trial court suspended imposition of sentence and placed Witt on two years of formal probation and ordered her to serve 364 days in jail and yet, she appealed.

Read the full text of ZIFL in Adobe .pdf format at ZIFL-07-01-2023

Health Insurance Fraud Convictions

Gloucester County Man Admits Healthcare Fraud

Christopher Gualtieri, 50, of Franklinville, New Jersey, pleaded guilty before U.S. District Judge Robert B. Kugler to one count of an indictment charging him with conspiracy to commit health care and mail fraud and one count charging him with obtaining oxycodone through fraud. Gualtieri, a Gloucester County, New Jersey, man on June 12, 2023 admitted defrauding his employer’s health insurance plan out of more than $4 million by submitting fraudulent claims for medically unnecessary compounded medications.

Read the full text of ZIFL and dozens of convictions in Adobe .pdf format at ZIFL-07-01-2023

Other Insurance Fraud Convictions

Clegg Gifford Shuns Over £7 Million Worth of Fraudulent Claims

Insurance broker Clegg Gifford (CG) has successfully identified and avoided more than £7 million worth of fraudulent motor trade claims over a period of four years with the help of the counter-fraud team at law firm DAC Beachcroft (DACB). 

Read the full text of ZIFL and more convictions in Adobe .pdf format at ZIFL-07-01-2023

Barry Zalma

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 54 years in the insurance business. He is available at http://www.zalma.com and zalma@zalma.com

Over the last 55 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.

Barry Zalma, Inc., 4441 Sepulveda Boulevard, CULVER CITY CA 90230-4847, 310-390-4455; Subscribe to Zalma on Insurance at locals.com https://zalmaoninsurance.local.com/subscribe. Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; I publish daily articles at https://zalma.substack.com, Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ to consider more than 50 volumes written by Barry Zalma on insurance and insurance claims handling.

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The Fourteenth Amendment to the Constitution Ensures Racial Equality

Justice Thomas Concurs

STUDENTS FOR FAIR ADMISSIONS, INC., PETITIONER 20–1199 v. PRESIDENT AND  FELLOWS OF HARVARD COLLEGE ON WRIT OF CERTIORARI TO THE UNITED  STATES COURT OF APPEALS FOR THE FIRST CIRCUIT STUDENTS FOR FAIR ADMISSIONS, INC., PETITIONER 21–707 v. UNIVERSITY OF NORTH CAROLINA, ET AL

I’m an insurance law expert and seldom get involved in issues of race. I was one of very few Jews at my college and had a cross burned on the lawn of an old apartment where I was housed since there was no room in a dormitory. One student always greeted me with the comment: “Six Million and One, Zalma.”

I managed to graduate and made a few friends. One of the few black students was a native of the Congo who was shocked to learn that my brother had married a native of the Congo who was actually a Belgian Jew. Discrimination is wrong but it can be overcome and this decision of the Supreme Court has made it unconstitutional. I graduated from college in 1964 long after the 14th Amendment and its statement of the Constitution’s requirement that no one should either suffer or profit from discrimination. I thank members of the Supreme Court for recognizing the mandate of the Constitution before I shuffle off this mortal coil.

If you have the time I suggest that you read the full opinion and the various concurrences and the dissents at https://www.supremecourt.gov/opinions/22pdf/20-1199_hgdj.pdf

I have excepted what I believe to be important parts of Justice Thomas’ concurrence, in a lengthy 58 pages wrote cogently, among other things:

[T]he Fourteenth Amendment—ensures racial equality with no textual reference to race whatsoever. The history of these
measures’ enactment renders their motivating principle as
clear as their text: All citizens of the United States, regard-
less of skin color, are equal before the law.

* * *

As enacted, the text of the Fourteenth Amendment pro-
vides a firm statement of equality before the law. It begins
by guaranteeing citizenship status, invoking the
“longstanding political and legal tradition that closely asso-
ciated the status of citizenship with the entitlement to legal
equality.” Vaello Madero, 596 U. S., at ___ (THOMAS, J.,
concurring) (slip op., at 6) (internal quotation marks omit-
ted). It then confirms that States may not “abridge the
rights of national citizenship, including whatever civil
equality is guaranteed to ‘citizens’ under the Citizenship
Clause.” Id., at ___, n. 3 (slip op., at 13, n. 3). Finally, it
pledges that even noncitizens must be treated equally “as
individuals, and not as members of racial, ethnic, or reli-
gious groups.” Missouri v. Jenkins, 515 U. S. 70, 120–121
(1995) (THOMAS, J., concurring).

* * *

Despite the extensive evidence favoring the colorblind
view, as detailed above, it appears increasingly in vogue to
embrace an “antisubordination” view of the Fourteenth
Amendment: that the Amendment forbids only laws that
hurt, but not help, blacks. Such a theory lacks any basis in
the original meaning of the Fourteenth Amendment.

* * *

To satisfy strict scrutiny, universities must be able to es-
tablish a compelling reason to racially discriminate.

* * *

The Constitution’s colorblind rule reflects one of the core
principles upon which our Nation was founded: that “all
men are created equal.” Those words featured prominently
in our Declaration of Independence and were inspired by a
rich tradition of political thinkers, from Locke to Montes-
quieu, who considered equality to be the foundation of a just
government.

* * *

Even taking the desire to help on its face, what initially
seems like aid may in reality be a burden, including for the
very people it seeks to assist. Take, for example, the college
admissions policies here. “Affirmative action” policies do
nothing to increase the overall number of blacks and His-
panics able to access a college education. Rather, those ra-
cial policies simply redistribute individuals among institu-
tions of higher learning, placing some into more competitive
institutions than they otherwise would have attended. See
T. Sowell, Affirmative Action Around the World 145–146
(2004). In doing so, those policies sort at least some blacks
and Hispanics into environments where they are less likely
to succeed academically relative to their peers.

* * *

Finally, it is not even theoretically possible to “help” a
certain racial group without causing harm to members of
other racial groups.

***

Whatever their skin color, today’s youth simply are not responsible for instituting the segregation of the 20th century, and they do not shoulder the moral debts of their ancestors. Our Nation should not punish today’s youth for the sins of the past.

* * *

In fact, all racial categories are little more than stereotypes, suggesting that immutable characteristics somehow conclusively determine a person’s ideology, beliefs, and abilities. Of course, that is false. …  Members of the same race do not all share the exact same experiences and viewpoints; far from it. A black person from rural Alabama surely has different experiences than a black person from Manhattan or a black first-generation immigrant from Nigeria, in the same way that a white person from rural Vermont has a different perspective than a white person from Houston, Texas. Yet, universities’ racial policies suggest that racial identity “alone constitutes the being of the race or the man.” J. Barzun, Race: A Study in Modern Superstition 114 (1937). That is the same naked racism upon which segregation itself was built. Small wonder, then, that these policies are leading to increasing racial polarization and friction. This kind of reductionist logic leads directly to the
“disregard for what does not jibe with preconceived theory,”
providing a “cloa[k] to conceal complexity, argumen[t] to the
crown for praising or damning without the trouble of going
into details”—such as details about an individual’s ideas or
unique background. Ibid. Rather than forming a more plu-
ralistic society, these policies thus strip us of our individu-
ality and undermine the very diversity of thought that uni-
versities purport to seek.

* * *

Racialism simply cannot be undone by different or more racialism. Instead, the solution announced in the second founding is incorporated in our Constitution: that we are all equal, and should be treated equally before the law without regard to our race.

* * *

With the passage of the Fourteenth Amendment, the people of our Nation proclaimed that the law may not sort citizens based on race. It is this principle that the Framers of the Fourteenth Amendment adopted in the wake of the Civil War to fulfill the promise of equality under the law. And it is this principle that has guaranteed a Nation of equal citizens the privileges or immunities of citizenship and the equal protection of the laws. To now dismiss it as “two-dimensional flatness,” post, at 25 (J ACKSON, J., dissenting), is to abdicate a sacred trust to ensure that our “honored dead . . . shall not have died in vain.” A. Lincoln, Gettysburg Address (1863)

* * *

If social reorganization in the name of equality may be justified by the mere fact of statistical disparities among racial groups, then that reorganization must continue until these disparities are fully eliminated, regardless of the reasons for the disparities and the cost of their elimination. If blacks fail a test at higher rates than their white counterparts (regardless of whether the reason for the disparity has anything at all to do with race), the only solution will be race-focused measures. If those measures were to result in blacks failing at yet higher rates, the only solution would be to double down. In fact, there would seem to be no logical limit to what the government may do to level the racial playing field—outright wealth transfers, quota systems, and racial preferences would all seem permissible. In such a system, it would not matter how many innocents suffer race-based injuries; all that would matter is reaching the race-based  goal.

* * *

Even today, affirmative action programs that offer  an admissions boost to black and Hispanic students discriminate against those who identify themselves as members of other races that do not receive such preferential treatment.

* * *

Historically Black Colleges and Universities (HBCUs) do not have a large amount of racial diversity, but they demonstrate a marked ability to improve the lives of their students.

* * *

The great failure of this country was slavery and its progeny. And, the tragic failure of this Court was its misinterpretation of the Reconstruction Amendments, as Justice Harlan predicted in Plessy. We should not repeat this mistake merely because we think, as our predecessors thought, that the present arrangements are superior to the Constitution.

The Court’s opinion rightly makes clear that Grutter is, for all intents and purposes, overruled. And, it sees the universities’ admissions policies for what they are: rudderless, race-based preferences designed to ensure a particular racial mix in their entering classes. Those policies fly in the face of our colorblind Constitution and our Nation’s equality ideal. In short, they are plainly—and boldly—unconstitutional. See Brown II, 349 U. S., at 298 (noting that the Brown case one year earlier had “declare[d] the fundamental principle that racial discrimination in public education is unconstitutional”).

While I am painfully aware of the social and economic ravages which have befallen my race and all who suffer discrimination, I hold out enduring hope that this country will live up to its principles so clearly enunciated in the Declaration of Independence and the Constitution of the United States: that all men are created equal, are equal citizens, and must be treated equally before the law.

zalma@zalma.com

 

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No Privity, No Right to Sue

Suing All State Farm Insurers Unconscionable

See the full video at https://rumble.com/v2wttdw-no-privity-no-right-to-sue.html and at https://youtu.be/MmcdUew2fcM

State Farm Mutual Automobile Insurance Company (“State Farm Auto”) and Defendant State Farm General Insurance Company (“State Farm General”) moved the court to dismiss all Plaintiff’s claims against the entities. The motion was regarded as unopposed.

In Bridget Butler v. State Farm Fire And Casualty Company, State Farm General Insurance Company, And State Farm Mutual Automobile Insurance Company, No. 3:22-Cv-03433, United States District Court, W.D. Louisiana, Lake Charles Division (June 23, 2023) a Bridget Butler whose home was damaged by two hurricanes sued three State Farm Insurance companies when only one insured her against the risk of loss of her property.

INTRODUCTION

Hurricane Laura made landfall near Lake Charles, Louisiana then Hurricane Delta made landfall near Lake Charles, Louisiana. During the relevant time period, Plaintiff Bridget Butler owned property in Monroe, Louisiana. An entity of State Farm provided a policy of insurance to Plaintiff. Plaintiff alleged that Defendant failed to timely and adequately compensate Plaintiff for her substantial losses pursuant to the Policy. In turn, Plaintiff filed suit against State Farm Auto, State Farm General, and State Farm Fire and Casualty Company (“State Farm Fire and Casualty”) claiming liability for damages for breach of contract plus general damages and for statutory violations and penalties under Louisiana Revised Statutes.

State Farm General and State Farm Auto moved for dismissal of the claims against them. Plaintiff filed no response to the motion.

RULE 12(b)(6) STANDARD

Rule 12(b)(6) allows for dismissal when a plaintiff “fail[s] to state a claim upon which relief can be granted.”

LAW AND ANALYSIS

The Complaint alleges that the “Defendant” issued and maintained a Policy insuring Plaintiff’s Property. The Complaint does not provide a specific policy number, and the Complaint asserts a policy number was unable to be identified because “Defendant” did not comply with Plaintiff’s request for production of the policy number.

Attached to their Motion to Dismiss State Farm General and State Farm Auto put forth an insurance policy with the policy number 99-CC-X642-7, and both companies assert that the attached policy is the Policy referenced in the Complaint. The attached policy is from State Farm Fire and Casualty and names Plaintiff as insured and the Property as the location of premises insured with a policy period of twelve months beginning August 25, 2020. State Farm General and State Farm Auto are not listed as parties in the attached policy. Additionally, both State Farm General and State Farm Auto maintain that neither entity has issued a policy to Plaintiff.

Under Louisiana law, no action for breach of contract may lie in the absence of privity of contract between the parties. State Farm General and State Farm Auto are not parties to the attached policy, and each assert it did not provide Plaintiff with any insurance coverage. Therefore, neither State Farm General nor State Farm Auto are in privity of contract with the Plaintiff. According to the attached policy, Plaintiff is only in privity of contract with State Farm Fire and Casualty.

CONCLUSION

Defendants State Farm General Insurance Company and State Farm Automobile Insurance Company’s Motion to Dismiss was granted.

Plaintiff maintains claims against State Farm Fire and Casualty Insurance Company.

ZALMA OPINION

There should be no excuse for a plaintiff to require the State Farm entities that did not insure Ms. Butler to move the court for dismissal. A telephone call from defense counsel to plaintiff’s counsel informing Ms. Butler of the proper defendant and voluntarily dismiss the wrong State Farm entities. The decision of the court was easy but Judge Cain has more important things to do than deal with an unnecessary motion. Sanctions against Plaintiff’s attorney could have been warranted.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos.

Subscribe and receive videos limited to subscribers of Excellence in Claims Handling at locals.com https://zalmaoninsurance.locals.com/subscribe.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Justice Thomas on Rascisim

Race Has Nothing to Do with Insurance or Education

Racism is not Cured by More Racism

In the final paragraphs of his concurring opinion today Justice Thomas explains the reality of racism as follows:

The great failure of this country was slavery and its progeny. And, the tragic failure of this Court was its misinterpretation of the Reconstruction Amendments, as Justice Harlan predicted in Plessy. We should not repeat this mistake merely because we think, as our predecessors thought, that the present arrangements are superior to the Constitution.

The Court’s opinion rightly makes clear that Grutter is, for all intents and purposes, overruled. And, it sees the universities’ admissions policies for what they are: rudderless, race-based preferences designed to ensure a particular racial mix in their entering classes. Those policies fly in the face of our colorblind Constitution and our Nation’s equality ideal. In short, they are plainly—and boldly—unconstitutional. See Brown II, 349 U. S., at 298 (noting that the Brown case one year earlier had “declare[d] the fundamental principle that racial discrimination in public education is unconstitutional”).

While I am painfully aware of the social and economic ravages which have befallen my race and all who suffer discrimination, I hold out enduring hope that this country will live up to its principles so clearly enunciated in the Declaration of Independence and the Constitution of the United States: that all men are created equal, are equal citizens, and must be treated equally before the law.

Although I usually only write about insurance this is too important a decision of the Supreme Court and its best writer to ignore.

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Where there is a Will There are Relatives

Settlement Based on Mutual Mistake Must be Rescinded

See the full video at https://rumble.com/v2wpbqk-where-there-is-a-will-there-are-relatives.html and at https://youtu.be/29wqpnXCBP0

People with a claim against an estate entered into a settlement agreement to resolve a claim against the estate regarding life insurance coverage that the decedent was required under a divorce decree to maintain for the benefit of the children of the broken marriage. Subsequently, the parties jointly petitioned the county court for Douglas County, Nebraska, for a declaration of their rights and obligations under the agreement. The county court reformed the agreement to be fair to all. The ex-wife appealed.

In In re Estate of Jordon R. Wiggins, deceased et a., No. S-22-543, 314 Neb. 565, Supreme Court of Nebraska (June 23, 2023) the Supreme Court of Nebraska resolved the dispute in a Solomon-like fashion.

BACKGROUND

Jordon R. Wiggins died on August 28, 2019. Prior to his death, Jordon executed a will, which established the Jordon R. Wiggins Family Trust (the Trust) for his children’s benefit. Jordon’s father, Robert Wiggins, was appointed personal representative of Jordon’s estate on October 17, 2019.

Jordon was previously married to Allison Hardy, and two minor children, Elizabeth Wiggins and Leah Wiggins, were born to them during the marriage. The divorce decree required Jordon and Allison each to “maintain a life insurance policy” of at least $250,000 “to provide for the minor children” if Jordon or Allison died.

On December 20, 2019, Allison brought a claim for $250,000 plus interest against the estate on the children’s behalf, alleging that the personal representative had not yet identified any life insurance policy maintained by Jordon for the children’s benefit. However, after the claim was brought, Jordon’s former employer informed Jordon’s brother, Jason Wiggins, that Jason was the sole beneficiary of Jordon’s two employer-provided life insurance policies, valued at $360,000 total.

The Settlement

Subsequently, Jason, as an interested party; Allison, on behalf of the minor children; and Robert, as personal representative, agreed to settle Allison’s claim against the estate. The settlement agreement began by acknowledging that “to the best of the [p]arties’ knowledge,” Jordon had not designated the children as beneficiaries of a life insurance policy of at least $250,000. The agreement then called for Jason to “gift” $250,000 of the insurance proceeds that he received to the Trust, whereupon Allison would withdraw the claim.

However, after they entered the settlement agreement, the parties learned that Jordon’s daughter Elizabeth was actually the beneficiary of one of Jordon’s life insurance policies, while Jason was the beneficiary of the other policy. Thereafter, the insurer paid $120,000 “directly” to Elizabeth; this money was not placed in the Trust. The insurer also paid $240,000 to Jason, who then paid $130,000 into the Trust and retained $110,000. Allison took issue with Jason’s action, arguing that he was required under the divorce decree, the settlement agreement, and Nebraska law to pay the entire $240,000 into the Trust for the children.

The Validity of the Settlement

At the hearing on the motion for declaratory judgment, Jason argued that the settlement agreement should be rescinded on various grounds, including the parties’ mutual mistake as to Jordon’s life insurance coverage. Alternatively, Jason argued that the agreement should be reformed due to this mutual mistake. Allison countered that there was no basis for reformation or rescission because the agreement in its written form correctly expressed the parties’ intent at the time they entered the agreement and Jason assumed the risk of mistake.

The county court ruled in Jason’s favor. The county court ordered that the $130,000 that Jason paid into the Trust satisfied his obligation under the settlement agreement, because he was entitled to a credit of $120,000 for the life insurance proceeds that Elizabeth received. Believing that this $120,000 had been placed in the Trust, the county court also ordered that the $250,000 received into the Trust for the children’s benefit satisfied the claim against the estate. It ordered that the settlement agreement be reformed accordingly.

ANALYSIS

Allison argued that the settlement agreement should be enforced against Jason because the agreement as written accurately reflects the parties’ intent at the time they signed the agreement.

A settlement agreement is subject to the general principles of contract law.

Rescission, in contrast to reformation, may be granted where the parties have apparently entered into a contract evidenced by a writing, but owing to a mistake, their minds did not meet as to all the essential elements of the transaction, so that no real contract was made by them. Generally, grounds for cancellation or rescission of a contract include fraud, duress, unilateral or mutual mistake, and inadequacy of consideration.

When used in reference to rescission, however, the term “mutual mistake” is not limited to a mistake in drafting the instrument. Specifically, for purposes of rescission, a mutual mistake of fact must relate to either a present or past fact or facts that are material to the contract, and not to an opinion as to future conditions as the result of present known facts.

The situation is different as to rescission. Here, the evidence clearly and convincingly showed that the parties were mutually mistaken as to a fact which was a material inducement for the contract. Specifically, their mutual mistake of fact was their belief that Jordon failed to maintain any life insurance for the benefit of the children and instead named Jason as the sole beneficiary.

On its face, the settlement agreement calls for Jason to pay money that he did not receive from the life insurance proceeds. It does not seem just and fair to require Jason to pay an additional $110,000-which would result in a total of $360,000 in life insurance proceeds’ being available to the children-where the divorce decree contemplated a minimum of $250,000 in life insurance proceeds, Elizabeth received $120,000 of life insurance proceeds directly from the insurer, and Jason has already paid $130,000 into the Trust, which is available to both Elizabeth and Leah.

The purpose of rescission is to place the parties in a status quo, that is, return the parties to their position which existed before the rescinded contract.

A mutual mistake as to the existence of a fact that was a material inducement to the contract is not ground for reformation, although it may be ground for rescission. Accordingly, the Supreme Court reversed the judgment of the county court and remand the cause with directions for the county court to rescind the settlement agreement and conduct further proceedings not inconsistent with this opinion.

ZALMA OPINION

The most difficult problem raised by the need for life insurance after a divorce is what to do when the spouse required to carry life insurance for the benefit of the children of the broken marriage is how to enforce the agreement. It would be simple to buy the insurance, name the children as beneficiaries and provide copies of the policy to the divorced spouse and/or the children. In this case, communications failed and the parties tried to be fair with to little information. Rescission was the appropriate resolution because the settlement was reached based on false information resulting in an unfair result.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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It’s Not Nice to Defraud Your Elderly Mother

Guilty Pleas Support to Crimes Against Family & Friends Deserves Consecutive Sentences

See the full video at https://rumble.com/v2wn9me-its-not-nice-to-defraud-your-elderly-mother.html  and at https://youtu.be/YHzJcRoPiAI

Jon Settlemire (“Settlemire”), appealed the judgment of sentence imposing consecutive sentences only to find an appeals court with no mercy. When the Marion County Grand Jury returned a 45-count indictment charging Settlemire with a variety of felony-level crimes Settlemire entered a plea of not guilty to the indictment. After pre-trial proceedings Settlemire entered a negotiated plea of guilty to five crimes.

In State Of Ohio v. Jon M. Settlemire, 2023-Ohio-1852, No. 9-22-33, Court of Appeals of Ohio (June 5, 2023) Settlemire pled guilty to a charge of Theft in violation, a fourth-degree felony; a charge of Forgery, a fifth-degree felony; a charge of Forgery in violation of, a fifth-degree felony; a charge of Theft, a fourth-degree felony; and amended to a charge of Forgery a third-degree felony. In exchange for the guilty plea the prosecution dismissed the remaining counts of the indictment.

On April 28, 2022, a sentencing hearing was held. At that time, the trial court imposed a sentence and that all counts be served consecutively, for an aggregate sentence of 86 months in prison.

THE CLAIMED ERROR

In the sole assignment of error, Settlemire argueD that the trial court erred in ordering that the sentences in this case be served consecutively. Specifically, Settlemire assertd that the aggregate sentence here is disproportionate and overly severe when compared to the criminal conduct of which he was convicted.

If multiple prison terms are imposed on an offender for convictions of multiple offenses, the court may require the offender to serve the prison terms consecutively if the court finds that the consecutive service is necessary to protect the public from future crime or to punish the offender and that consecutive sentences are not disproportionate to the seriousness of the offender’s conduct and to the danger the offender poses to the public.

In State v. Gwynne,___ Ohio St.3d ___, 2022-Ohio-4607, the Supreme Court of Ohio noted that defendants may appeal consecutive sentences, and that a statute states that an appellate court may increase, reduce, or otherwise modify a sentence or that it may vacate the sentence and remand the case for resentencing when it clearly and convincingly finds that the record does not support the sentencing courts decision.

The appellate court’s review of Settlemire’s sentences reflects that the trial court made the requisite consecutive-sentence findings pursuant to the statute at the sentencing hearing and incorporated those findings into the judgment entry of sentencing.

The trial court noted when imposing sentence, and as confirmed by the record, Settlemire’s multiple crimes of Theft and Forgery resulted in a loss of nearly $50,000.00 to the various victims, and the multiple victims in this case suffered serious economic harm. Settlemire’s relationship with the victims facilitated the offenses, with one of those victims being Settlemire’s elderly mother. Finally, as the trial court noted, Settlemire was initially charged with 45 felony counts in this case, and a sentencing court may consider charges that have been dismissed or reduced pursuant to a plea agreement.

The number of consecutive sentences and the aggregate sentence here were not disproportionate or overly severe when compared to the criminal conduct of which Settlemire was found guilty.

Having found no error prejudicial to the defendant-appellant in the particulars assigned and argued, the judgment of the Marion County Court of Common Pleas s affirmed.

ZALMA OPINION

Bad people who are convicted of multiple crimes deserve punishment. No fraud perpetrator is more deserving of punishment than a man who defrauds his elderly mother and relatives. The Ohio court properly sentenced Settlemire to spend the next 86 months in an Ohio State prison.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

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Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

 

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Defense Required Because Exclusion is Ambiguous

Even Clear Language in Policy Can be Ambiguous

AI Collection of Facial Recognition Images Violates Illinois Statute

See the full video at https://rumble.com/v2wgqdk-defense-required-because-exclusion-is-ambiguous.html  and at https://youtu.be/ZviS2zl1Vas

After Wynndalco Enterprises, LLC was sued in two putative class actions for violating the Illinois Biometric Information Privacy Act (“BIPA”) its business liability insurer, Citizens Insurance Company of America sued seeking a declaration that it has no obligation under the terms of the insurance contract to indemnify Wynndalco for the BIPA violations or to supply Wynndalco with a defense. The district court entered judgment on the pleadings for Wynndalco, finding that the language of the catch-all exclusion is ambiguous on its face and that, construing that ambiguity in favor of the insured, Citizens consequently had a duty to defend Wynndalco.

In Citizens Insurance Company of America v. Wynndalco Enterprises, LLC, et al., No. 22-2313, United States Court of Appeals, Seventh Circuit (June 15, 2023) the litigation arose from a massive database of facial-image scans assembled by Clearview AI, an artificial intelligence firm that specializes in facial recognition software.

Clearview AI allegedly extracted in excess of three billion photographs of individuals from online social media; converted those images into biometric facial recognition identifiers using proprietary algorithms; collected the original images and their biometric counterparts into its database; and paired those images with information as to where those images were found on the Internet. Clearview AI has also created a facial recognition application or “app” that allows a user to identify an individual by uploading a photograph of that person to the app. The app then allows the user to see other photographs of that same person on the media platforms or websites where they appear, along with the identifying information (including their name, address, and other personal information) associated with that individual.

Both suits allege that Wynndalco’s role in this transaction ran afoul of BIPA. Illinois became the first state in the nation to enact biometric data privacy legislation when it promulgated BIPA. Broadly speaking, BIPA codifies an individual’s right of privacy in and control over his or her biometric identifiers and biometric information.

At the time of the sale of the Clearview AI app to the Chicago Police Department, Wynndalco had business owner’s insurance coverage through a policy issued to it by Citizens. Section II of the policy sets forth the liability coverage for the business. Citizens contends that coverage of the class action claims is barred by a catch-all provision in a policy exclusion barring coverage for injuries arising out of certain statutory violations. The catch-all exclusion provided: “Any other laws, statutes, ordinances, or regulations, that address, prohibit or limit the printing, dissemination, disposal, collecting, recording, sending, transmitting, communicating or distribution of material or information.

Illinois regards the proper interpretation of an insurance policy as a question of law. Policy terms that purport to limit the insurance company’s liability are construed in favor of coverage, but only when the terms are ambiguous or susceptible to more than one reasonable interpretation.

In some instances, the language of a policy exclusion may appear clear in isolation, but when compared with a separate policy provision granting coverage for the same type of action or injury that the exclusion ostensibly reaches, an ambiguity arises, in that the exclusion appears to take away with one hand coverage that the policy purports to give with the other. Because the aim of policy interpretation is to give effect to all provisions of the policy and avoid whenever possible construing one provision in a way that tends to nullify another provision, a court when confronted with such an ambiguity must consider whether the reach of the “swallowing” exclusion can be deemed narrower than its plain terms taken in isolation would otherwise suggest.

There was no dispute that a literal, plain-text reading of the catch-all provision would include BIPA violations.

The text does not seem particularly ambiguous. Quite the opposite, it seems clear as a bell- and the clear message is that the provision sweeps broadly. The text is undoubtedly broad. The Seventh Circuit agreed with Wynndalco that the catch-all provision of the exclusion is ambiguous. A plain-text reading of that provision would swallow a substantial portion of the coverage that the policy otherwise explicitly purports to provide in defining a covered “personal or advertising injury,” and arguably all of the coverage for certain categories of wrongs-copyright infringement, to take one example- that are entirely statutory in nature.

On a plain text reading, the catch-all provision has an extremely broad sweep-so broad, in fact, that the exclusion on its face would eliminate coverage for a number of statutory injuries expressly included in the definition of “personal and advertising injur[ies]” that the policy purports to cover. This clash between competing provisions of the policy gives rise to the Seventh Circuit concluding there is an ambiguity in the insurance contract language and that  catch-all provision is “intractably ambiguous.”

Applying yet another well-established canon the ambiguity must be construed against Citizens and in favor of the insured. As the catch-all provision says nothing about injuries arising from statutes regulating privacy interests, and “[o]ral or written publication, in any manner, of material that violates a person’s right of privacy” is covered the Seventh Circuit concluded that the injuries alleged complaints at least potentially fall within the coverage of the Citizens policy. The Seventh Circuit concluded that Citizens thus owes its insured, Wynndalco, a duty to defend it against those complaints.

ZALMA OPINION

Exclusions in policies exist to limit the coverages provided by the insuring agreement and cause it to provide less coverage than an unlimited insuring agreement. Since people are entitled to enter into any contract that the insurer is willing to offer and the insured is willing to accept, the court will usually not rewrite the contract. There was no question that the “catch-all” exclusion was clear and unambiguous but the District Court and the Seventh Circuit created an ambiguity because the exclusion limited the effect of the insuring agreements. In this case the Seventh Circuit rewrote the policy and provided the insured more coverage than was provided by the policy.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Fraud in Inception is Ground for Rescission

No Restitution from Defrauded Insurer

See the full video at https://rumble.com/v2vyecz-no-restitution-from-defrauded-insurer.html and at https://youtu.be/DDvjs7SYGVU

Esurance Property & Casualty Insurance Company (Esurance) appealed the trial court’s order granting summary disposition in favor of Nationwide Mutual Fire Insurance Company (Nationwide), and denying Esurance’s request for summary disposition. In Nationwide Mutual Fire Insurance Company v. Esurance Property & Casualty Insurance Company, and Derek Allen Gregory and Blair Gregory, No. 361298, Court of Appeals of Michigan (June 15, 2023) Esurance alleged its insured defrauded it when it acquired the policy and it was entitled to rescind the policy regardless of the trial court’s balancing the equities.

PERTINENT FACTS

In 2015, Derek Gregory (Derek) was driving a truck insured by Esurance and co-owned with his wife, Blair Gregory (Blair). The truck collided with Daniel Moore (Moore), who was riding a bicycle. Moore was injured in the accident. Moore was uninsured, and his claim for personal protection insurance (“PIP”) benefits was assigned to Nationwide via the Michigan Automobile Insurance Placement Facility (MAIPF). Nationwide paid a total of $454,871.09 in medical expenses on behalf of Moore.

Nationwide subsequently filed this lawsuit against Moore and Esurance seeking to recover the PIP benefits it paid on Moore’s behalf. Nationwide alleged that Esurance, as the insurer of the truck was in a higher priority position and was required to reimburse Nationwide.

The Bases for Rescission

Esurance subsequently filed a third-party complaint against Nationwide and the Gregorys, alleging that Blair had failed to disclose several material facts in her application for the insurance policy, including that she was married, that Derek occasionally drove the truck, that Derek had been in prior accidents involving alcohol, that Blair had been involved in prior accidents, and that Blair had filed prior claims with other insurance providers. Esurance argued that Blair’s misrepresentations in her insurance application constituted fraud, warranted rescission of the policy, and prohibited Nationwide from recovering from Esurance as a higher-priority insurer.

After a hearing on Nationwide’s motion, the trial court issued a written opinion granting summary disposition in favor of Nationwide. The trial court noted that rescission is not automatically applicable in the face of fraud. The trial court held that Esurance had failed to show that rescission was warranted, and that Nationwide could stand in Moore’s shoes and recover from Esurance on the basis of equitable subrogation

RESCISSION

Esurance argued that the trial court erred by granting summary disposition in Nationwide’s favor. Specifically, Esurance contended that the trial court abused its discretion in concluding that the balance of the equities weighed against rescission.

Equitable subrogation is a flexible, elastic doctrine of equity that is decided on a case-by-case basis. Equitable subrogation is the mode which equity adopts to compel the ultimate payment of a debt by one who in justice, equity, and good conscience ought to pay it.

The Michigan Supreme Court has held that the plain language of the no-fault act does not preclude or otherwise limit an insurer’s ability to rescind a policy on the basis of fraud.

Although PIP benefits are mandated by statute, the no-fault act neither prohibits an insurer from invoking the common-law defense of fraud nor limits or narrows the remedy of rescission.

However, the presence of fraud by the insured does not automatically entitle an insured to rescission. When innocent parties are affected, rescission is left to the trial court’s discretion. Rescission should not be granted in cases where the result thus obtained would be unjust or inequitable or in cases where the circumstances of the challenged transaction make rescission infeasible.

There is no dispute that Esurance is an innocent insurer, and that Moore is an innocent third party.

Caselaw clearly demonstrates that the equities must be balanced between the injured person and the party seeking rescission. The Michigan Supreme Court already rejected Esurance’s arguments and held that such insurers may be reimbursed via equitable subrogation for PIP benefits paid on behalf of an uninsured person.

There was no evidence presented demonstrating that Esurance knew about this fraud before Moore was injured, and there was no showing of how Esurance could have been more diligent in reviewing the insurance application or in detecting the fraud.

A determination of whether policy enforcement only serves to relieve the fraudulent insured of what would otherwise be the fraudulent insured’s personal liability to the innocent third party.

In totality, the court of appeal concluded that the trial court abused its discretion by holding that Esurance had failed to show that rescission was warranted. The ultimate issue in innocent-third-party cases is which innocent party should bear the ultimate burden of the insured’s fraud. In this case, Moore has already recovered benefits from an alternate source, and rescission will have no effect on that coverage. In other words, if the policy is rescinded, neither Esurance nor Moore would, in practical terms, bear the burden of Blair’s fraud. Under these circumstances, the trial court’s decision to deny rescission fell outside the range of principled outcomes.

The trial court was ordered to enter an order granting summary disposition in favor of Esurance.

ZALMA OPINION

No one should profit from fraud. Not even an innocent insurer that paid benefits under a no-fault insurance scheme since it would have had to pay even if there was no insurance on the other side. Esurance was entitled to rescind because it would never have insured the Gregorys but for the fraud in the inception.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Courts do not Make Different Contracts

Notice-Prejudice Rule Does not Apply to Claims Made and Reported Policy

See the full video at https://rumble.com/v2vj2nn-courts-do-not-make-different-contracts.html  and at https://youtu.be/khhpef45LjY

The Kentucky Supreme Court was asked to determine if the claims-made-and-reported management liability policy (“Policy”) Allied World Specialty Insurance Company (“Allied World”), issued to Kentucky State University (“KSU”) provided coverage because KSU did not comply with the Policy’s notice provisions. The trial court applied the notice prejudice rule and the Court of Appeal reversed and the case was brought to the Kentucky Supreme Court in Kentucky State University v. Darwin National Assurance Company N/K/A Allied World Specialty Insurance Company, No. 2021-SC-0130-DG, Supreme Court of Kentucky (June 15, 2023)

FACTS

The Policy KSU purchased from Allied World was for the period from July 1, 2014 to July 1, 2015. The Policy allows claims made against KSU within the policy period to be reported to Allied World up to ninety days after the end of the policy period. The Policy expired July 1, 2015, and the 90-day extended reporting period ended September 29, 2015.

During the policy period two professors submitted Notices of Charges of Discrimination to the United States Equal Employment Opportunity Commission (“EEOC”) and Kentucky Commission on Human Rights (collectively, “EEOC Charges”) related to their employment at KSU. KSU received written notice of the EEOC Charges on June 23, 2015. On September 2, 2015, the professors brought employment-related claims against KSU in Franklin Circuit Court, the substance of which would be covered under the Policy. On October 2, 2015, three days after the extended reporting period expired, KSU notified Allied World who denied coverage.

KSU eventually sued Allied World and both moved for summary judgment. The circuit court granted summary judgment in favor of KSU.

The circuit court concluded that the notice-prejudice doctrine applied.  The Court of Appeals disagreed and held that the terms of the Policy are clear about the extended reporting period. The Court of Appeals determined that the notice-prejudice rule does not apply to the Policy in this case.

ANALYSIS

The primary issue before the Supreme Court was whether the circuit court properly interpreted the notice provisions within the claims-made-and-reported insurance policy issued by Allied World to KSU and then, based upon that interpretation, correctly assessed the role, if any, that the notice-prejudice rule plays in this case.

Construction and Interpretation of Contracts.

In the absence of ambiguity, a written instrument will be enforced strictly according to its terms, and a court will interpret the contract’s terms by assigning language its ordinary meaning and without resort to extrinsic evidence

THE POLICY.

The Policy provisions which explain the insurer’s coverage obligations in relation to the insured’s reporting obligations and which present the notice requirements are found in three clauses all of which require notice no later than ninety days after the end of the policy period.

Furthermore, with regard to reporting beyond the policy period, the Policy also provided KSU the right to purchase a Discovery Period after the expiration of the Policy. KSU did not purchase Discovery Period coverage.

THE NOTICE-PREJUDICE RULE.

The Policy expressly informed KSU that a condition of coverage – a condition precedent – was giving written notice of a claim as soon as practicable, but in no event was such notice of any claim to be provided to Allied World later than ninety days after the end of the Policy period. Since KSU did not purchase Discovery Period coverage, so the reporting period did not extend beyond the 90-day reporting period, the Policy clearly defined when notice was due and the consequences if notice is late.

The Policy unambiguously informed KSU that if the notice provisions were not met, Allied World had no obligation to KSU under the Policy.

Unlike the circuit court, the Supreme Court concluded that the Policy provisions at issue are unambiguous. Given the plain terms of the contract, their full force and effect does not equate to creating a windfall for the insurer. In the absence of circumstances justifying relief, courts do not make contracts different from those that the parties make for themselves, even when forfeiture provisions are harsh.

Application of the Notice-Prejudice Rule to Claims-Made-and-Reported Policies.

The Supreme Court concluded: “A claims-made-and-reported policy provides coverage only for claims made against the insured and reported to the insurer during the life of the policy regardless of when the underlying incident occurred. Timely notice of a claim is the event that not only triggers coverage, but also defines its scope.”

An occurrence-based policy is different. The Supreme Court concluded that Allied World was entitled to deny coverage to KSU when KSU did not comply with the notice requirements.

ZALMA OPINION

The claims made and reported liability insurance policy was designed to avoid long-term liability exposure faced by an “occurrence” policy and to avoid the insured’s ability to extend reporting requirements by use of the notice-prejudice rule that allowed a late report as long as the insurer was not prejudiced by the delay. In this case a three day delay would not cause prejudice to the insurer but it breached the clear and unambiguous condition precedent to coverage. KSU had months to report the claim and waited too long.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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No Coverage to Run Down Your Wife

For Want of $78 a Wife’s Injuries Go Uncompensated

See the full video at https://rumble.com/v2v5rvb-no-coverage-to-run-down-your-wife.html and at https://youtu.be/kEdfCLknNr8

Plaintiff Eric Levy sought a declaration that defendant New York Central Mutual Fire Insurance Company (New York Central) is obligated to provide plaintiff with coverage, defense, and indemnification for an August 29, 2021 car accident where he negligently injured his wife. New York Central moved for an order granting summary judgment dismissing plaintiff’s complaint and for a declaratory judgment declaring that it is not obligated to provide plaintiff with a defense or indemnification for the motor vehicle accident that is alleged to have occurred onAugust 29, 2021, as no Supplemental Spousal Liability coverage exists for this claim.

In Eric Levy v. New York Central Mutual Fire Insurance Company, Index No. 66227/2021, 2023 NY Slip Op 23183, the New York Court found in favor of the insurer.

FACTUAL AND RELEVANT PROCEDURAL BACKGROUND

On August 29, 2021, while driving his car, plaintiff accidentally struck his wife Lisa Grauer (Grauer), and Grauer allegedly suffered serious including a fracture. At the time of the accident, plaintiff had an active motor-vehicle insurance policy through New York Central with bodily-injury liability limits of $250,000.00 per person injured. Grauer filed a claim against plaintiff to New York Central, alleging that she was injured as a result of plaintiff’s negligence.

Plaintiff alleged that New York Central is liable for breach of contract in the amount of $250,000.00 for failing to provide plaintiff with coverage, a defense and indemnification. Plaintiff moved for summary judgment on his amended complaint and is requesting a declaratory judgment, as set forth in the first cause of action. Plaintiff submitted an affidavit, describing the events that transpired and alleges that he was not provided with proper notice of SSL coverage.

New York Central avered that no SLL coverage exists for plaintiff’s policy, that it did comply with all notification requirements, and that plaintiff declined to purchase SLL coverage. New York Central issued a revised renewal policy adding an additional vehicle and included an SSL endorsement. The additional premium for the SSL coverage was $78.00 and plaintiff declined to purchase it.

Supplemental spousal liability insurance provides bodily injury liability coverage under a motor vehicle insurance policy to cover the liability of an insured spouse because of the death of or injury to his or her spouse, even where the injured spouse must prove the culpable conduct of the insured spouse.

DISCUSSION

Insurance Law § 3420 (g) was amended by Chapter 584 of the Laws of 2002, to require insurance carriers to offer their insureds supplemental spousal liability (SSL) insurance for an additional premium. This SSL coverage provides drivers with the option to be insured in cases where their negligence causes death or injury to their spouse.

Both parties present the insurance policy in support of their summary judgment motions and do not dispute the contents. The Court found that New York Central has made prima facie showing it is not obligated to provide plaintiff with indemnification or a defense for the motor vehicle accident occurring on August 29, 2021, because no SSL liability existed for this claim. Since Plaintiff declined to purchase the SLL an insurer is not required to provide insurance coverage for injuries sustained by an insured’s spouse.

It was undisputed that plaintiff did receive notification of the availability of the supplementary spousal liability insurance, and he refused to pay the extra $78 premium.

Accordingly, it was ordered that plaintiff Eric Levy’s motion was denied it its entirety. New York Central Mutual Fire Insurance Company’s cross motion for an order granting summary judgment dismissing plaintiff’s complaint and for a declaratory judgment, is granted; and it was further ordered that defendant New York Central, because, as no Supplemental Spousal Liability coverage existed; and it was further ordered that the case was dismissed, and the Clerk was directed to enter judgment accordingly.

ZALMA OPINION

Insurers do not like, because of the potential for fraud, to insure against injury to a family member of the insured. New York passed a law requiring insurers to provide coverage for injury caused to a spouse as long as the insured pays an additional premium. Mr. Levy refused to pay the extra $78 and, by so doing, refused the coverage that only after the accident he wanted. No luck since he got the offer and the charge and refused it.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

 

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Judicial Restraint

Appeal Back to District Court on Coverage Claim by Injured

See the full video at https://rumble.com/v2vbz0l-judicial-restraint.html and at https://youtu.be/Z2XZZVDfAqM

Jacob E. Godlove, Sr., and Kayla Kelley, on behalf of themselves and the Estate of Jacob Godlove, Jr., (collectively, Appellants), appealed to the District Court’s order denying their motion to intervene in an insurance-coverage dispute. In County Hall Insurance Company, Inc. v. Mountain View Transportation, LLC; John R. Humes, Jacob E. Godlove; Kayla Kelley; Estate Of Jacob Godlove, Jr., No. 22-2397, United States Court of Appeals, Third Circuit (June 16, 2023) the Third Circuit deal with changed circumstances.

FACTS

Godlove and Kelley, who was pregnant at the time with Godlove, Jr., were in a motor-vehicle accident with a tractor-trailer owned by Mountain View Transportation, LLC and driven by John R. Humes. Godlove and Kelley, on behalf of themselves and the Estate, sued Mountain View and Humes in state court for the resulting injuries, including the death of Godlove, Jr., which occurred two months after the accident.

Mountain View’s insurer, County Hall Insurance Company, Inc., claimed its insurance policy did not cover the accident because Humes was not listed on the relevant schedule of drivers. The letter also informed Mountain View that County Hall would defend the state-court tort action under a reservation of rights.

County Hall filed a federal court case against Mountain View and Humes, seeking a declaration that the policy did not cover the accident. After Mountain View and Humes failed to respond, the Clerk of Court entered a default against them at County Hall’s request.

After Appellants filed the state-court declaratory judgment action, County Hall moved the District Court for a default judgment in this federal action. The same day, Appellants moved to intervene in this action and to strike the entry of default.

The District Court denied the motion to intervene and the motion to strike.

During the pendency of the appeal, Appellants settled the underlying state-court tort suit against Mountain View and Humes, who were represented by counsel under County Hall’s reservation of rights. Appellants obtained a $1,000,000 judgment against Mountain View and Humes and an assignment of rights under any insurance policies.

Soon after, Appellants again sought a declaration in state court that the insurance policy covered the accident-this time standing in the shoes of Mountain View and Humes. That action remains pending.

When the District Court entered its order denying the motion to intervene, Appellants were only “plaintiffs who ha[d] asserted tort claims against the insured.” In the District Court’s words, they were “strangers to [the] insurance contract.” That is no longer so.

ANALYSIS

First, Appellants now have a judgment against Mountain View and Humes. Second, they have a purported assignment of rights under Mountain View’s insurance policy and have sued County Hall in state court on that basis.

The Third Circuit concluded that since the District Court might reach a different conclusion on the motion to intervene in view of the changed circumstances; or the purported assignment of rights might require or permit party substitution of the Federal Rules of Civil Procedure; and because no declaratory judgment has been entered it might be appropriate for the District Court to stay this action pending resolution of the state-court declaratory judgment action.

The Third Circuit, therefore exercised judicial restraint and refused to express any view on the propriety of the stated possibilities. For that reason the Third Circuit decided to avoid making a decision and allow the District Court to evaluate the changed circumstances in the first instance.

Consistent with that principle, the Third Circuit vacated the District Court’s order and remanded the case back to the District Court for further proceedings.

ZALMA OPINION

When facts change after a ruling by a district court on an insurance coverage issue it is inappropriate for an appellate court to stomp on the jurisdiction of the trial court. Noting that the changed facts could have resulted in multiple different resolutions the Third Circuit exercised required judicial restraint and required to trial court to decide the issues by taking into consideration the changed facts exercising the wisdom accorded to King Solomon.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library

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Bee Gees Were Right: Staying Alive is Important

Failure of Proposed Insured Stay Alive Until Policy Delivered Costs Fiance Almost $5 Million

See the full video at https://rumble.com/v2v599w-bee-gees-were-right-staying-alive-is-important.html  and at https://youtu.be/QgAhIJh_oRQ

On January 27, 2021, Dr. Travis Richardson completed an application for an individual life insurance policy with Pacific Life seeking $4,816,949.00 in coverage. Blevins was Dr. Richardson’s fiancé and was listed as the primary beneficiary of the policy. Lamar Breshears was the insurance agent for Pacific Life. Champion Agency (“Champion”) handled details. Dr. Richardson died unexpectedly before the policy was delivered and the insurer refused to pay.

In Pacific Life Insurance Company v. Katie Blevins, No. 3:21-CV-00143 JM, United States District Court, E.D. Arkansas, Northern Division (June 15, 2023} the USDC resolved the claim of the beneficiary.

FACTS

On February 1, 2021, Champion transmitted Dr. Richardson’s application to Pacific Life with the instructions to process the application and to mail the policy to Champion at its office in Albuquerque, New Mexico. Pacific Life received Dr. Richardson’s application on February 2, 2021. On March 11, 2021, Pacific Life’s underwriting department approved Dr. Richardson for Policy and the initial monthly premium of $16,668.68 was paid. The same day that the policy was approved, Pacific Life uploaded an electronic copy of the policy to its Planned Performance Tracking portal (the “PPT portal”).

On March 12, 2021, Dr. Richardson emailed Breshears and asked him when the policy was active. Breshears responded the same day, stating, “Today. If you were to die today, the policy would pay out a death benefit.” Breshears was wrong because Dr. Richardson died unexpectedly on March 14, 2021.

The physical policy was received by Champion March 15, 2021. Pacific Life refunded the initial premium payment on March 25, 2021, taking the position that the policy was not “in force” at the time of Dr. Richardson’s death because it had not been “delivered” as required by the application and policy.

ANALYSIS

It was undisputed that delivery of the policy was a valid condition precedent to Blevins being entitled to receive payment under the policy. The application states that: “[c]overage will take effect when the Policy is delivered and the entire first premium is paid only if at that time each Proposed Insured is alive, and all answers in this Application are still true and complete.” (emphasis added.).

The policy, which incorporates the application, states that a Policy is in effect and provides a Death Benefit on the Insured on the date the Policy and associated riders become effective. The Policy Date for this policy was March 11, 2021 a date before Dr. Richardson died.

Pacific Life claimed that delivery of the policy required Dr. Richardson to have received and accepted a physical copy of the policy. It is undisputed that this did not happen, and Pacific Life sought summary judgment. The Court found that there were no material facts in dispute and agreed that the policy was not delivered.

The fact that the challenged terms are not defined does not make them vague and ambiguous.

Importantly, the USDC noted that the policy must be read as a whole, and effect given to all provisions. Construction that neutralizes any provision of a contract should never be adopted if the contract can be construed to give effect to all provisions. The policy in question unambiguously state that it is in force (defined as meaning in effect and paying death benefits), “subject to your acceptance of the delivered policy and payment of the initial premium.” (emphasis added).

While the term “policy date” clearly was confusing even to Breshears, it did not neutralize the delivery and acceptance requirements.

In addition to the delivery requirement, the application stated that coverage under the policy would take effect when it was delivered “only if at that time” the proposed insured was alive and “all answers in this Application are still true and complete.” Under Arkansas law, “if the policy was mailed [to the agent] unconditionally for the sole purpose of delivery to the assured,” the mailing of the policy from the insurance company to the agent would constitute constructive delivery. The burden of proof to show that the policy was unconditionally delivered to the agent for delivery to the insured is on the plaintiff.

Breshears testified that he understood delivery of the policy to mean “physically sending the policy to the client,” and that a “hundred percent of his policies have been delivered by paper.” Pacific Life has established that it physically mailed the policy to Champion pursuant to the instructions it received with the transmittal of Dr. Richardson’s application. Included with the mailed policy were a delivery receipt and an amendment to the application to correct minor inaccuracies. Blevins did not establish that there is a genuine issue of material fact on the issue of constructive delivery of the policy.

Since at that time the outstanding delivery requirements had not been communicated to Breshears or Champion at that time, she argues that those delivery requirements were waived. However, that does not support her claim that the precondition of delivery itself was waived.

The Court has no doubt that Dr. Richardson, Breshears, and Blevins believed that Dr. Richardson was covered under the policy as of March 11, 2021. However,  Pacific Life’s motion for summary judgment  was granted.

ZALMA OPINION

People buy life insurance because they recognize that life is a disease from which all humans suffer. We all, eventually, die. Dr. Richardson wanted to protect his fiance and applied for a life insurance policy that he expected to have for many years only to die before the policy was delivered to him. Insurance policies must be read as a whole. In this case, the policy never came into effect because he was not alive when the policy was delivered. A sad result but on its face a correct decision.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Life Insurance Can Be Hazardous to Your Health

Fictionalized True Insurance Fraud

See the full video at https://rumble.com/v2ufulw-life-insurance-can-be-hazardous-to-your-health.html and at https://youtu.be/l2rVoDHIkXw

A Story of Life Insurance Fraud

This is a fictionalized True Crime Story of Insurance Fraud to explain why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is intended to  help you to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the ­­­Perpetrators than any Other Crime.

The Hungarian owned and operated a board and care facility for the aging in Carson City, Nevada. He brought his younger brother over from Hungary in 1975 to help him in the business. It was only a twenty-bed facility and with little help, the two could manage the entire business.

The oldest brother was the thinker. He got an honorary Ph.D. from the New World Society of Abundant Consciousness that ran a school in the desert just north of Pahrump. After receiving his honorary degree for a donation of $15,000, he insisted on the title doctor.

The doctor had no training in any field. He had a high school diploma and had operated several restaurants before buying the board and care facility. He believed that the title conferred on him the right to prescribe medicine, to give psychological advice, and to do anything he pleased. He would get drugs for his patients from other than legitimate sources. He would bill their insurers as if they were prescription drugs prescribed by a staff physician.

His younger brother maintained the facility, cooked the meals for the residents, doubled as a nurse and ran the business. The doctor acted like royalty.

Since the small business required both to work if it was to make a profit, the business began to deteriorate. Cash flow was minimal. Patient services became almost nonexistent. The doctor skimmed as much money into his pocket as he could and keep the patients alive. Neither he nor his brother drew anything much more than subsistence monies from the business.

The dedicated younger brother made the business work. He began to cut personal corners. First, he decided to drop a $100,000 life insurance policy. With the reduced earnings of the business, he could not afford to pay the premium.

The doctor, who used the same insurance agent, was told of the intent of the brother to cancel. The doctor asked the agent to keep the policy in effect without his brother’s knowledge. The doctor would pay the premium as a business expense of the board and care facility.

The agent, not wishing to lose his commission, agreed and kept the policy in force, accepting premium payments from the doctor.

The younger brother suffered from severe hypertension. His controlled the disease by diet and medications. He trusted his older brother. He thought his older brother was wise and knowledgeable. He thought his older brother had, at least, the same level of expertise as any physician and trusted his brother more than a physician.

After the doctor had paid the first monthly premium on the life insurance policy, he explained to his brother that the hypertension drugs prescribed for him were dangerous. He told his younger brother that he had in the inventory of the board and care facility drugs that were more effective. Since they were in the stock of the facility the doctor could give them to his brother at no cost. The brother stopped taking his prescribed medicine and started taking the drugs given him by his brother. The doctor did not tell his brother that the drugs contained digitalis. Digitalis is a drug that, although useful in reducing chest pains in people with heart conditions, is poisonous in the amounts the doctor told his brother to take. It is even more poisonous to a person with hypertension.

Within two weeks of taking his brother’s drugs, the younger brother was found by his wife apparently dead, on his kitchen floor. Paramedics arrived and immediately began CPR. Because she did not know what to do after calling the paramedics, the wife called her brother-in-law. He arrived at the scene about the same time as the paramedics. He was hysterical and interfered with the paramedics. They had to forcibly remove him from his brother so they could perform CPR. They put the brother in an ambulance and began racing toward the emergency hospital with red lights and siren. The doctor followed and almost sideswiped the ambulance twice. They called for police help on their radio. A Carson City police officer pulled the doctor off to the side of the road and restrained him for sufficient time to allow the ambulance to arrive at the hospital.

They could not revive the younger brother. They pronounced him dead one hour after arrival at the hospital. The doctor convinced the wife there should be no autopsy. His brother, her husband, had a severe heart condition that was well documented. He explained that there should be no reason to cut his body to satisfy a local ordinance.

The doctor convinced the brother’s family physician to sign the death certificate showing the cause of death as a heart attack. The family physician did so without evidence of such a heart attack. The family physician had not even seen the deceased within six months of his death. The family physician clearly violated the law. He thought the death certificate would help the family who appeared adamantly against the invasive procedures of an autopsy.

The widow was not an intelligent woman. She had limited education in her country of birth, Hungary. She could barely read or write the English language and spoke it with a thick accent. She relied totally on her brother-in-law. He handled the disposition of her husband’s estate. She signed whatever papers he put before her.

One paper he put in front of her was a claim form making claim on the life insurance policy. The claim form did not use the sister-in-law’s address but, rather, a P.O. box held in secret by the doctor. The insurance company, presented with an appropriate claim form signed by the widow and what appeared to be a proper death certificate, immediately issued its check for $100,000 plus interest, made payable to the widow, the sole beneficiary named in the policy.

The doctor received the check. He signed the widow’s name to it and deposited the money in his account. He used the money to pay the debts of the board and care facility and to buy a new home for himself on five acres of desert property outside Carson City. The widow was left with nothing but debts. She sold the home she and her husband lived in since arriving in the U.S. After paying a commission to the realtor and the funeral expenses she had only $1,000 left. Her brother-in-law loaned her $10,000 which she used to buy some secondhand furniture and move into a small apartment. She met a blackjack dealer at a casino and married him so she would have some means of support.

The doctor lived in luxury for a year off the proceeds and then began planning his next insurance fraud. He has no other brothers to kill, so he decided to obtain life insurance on the residents of the board and care facility none of whom had a long life expediency.

 

(c) 2023 Barry Zalma & ClaimSchool, Inc.

Subscribe and receive videos limited to subscribers of Excellence in Claims Handling at locals.com https://zalmaoninsurance.locals.com/subscribe.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Zalma’s Insurance Fraud Letter – June 15, 2023

ZIFL – 6-15-2023 – Volume 27, Issue 12

See the full video at https://rumble.com/v2u5x6o-zalmas-insurance-fraud-letter-june-15-2023.html  and at https://youtu.be/ftQmCWmT-gE

The Source For Insurance Fraud Professionals

From https://zalma.com/blog, this, the Twelfth issue of the 27th year of publication Zalma’s Insurance Fraud Letter provides multiple articles on how to deal with insurance fraud in the United States. The issue begins with:

Restitution Order Can’t Be Discharged in Bankruptcy

After Frayba Tipton and William Tipton pled guilty to committing insurance fraud, they were ordered to pay victim restitution to Nationwide Insurance Company of America (Nationwide). Nationwide obtained a civil judgment and an award of over $1,200,000 in civil litigation against the Tipton’s only to have the judgment discharged in bankruptcy. Nationwide then petitioned the trial court to convert the criminal restitution orders to civil judgments against both defendants. The trial court granted Nationwide’s petition and entered civil judgments against the defendants.

In Nationwide Insurance Company Of America v. Frayba Tipton et al., C095606, California Court of Appeals, Third District, San Joaquin (May 26, 2023) the court agreed that the restitution order could be made collectible as a civil judgment and not subject to discharge in bankruptcy.

See the full issue at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

More McClenny Moseley & Associates Issues

This is ZIFL’s eighth installment of the saga of McClenny, Moseley & Associates and its problems with the federal courts in the State of Louisiana and what appears to be an effort to profit from what some Magistrate and District judges indicate may be criminal conduct to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana.

See the full issue at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

Another Insurer Bites the Dust

Nevada Insurance Commissioner Petitions to Place Friday Health in Receivership

Friday Health Plans of Nevada has fallen afoul of Nevada Insurance Commissioner Scott Kipper who filed legal action with the Nevada District Court to place it under regulatory supervision.

See the full issue at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

Bad News from The Public

A new survey shows it’s, like, totally cool to exaggerate damages on an insurance claim or, like, totally awesome to say you hurt yourself at work when you didn’t.

See the full issue at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

Health Insurance Fraud Convictions

Fifteen Year Sentence in $134 Million COVID-19 Health Care Fraud and Money Laundering Scheme

Billy Joe Taylor, age 44, pleaded guilty to conspiracy to commit health care fraud and money laundering on October 27, 2022. According to court documents, Taylor and his co-conspirators submitted more than $134 million in false and fraudulent claims to Medicare in connection with diagnostic laboratory testing, including urine drug testing and tests for respiratory illnesses during the COVID-19 pandemic, that were medically unnecessary, not ordered by medical providers, and not provided as represented. Taylor and his co-conspirators obtained medical information and private personal information for Medicare beneficiaries, and then misused that confidential information to repeatedly submit claims to Medicare for diagnostic tests. According to court documents, Taylor and his co-conspirators received more than $38 million from Medicare on those fraudulent claims.

See the full issue and dozens more convictions at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

Florida Judge Slams SFR Contractor for Misrepresentation, Fraud in Tower Hill Case

SFR Services, a Florida restoration firm made famous by its volume of claims litigation and its charges that United Property & Casualty Insurance Co. had instructed desk adjusters to alter their estimates, now finds itself in some legal trouble of its own.

See the full issue at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

Other Insurance Fraud Convictions

Man Sentenced to Prison for Staged Arson and Insurance Fraud

Denis Vladmirovich Molla falsely reported to the Brooklyn Center Police Department that his camper had been intentionally set on fire the 30-year-old Minnesota resident has been handed a 30-month prison sentence, followed by one year of supervised release, for filing fraudulent insurance claims related to a staged arson incident.

See the full issue and more convictions at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

The Baseball Card Scam

This is a Fictionalized True Crime Story of Insurance Fraud from my experience as an Insurance Fraud Expert and is provided to explain why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is true, only the names and places were changed to protect the guilty.

See the full issue at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

Qui Tam and Insurance Fraud

The qui tam portion of the California Insurance Frauds Prevention Act, like that in many other states, has a qui tam provision.

See the full issue at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

It’s Time to Subscribe to Locals or Substack

For Subscribers Only I Have Published Special Insurance Videos

See the full issue at http://zalma.com/blog/wp-content/uploads/2023/06/ZIFL-06-15-2023.pdf

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Primary Insurer On First

Umbrella Policy Always Excess Over Primary Policy

See the full video at https://rumble.com/v2ty5y4-primary-insurer-on-first.html  and at https://youtu.be/bfKSFHbzWmw

Two insurance companies argued who must indemnify an insured for a settlement involving their mutual insured. Great American Insurance Company paid subject to a reservation and sued the primary insurer, Allied World Assurance Company, alleging that because it was the umbrella insurer it only owed after Allied World as the primary insurer, paid its limits. The district court agreed, granting summary judgment in Great American’s favor.

In Great American Insurance Company v. Allied World Assurance Company, Inc., No. 22-12496, United States Court of Appeals, Eleventh Circuit (May 31, 2023) determined who was on first to the obligation to indemnify the insured, Tribridge Residential. After two women were shot and killed at an apartment complex that Tribridge managed an ensuing lawsuit alleged Tribridge negligently failed to implement security. Tribridge settled that suit with plaintiffs.

Three different insurance companies insured Tribridge. AmTrust International Underwriters DAC, an insurance company that issued Tribridge a primary commercial general liability policy, paid out its policy limit toward the settlement. Then, Allied World and Great American disagreed about which policy was the priority coverage for the rest of the settlement.

ALLIED WORLD POLICY

Allied World issued Tribridge a commercial general liability policy. Allied World issued a “primary policy,” it contains an excess clause purporting to render its coverage excess of other insurance when liability arises from Tribridge’s property management activities.

GREAT AMERICAN POLICY

Great American issued a “Commercial Umbrella Coverage” policy which includes Tribridge as an additional insured. The policy covers “those sums in excess of the ‘Retained Limit’ that the ‘insured’ becomes legally obligated to pay imposed by law or . . . because of ‘bodily injury.'”

Great American paid the rest of the settlement against Tribridge and sued Allied World, seeking equitable contribution and a declaratory judgment that its coverage obligation is not triggered until Allied World’s policy limit is exhausted.

ANALYSIS

Georgia law delineates between a “primary” insurance policy “written to provide primary coverage”- and an “umbrella” policy- operating as true excess over and above any type of primary insurance. All primary coverage must be exhausted before umbrella policy coverage is triggered.

Primary policies precede umbrella policies even when the primary policy includes an applicable “excess clause.” Umbrella policies, almost without dispute, are regarded as true excess over and above any type of primary coverage, excess provisions arising in regular policies in any manner, or escape clauses. Primary policies take priority to umbrella policies, even when the primary policy includes an applicable excess clause.

Great American’s commercial umbrella coverage policy only covers those sums in excess of listed underlying insurance. The Allied World policy is written to provide primary coverage and the Great American policy is the true excess policy. Accordingly, Allied World’s primary policy must be exhausted before the Great American umbrella policy applies.

In sum, Allied World is first in the pecking order as the “primary insurer.”

Summary judgment was affirmed for Great American but the court reversed the award of attorney’s fees.

ZALMA OPINION

The great comedians Abbot & Costello created the “Who’s on First Routine” that brought laughter to the question of who is in running the game. In this case a primary insurer, even with an “excess” and/or “escape” clause the primary is always on first and the umbrella only owes after the primary – the insurer on first – pays its limit and then the umbrella, on second base pays whatever is needed after the primary pays its limit. Allied World tried to avoid its obligation, failed, and is required to reimburse Great American.

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(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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No Defense of False Advertising

Kona Coffee Must be From the Big Island of Hawaii

See the full video at https://rumble.com/v2tqizk-no-defense-of-false-advertising.html and at https://youtu.be/PEiGcgzbQPU

L&K Coffee claimed its various insurance companies erroneously denied coverage to defend it against a Lanham Act false-advertising lawsuit brought by Hawaiian coffee growers. The district court concluded the applicable insurance policies did not obligate a defense and entered summary judgment in the insurance companies’ favor.

In L&K Coffee LLC, dba Magnum Roastery; Kevin Kihnke v. LM Insurance Corporation; Liberty Insurance Corporation; Selective Way Insurance Company; Valley Forge Insurance Company; Continental Casualty Company, No. 22-1727, United States Court of Appeals, Sixth Circuit (June 1, 2023) the Sixth Circuit resolved the coverage dispute.

FACTS

L&K Coffee, LLC, a Michigan-based company, roasts and sells coffee products throughout the United States. Defendants are insurance companies from whom L&K purchased general commercial liability and umbrella insurance policies.

Coffee growers from the Kona region of the Island of Hawai’i sued L&K and other coffee companies for “false designation of origin, false advertising, and unfair competition” in violation of the Lanham Act, 15 U.S.C. § 1125(a), in the Western District of Washington. These “Kona Plaintiffs” alleged that the defendants falsely designated the origin of the coffee they branded and distributed as “Kona” coffee “when most of the coffee beans contained in the coffee products were sourced from other regions of the world.”

The Kona Plaintiffs’ operative complaint summarized their contentions as to L&K as follows: “L&K falsely designates the geographic origin of its “Kona” coffee products with the prominent placement of KONA on the front of the packaging.”

The deceptive marketing was alleged to be designed to mislead consumers into believing that L&K’s Magnum Exotics “Kona” products contain coffee from the Kona District, when the coffee products actually do not contain a significant amount of Kona coffee, if any.  The plaintiffs also alleged that L&K deliberately misled the consumer into believing that L&K’s Magnum Exotics coffee products contain significant amounts of premium Kona coffee beans in order to justify the high price L&K charges for what is actually ordinary commodity coffee.

L&K asked the insurance companies to defend and indemnify them in that matter under the policies’ “personal and advertising injury” coverage. Personal and advertising injury, in pertinent part, is defined as an “injury . . . arising out of” (1) a publication that “disparages a person’s or organization’s goods, products or services,” or (2) “[i]nfringing upon another’s . . . slogan in your advertisement.” Based on this language and the Kona Plaintiffs’ allegations, the insurance companies denied coverage because, as one insurer put it, “none of the offenses in the definition of ‘personal and advertising injury’ include false advertising, and none of the allegations in the complaint fall within any of the offenses in the definition.”

ANALYSIS

The duty of an insurance company to provide a defense depends upon the allegations in the complaint and extends to allegations which even arguably come within the policy coverage. An insurer’s duty to defend does not depend solely upon the terminology used in a plaintiff’s pleadings. Rather, it is necessary to focus on the basis for the injury and not the nomenclature of the underlying claim in order to determine whether coverage exists.

The term “disparage” means an untrue statement directed towards another’s property. A disparagement claim requires a company to make false, derogatory, or disparaging communications about a competitor’s product.” (emphasis in the opinion)

The Kona Plaintiffs alleged L&K violated the Lanham Act’s prohibition on false designation of one’s own product. See 15 U.S.C. § 1125(a)(1). The Sixth Circuit concluded that this is not “disparagement.”

Upon review of the Kona Plaintiffs’ complaint, the Sixth Circuit Court agreed with the district court that the complaint does not set forth an arguable theory of recovery. In the Kona Plaintiffs’ own words, “only coffee grown on farms located within the Kona District of the Big Island of Hawaii . . . can be truthfully marketed, labeled, and sold as Kona coffee.” L&K violated the false designation of its product and that was not a covered cause of loss.

ZALMA OPINION

It never pays to lie to your customers. When doing so harms someone else you are subject to damages from those your lie harms. By falsely designating its product of “Kona” coffee when L&K claimed its cheap, generic coffee was “Kona” Coffee it was involved in a tort that was not covered by the policies of insurance.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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Policy Enforced as Written

“Reside” is not Ambiguous

See the full video at https://rumble.com/v2t3wke-policy-enforced-as-written.html and at https://youtu.be/AG0d2guHKmE

NO COVERAGE FOR INSURED WHO DOES NOT RESIDE IN DWELLING

The plaintiffs appealed the dismissal of their suit against Farmers Automobile Insurance Association (Farmers). The plaintiffs were insured by Farmers for a St. Joseph residence that the plaintiff Judy had inherited from her deceased brother. The plaintiffs filed a claim with the company following a fire that destroyed the residence. Farmers denied the claim as the plaintiffs were not occupying the property at the time of the fire and were therefore not covered under the terms of the policy.

In Judy Dardar and Ivan Dardar v. Farmers Automobile Insurance Association and Jason Sticklen, Farmers Automobile Insurance Association, No. 5-22-0357, 2023 IL App (5th) 220357-U, Court of Appeals of Illinois, Fifth District (June 2, 2023) the claim of the Dardar’s was resolved.

BACKGROUND

Before he died David Jones, Judy’s brother, purchased an insurance policy from Farmers through Sticklen for property and liability insurance coverage for his residence in Champaign County. After David’s death Judy was appointed the legal independent representative of his estate.

Farmers issued a homeowner’s policy amending declarations, which added the decedent’s estate and Judy as additional insureds as well as a non-occupancy permit endorsement.

Once the estate was closed, and the house was transferred to Judy, she began making renovations to the residence. The plaintiffs were undecided as to whether they were going to live in the house after the renovations were complete or sell it. Then, on July 4, 2018, firework embers from an unidentified source caught the house on fire, and it was destroyed.

The plaintiffs never lived in or occupied the home. Judy had no knowledge that the policy was issued without the non-occupancy permit endorsement.

Farmers denied the claim on the basis that the policy covered their “residence premises,” which was defined as:

  • the one-family dwelling where you reside;
  • the two, three, or four-family dwelling where you reside in at least one of the units; or
  • that part of any other building in which you reside.

Farmers determined that the plaintiffs did not reside at the St. Joseph property and therefore were not covered under the policy terms. Judy claimed Sticklen failed to properly inform Farmers of her condition, and Farmers issued a new policy without the non-occupancy permit endorsement.

The court found that, based on the facts alleged, there was not a sufficient basis for a breach of contract claim against Farmers and granted Farmers’ motion to dismiss. Based on the relevant facts, the plaintiffs could never plead that they ever resided on the St. Joseph property.

ANALYSIS

The issue on appeal was whether the trial court erred in granting Farmers’ motion to dismiss the breach of contract count.

A court must construe a policy of insurance as a whole and take into account the type of insurance purchased, the nature of the risks involved, and the overall purpose of the contract.

“Reside” is not ambiguous as it is used in the policy contract language between Farmers and the plaintiffs. The record established that the plaintiffs never lived on the property, were not occupying it in any way, and had not decided whether they would move into the home once the renovations were done.  The mere fact that because “reside” has more than one definition does not make it ambiguous when, as here, there is no definition of the word that would apply to the plaintiffs. The Court of Appeal, like the trial court, concluded that the term “reside” as used in Farmers’ policy s not ambiguous.

ZALMA OPINION

There is nothing secret or difficult to understand about a policy definition that provides “one-family dwelling where you reside.”  Since the insured did not reside in the dwelling and never resided in the premises, the unambiguous requirement of coverage was not met. They could easily have acquired a fire insurance policy that insured the plaintiffs, as a non resident, against the risk of loss of the house by fire. Instead they acquired a homeowners policy that required that they reside in the house. They did not and they recovered nothing.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Barry Zalma, Esq., CFE, is available at http://www.zalma.com and zalma@zalma.com

Follow me on LinkedIn: www.linkedin.com/comm/mynetwork/discovery-see-all?usecase=PEOPLE_FOLLOWS&followMember=barry-zalma-esq-cfe-a6b5257

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published at https://zalma.substack.com. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; https://creators.newsbreak.com/home/content/post; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library.

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