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ISSUE OF FACT ABOUT MEANING OF AN EXCLUSION IN A FLOOD INSURANCE POLICY.

The First Department determined there was a question of fact about the meaning of an exclusion in a flood insurance policy. The policy excluded coverage for property in (FEMA) Flood Zone A. The plaintiff’s property was located in (FEMA) Flood Zone AE:

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When it comes to exclusions from coverage, the exclusion “must be specific and clear in order to be enforced” … and ambiguities in exclusions are to be construed “most strongly” against the insurer … . As this Court has recognized, there are circumstances where extrinsic evidence may be admitted prior to an exclusion being strictly construed against an insurer … , and “[w]here [] ambiguous words are to be construed in the light of extrinsic evidence or the surrounding circumstances, the meaning of such words may become a question of fact for the jury” … .

Here, the language of FEMA’s flood zone regulations raises an issue of fact rendering the insurance policy’s exclusion of flood coverage ambiguous … . Heartland Brewery, Inc. v Nova Cas. Co., 2017 NY Slip Op 02908, 1st Dept 4-13-17

 

INSURANCE LAW (ISSUE OF FACT ABOUT MEANING OF AN EXCLUSION IN A FLOOD INSURANCE POLICY)/CONTRACT LAW (INSURANCE POLICY, ISSUE OF FACT ABOUT MEANING OF AN EXCLUSION IN A FLOOD INSURANCE POLICY)/EXCLUSION (INSURANCE LAW, ISSUE OF FACT ABOUT MEANING OF AN EXCLUSION IN A FLOOD INSURANCE POLICY)

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INSURER’S FRAUDULENT INCORPORATION DEFENSE TO ITS REFUSAL TO PAY NO-FAULT BENEFITS TO A CORPORATION RUN BY NON-PHYSICIANS WAS PROPERLY PRESENTED TO THE JURY, DEPOSITION TESTIMONY IN WHICH NON-PARTIES INVOKED THE FIFTH AMENDMENT SHOULD NOT HAVE BEEN READ TO THE JURY.

The Second Department, in a full-fledged opinion by Justice Duffy, determined defendant insurance company was entitled to the fraudulent incorporation defense in support of its refusal to pay no-fault benefits to plaintiff corporation for MRI’s administered by plaintiff corporation. The Business Corporation Law required that plaintiff corporation be run by physicians. There was substantial evidence the corporation was being run by two non-physicians with a physician as a cover. The Second Department found that the jury instructions explaining the criteria for the fraudulent incorporation defense were proper. The Second Department noted that the deposition testimony in which the two non-physician operators of plaintiff corporation refused to answer questions (invoking the Fifth Amendment) should not have been read to the jury because they were non-party witnesses. However, the error was deemed harmless. With respect to the fraudulent incorporation defense, the court wrote:

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… [T]he jury charge, read as a whole, adequately conveyed the correct legal principles on “fraudulent incorporation” … . The instructions asked the jury to consider whether, under the totality of the circumstances, the plaintiff was operating as a proper professional medical corporation in compliance with state regulations or whether, in order to obtain money that insurers were otherwise entitled to deny, the plaintiff was organized under the facially valid cover of [a physician] but was, in actuality, operated and controlled by [two non-physicians] to funnel profits to themselves. Carothers v Progressive Ins. Co., 2017 NY Slip Op 02614. 2nd Dept 4-5-17

INSURANCE LAW (INSURER’S FRAUDULENT INCORPORATION DEFENSE TO ITS REFUSAL TO PAY NO-FAULT BENEFITS TO A CORPORATION RUN BY NON-PHYSICIANS WAS PROPERLY PRESENTED TO THE JURY)/CORPORATION LAW (INSURER’S FRAUDULENT INCORPORATION DEFENSE TO ITS REFUSAL TO PAY NO-FAULT BENEFITS TO A CORPORATION RUN BY NON-PHYSICIANS WAS PROPERLY PRESENTED TO THE JURY)/EVIDENCE (DEPOSITION TESTIMONY IN WHICH NON-PARTIES INVOKED THE FIFTH AMENDMENT SHOULD NOT HAVE BEEN READ TO THE JURY)/FRAUDULENT INCORPORATION DEFENSE  (INSURER’S FRAUDULENT INCORPORATION DEFENSE TO ITS REFUSAL TO PAY NO-FAULT BENEFITS TO A CORPORATION RUN BY NON-PHYSICIANS WAS PROPERLY PRESENTED TO THE JURY)

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LANDLORD (SUBLESSOR) DID NOT OWE A DUTY TO PLAINTIFF’S SUBROGEE TO PREVENT A MENTALLY ILL TENANT FROM SMOKING IN THE APARTMENT WHERE A FIRE STARTED.

The Second Department determined defendant nonprofit did not owe a duty of care to plaintiff’s subrogee for the actions of a tenant which apparently started a fire in the tenant’s apartment. Defendant nonprofit leased apartments to tenants suffering from mental illness. The tenants lived independently with little supervision:

Under limited circumstances, the relationship between a lessor and a lessee can give rise to a duty of care inasmuch as the lessor “must exercise reasonable care not to expose third persons to an unreasonable risk of harm” … . … [T]he relevant inquiry [is] whether the defendant, as sublessor, exposed the plaintiff’s insured in this case to an unreasonable risk of harm. Moreover, in evaluating the existence and scope of the duty of care, we are mindful that where, as here, the action involves only property damage, “the public policies, factors, and other analytical considerations used in setting the orbit of duty are different from those at play in cases involving physical injury” … .

Under the circumstances presented, the defendant established, prima facie, that it owed no duty to the plaintiff’s insured to take affirmative steps to prevent the tenant from smoking in the demised premises … . The evidence showed, inter alia, that all participants in the defendant’s housing program had to be able to live independently, and the degree of oversight provided by the defendant under the terms of its agreement with the tenant was limited. …

“[I]n the absence of fault or a specific contract provision to the contrary, neither the landlord nor the tenant is obligated to perform repairs after a fire” … . Here, the defendant established its prima facie entitlement to judgment as a matter of law dismissing the breach of contract cause of action by showing that the subject lease did not impose an obligation on it to repair the premises after a fire … , or to answer in damages for a fire caused by its sublessee … . Tower Ins. Co. of N.Y. v Hands Across Long Is., Inc., 2017 NY Slip Op 02082, 2nd Dept 3-22-17

 

NEGLIGENCE (LANDLORD DID NOT OWE A DUTY TO PLAINTIFF’S SUBROGEE TO PREVENT A MENTALLY ILL TENANT FROM SMOKING IN THE APARTMENT WHERE A FIRE STARTED)/INSURANCE LAW (LANDLORD DID NOT OWE A DUTY TO PLAINTIFF’S SUBROGEE TO PREVENT A MENTALLY ILL TENANT FROM SMOKING IN THE APARTMENT WHERE A FIRE STARTED)/LANDLORD-TENANT (LANDLORD DID NOT OWE A DUTY TO PLAINTIFF’S SUBROGEE TO PREVENT A MENTALLY ILL TENANT FROM SMOKING IN THE APARTMENT WHERE A FIRE STARTED)

INSURANCE BROKER ENGAGED IN UNTRUSTWORTHY CONDUCT STEMMING FROM A MISLEADING AD FOR VIATICAL SETTLEMENT AGREEMENTS AND WAS PROPERLY FINED.

The Third Department determined petitioner, a licensed insurance agent/broker, had engaged in untrustworthy conduct and was properly fined. Petitioner sold so-called viatical settlement agreements involving the purchase of interests in life insurance policies of elderly and terminally ill persons. Whether the purchased interests would return a profit depended on whether the amounts paid for the policies and premiums was less than the amount the policies paid out upon death. Petitioner took out an ad which was deemed misleading and there was evidence petitioner did not inform purchasers of the risks:

Insurance Law article 21 tasks respondent’s superintendent with, among other things, the dual responsibility of “ensuring that licenses are issued only to trustworthy and competent [insurance] producers” … and disciplining any insurance producer who demonstrates untrustworthiness or incompetence … . These statutory mandates are designed “to protect the public by requiring and maintaining professional standards of conduct on the part of all insurance brokers acting as such within this state” … . * * *

… [W]e agree with respondent’s determination that the subject advertisement was misleading. As a starting point, the language at issue indeed could be read as suggesting that an investor would receive a fixed rate of return at the end of a predetermined period of time — a representation that was not universally true, as the timing of the payout was entirely dependent upon when the viator died; more to the point, the promised fixed rate of return could effectively be diminished if the viator exceeded his or her life expectancy, i.e., did not die within the “plan” period, and the investor’s profit might be eliminated altogether if he or she was required to assume responsibility for paying the premiums due.  * * *

We reach a similar conclusion with respect to the finding that respondent failed to fully disclose the risks of viatical settlements to some of his clients. … [R]espondent’s finding that petitioner acted in an untrustworthy manner in this regard stems from petitioner’s failure to “sufficiently disclose the risks in his oral presentations to some of his clients.” Without recounting the extensive testimony adduced on this point, suffice it to say that the record contains conflicting evidence as to what petitioner did or did not say to investors regarding the nature and risks of viatical settlements. Matter of Nichols v New York State Dept. of Fin. Servs., 2017 NY Slip Op 01944m 3rd Dept 3-16-17

INSURANCE LAW (INSURANCE BROKER ENGAGED IN UNTRUSTWORTHY CONDUCT STEMMING FROM A MISLEADING AD AND WAS PROPERLY FINED)/UNTRUSTWORTHY CONDUCT (INSURANCE LAW, INSURANCE BROKER ENGAGED IN UNTRUSTWORTHY CONDUCT STEMMING FROM A MISLEADING AD AND WAS PROPERLY FINED)/VIATICAL SETTLEMENT AGREEMENTS (INSURANCE LAW, INSURANCE BROKER ENGAGED IN UNTRUSTWORTHY CONDUCT STEMMING FROM A MISLEADING AD AND WAS PROPERLY FINED)

NOTICE OF DISCLAIMER SENT TO PLAINTIFF’S INSURER WAS NOT EFFECTIVE NOTICE TO PLAINTIFF.

The Second Department determined a notice of disclaimer sent by defendant insurer (FMIC) to plaintiff’s insurer (Mt.Hawley) was not sufficient to disclaim coverage of plaintiff (Harco):

Here, although Mt. Hawley was acting on behalf of the plaintiffs when it sent notice of the occurrence to FMIC and demanded that FMIC assume the plaintiffs’ defense and indemnification in connection with any lawsuits arising from the incident, that did not make Mt. Hawley the plaintiffs’ agent for all purposes, or for the specific purpose that is relevant here: receipt of a notice of disclaimer … . Contrary to FMIC’s contention, Mt. Hawley’s interests were not necessarily the same as Harco’s in this litigation and because Harco had its own interests at stake, separate from that of Mt. Hawley, Harco was entitled to notice delivered to it … . Since FMIC failed to provide timely notice of its denial of coverage on the basis of a policy exclusion to Harco, it is estopped from disclaiming insurance coverage on that ground … . Harco Constr., LLC v First Mercury Ins. Co., 2017 NY Slip Op 01846, 2nd Dept 2-15-17

INSURANCE LAW (NOTICE OF DISCLAIMER SENT TO PLAINTIFF’S INSURER WAS NOT EFFECTIVE NOTICE TO PLAINTIFF)/DISCLAIMER (INSURANCE LAW, NOTICE OF DISCLAIMER SENT TO PLAINTIFF’S INSURER WAS NOT EFFECTIVE NOTICE TO PLAINTIFF)

EVEN AN INNOCENT MATERIAL MISTAKE ON AN INSURANCE APPLICATION RENDERS THE POLICY UNENFORCEABLE.

The Second Department determined the trial court property granted the insurer’s motion for a judgment as a matter of law. The insured acknowledged that the property was configured as a three-family home, but that he indicated it was a two-family home on the application for insurance. Even an innocent material misrepresentation renders the policy unenforceable:

In order to establish the right to rescind an insurance policy, an insurer must show that its insured made a material misrepresentation of fact when he or she secured the policy … . A misrepresentation is material if the insurer would not have issued the policy had it known the facts misrepresented … .

Here, the plaintiff’s own testimony established that his house was structurally configured as a three-family dwelling, and thus, the statement on his insurance application indicating that it was a two-family dwelling was a misrepresentation … . Although the plaintiff testified that he believed his house was a legal two-family dwelling, an insurer may rescind a policy if the insured made a material misrepresentation of fact even if the misrepresentation was innocently or unintentionally made … . Further, the defendant established that the plaintiff’s misrepresentation was material through the uncontroverted testimony of its witnesses and documentary evidence, including its underwriting guidelines, which established that the defendant did not insure three-family dwellings, and would not have issued the subject policy if the plaintiff and his wife had disclosed that the house contained three dwelling units … . Estate of Gen Yee Chu v Otsego Mut. Fire Ins. Co., 2017 NY Slip Op 01536, 2nd Dept 3-1-17

 

INSURANCE LAW (EVEN AN INNOCENT MATERIAL MISTAKE ON AN INSURANCE APPLICATION RENDERS THE POLICY UNENFORCEABLE)/MISREPRESENTATION (INSURANCE LAW, EVEN AN INNOCENT MATERIAL MISTAKE ON AN INSURANCE APPLICATION RENDERS THE POLICY UNENFORCEABLE)

EVEN WHERE PLAINTIFF CAN NOT DEMONSTRATE SERIOUS INJURY WITHIN THE MEANING OF THE NO-FAULT LAW, PLAINTIFF MAY BE ABLE TO RECOVER ECONOMIC LOSS ABOVE THE STATUTORY BASIC ECONOMIC LOSS ($50,000).

The Third Department noted that even where (as in this case) “serious injury” within the meaning of the No-Fault law has not been demonstrated, an injured plaintiff may still be entitled economic loss above “basic economic loss:”

Under New York’s No-Fault Law, an injured party’s right to bring a personal injury action for noneconomic losses, i.e., “pain and suffering” (Insurance Law § 5102 [c]), arising out of an automobile accident is limited to those instances where such individual has incurred a serious injury … . However, basic economic loss coverage (up to $50,000) is available to a covered person regardless of fault (see Insurance Law § 5102 [a]) and “includes payments . . . for items such as lost earnings of up to $2,000 per month for three years after the date of the accident” … . Where, as here, an injured party asserts a claim for economic loss in excess of basic economic loss, he or she need not demonstrate that a serious injury was sustained … . Rather, all that is required is that such party demonstrate that his or her total economic loss actually exceeded basic economic loss … . To our analysis, “plaintiff[s] made a sufficient showing that [Jones] sustained economic loss in excess of basic economic loss to warrant submission of the issue to [a] jury” … and, therefore, Supreme Court should not have dismissed plaintiffs’ claim in this regard. Jones v Marshall, 2017 NY Slip Op 01432, 3rd Dept 2-23-17

INSURANCE LAW (NO-FAULT, EVEN WHERE PLAINTIFF CAN NOT DEMONSTRATE SERIOUS INJURY WITHIN THE MEANING OF THE NO-FAULT LAW, PLAINTIFF MAY BE ABLE TO RECOVER ECONOMIC LOSS ABOVE THE STATUTORY BASIC ECONOMIC LOSS ($50,000))/SERIOUS INJURY (NO-FAULT, EVEN WHERE PLAINTIFF CAN NOT DEMONSTRATE SERIOUS INJURY WITHIN THE MEANING OF THE NO-FAULT LAW, PLAINTIFF MAY BE ABLE TO RECOVER ECONOMIC LOSS ABOVE THE STATUTORY BASIC ECONOMIC LOSS ($50,000))/BASIC ECONOMIC LOSS (NO-FAULT, EVEN WHERE PLAINTIFF CAN NOT DEMONSTRATE SERIOUS INJURY WITHIN THE MEANING OF THE NO-FAULT LAW, PLAINTIFF MAY BE ABLE TO RECOVER ECONOMIC LOSS ABOVE THE STATUTORY BASIC ECONOMIC LOSS ($50,000))/ECONOMIC LOSS (NO-FAULT, EVEN WHERE PLAINTIFF CAN NOT DEMONSTRATE SERIOUS INJURY WITHIN THE MEANING OF THE NO-FAULT LAW, PLAINTIFF MAY BE ABLE TO RECOVER ECONOMIC LOSS ABOVE THE STATUTORY BASIC ECONOMIC LOSS ($50,000))

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ALTHOUGH THE INSURANCE POLICY EXCLUDED WATER DAMAGE AND THE INSURED PROPERTY WAS FLOODED DURING HURRICANE SANDY, THE INSURER’S EXPERT’S AFFIDAVIT DID NOT REFUTE THE ALLEGATION THE INSURED PROPERTY WAS DAMAGED BY AN ELECTRICAL SHORT A MONTH AFTER THE STORM WHEN ELECTRICITY WAS RESTORED.

The First Department determined the insurer’s (National Specialty’s) motion for summary judgment dismissing the complaint was properly denied. The insurance policy excluded water-related damage. There was no question that the building housing plaintiff’s (Pastabar’s) refrigeration equipment was flooded during Hurricane Sandy. However, plaintiff alleged damage to the refrigeration equipment was caused by an electrical short when the electricity was turned on a month after the storm. The affidavit from the insurer’s expert did not refute plaintiff’s allegation:

In compliance with its obligations under its lease, Pastabar had bought a commercial package policy containing commercial general liability and property damage coverage from defendant National Specialty. * * *

National Specialty failed to establish prima facie that all of Pastabar’s claimed losses were caused by flood waters resulting from Hurricane Sandy … , and were thus within the insurance policy exclusion for water and floods. Based on photographs that Pastabar received from an unidentified neighbor, National Specialty’s expert made a finding concerning the exterior water level at the premises … . However, the expert never inspected the site or the electrical wiring. Therefore, the expert could not refute testimony by Pastabar’s manager that Pastabar suffered additional damage a month after the storm, when electricity was restored and caused “the melting of wires and burning of . . . most of the equipment.” Thus, the expert’s report never rose above the level of speculation … . Pastabar Café Corp. v 343 E. 8th St. Assoc., LLC, 2017 NY Slip Op 01305, 1st Dept 2-21-17

 

INSURANCE LAW (ALTHOUGH THE INSURANCE POLICY EXCLUDED WATER DAMAGE AND THE INSURED PROPERTY WAS FLOODED DURING HURRICANE SANDY, THE INSURER’S EXPERT’S AFFIDAVIT DID NOT REFUTE THE ALLEGATION THE INSURED PROPERTY WAS DAMAGED BY AN ELECTRICAL SHORT A MONTH AFTER THE STORM WHEN ELECTRICITY WAS RESTORED)/CONTRACT LAW (INSURANCE, ALTHOUGH THE INSURANCE POLICY EXCLUDED WATER DAMAGE AND THE INSURED PROPERTY WAS FLOODED DURING HURRICANE SANDY, THE INSURER’S EXPERT’S AFFIDAVIT DID NOT REFUTE THE ALLEGATION THE INSURED PROPERTY WAS DAMAGED BY AN ELECTRICAL SHORT A MONTH AFTER THE STORM WHEN ELECTRICITY WAS RESTORED)/HURRICANE SANDY (INSURANCE LAW, ALTHOUGH THE INSURANCE POLICY EXCLUDED WATER DAMAGE AND THE INSURED PROPERTY WAS FLOODED DURING HURRICANE SANDY, THE INSURER’S EXPERT’S AFFIDAVIT DID NOT REFUTE THE ALLEGATION THE INSURED PROPERTY WAS DAMAGED BY AN ELECTRICAL SHORT A MONTH AFTER THE STORM WHEN ELECTRICITY WAS RESTORED)

EVIDENCE WAS SUFFICIENT TO SUPPORT THE JURY’S FINDING PLAINTIFF’S HEAD INJURY WAS A SERIOUS INJURY WITHIN THE MEANING OF INSURANCE LAW 5102, SUPREME COURT REVERSED.

The Third Department, in a full-fledged opinion by Justice Clark, over a dissent, reversing Supreme Court, determined plaintiff had proved at trial that he suffered a serious injury within the meaning of Insurance Law 5102 (d) and was therefore entitled to the jury’s damages award. Plaintiff was unloading his car when defendant’s car struck plaintiff’s, which then struck plaintiff. Plaintiff came out of his shoes and was thrown to the sidewalk. He was knocked unconscious, suffered a gash on the back of his head, and suffered a concussion. Plaintiff presented evidence at trial of traumatic brain injury with cognitive loss. The trial judge had granted defendant’s motion to set aside the verdict and dismissed the complaint, finding the evidence of serious injury insufficient:

Notwithstanding the negative scans, the absence of neurological testing and the subjectivity of plaintiff’s complaints, many of plaintiff’s reported symptoms, including his impaired concentration and balance and difficulty with problem solving and word retrieval, were objectively and personally observed by plaintiff’s primary care physician, who had the necessary historical knowledge and ability to compare his clinical, postaccident observations of plaintiff’s condition to his prior observations of plaintiff’s preaccident condition … . Contrary to the dissent’s assertion, the primary care physician’s treatment and assessment of plaintiff’s injuries were also informed by his review of the medical records of the rehabilitation psychologist and plaintiff’s physical and occupational therapists, which documented their objective observations of plaintiff’s physical and cognitive deficiencies and limited improvements over a period of nearly two years. Moreover, the bases for the primary care physician’s qualitative assessment of the seriousness of plaintiff’s injury, including his observations of plaintiff’s preaccident and postaccident conditions, as well as the accuracy of his memory, could “be tested during cross-examination, challenged by another expert and weighed by the trier of fact” … .

In our view, the comparative determination of plaintiff’s primary care physician, taken together with plaintiff’s defined head wound and subjective complaints immediately after the accident and continuing four years later, provided the jury with a valid line of reasoning and permissible inferences that could lead it to the rational conclusion that plaintiff suffered a permanent consequential limitation of use of a body organ or member and a significant limitation of use of a body function or system … . Rodman v Deangeles, 2017 NY Slip Op 01260, 3rd Dept 2-16-17

 

INSURANCE LAW (EVIDENCE WAS SUFFICIENT TO SUPPORT THE JURY’S FINDING PLAINTIFF’S HEAD INJURY WAS A SERIOUS INJURY WITHIN THE MEANING OF INSURANCE LAW 5102, SUPREME COURT REVERSED)/NO-FAULT (EVIDENCE WAS SUFFICIENT TO SUPPORT THE JURY’S FINDING PLAINTIFF’S HEAD INJURY WAS A SERIOUS INJURY WITHIN THE MEANING OF INSURANCE LAW 5102, SUPREME COURT REVERSED)/SERIOUS INJURY (NO-FAULT INSURANCE, EVIDENCE WAS SUFFICIENT TO SUPPORT THE JURY’S FINDING PLAINTIFF’S HEAD INJURY WAS A SERIOUS INJURY WITHIN THE MEANING OF INSURANCE LAW 5102, SUPREME COURT REVERSED)

INSURER DID NOT DEMONSTRATE REQUIREMENTS FOR DISCLAIMER BASED UPON THE INSURED’S NONCOOPERATION.

The Second Department determined the insurer (Global) did not demonstrate it was entitled to disclaim coverage based upon the noncooperation of the insured:

“An insurer who seeks to disclaim coverage on the ground of noncooperation is required to demonstrate that (1) it acted diligently in seeking to bring about the insured’s cooperation, (2) its efforts were reasonably calculated to obtain the insured’s cooperation, and (3) the attitude of the insured, after its cooperation was sought, was one of willful and avowed obstruction” … . “[M]ere efforts by the insurer and mere inaction on the part of the insured, without more, are insufficient to establish non-cooperation as the inference of non-cooperation must be practically compelling'” … .

Here, Global established that it made diligent efforts that were reasonably calculated to obtain the cooperation of BMC and Abduahadov … . However, Global failed to demonstrate that the conduct of BMC and Abduahadov constituted “willful and avowed obstruction” … . Matter of Government Empls. Ins. Co. v Fletcher, 2017 NY Slip Op 01199, 2nd Dept 2-15-17

 

INSURANCE LAW (INSURER DID NOT DEMONSTRATE REQUIREMENTS FOR DISCLAIMER BASED UPON THE INSURED’S NONCOOPERATION)/DISCLAIMER (INSURANCE LAW, INSURER DID NOT DEMONSTRATE REQUIREMENTS FOR DISCLAIMER BASED UPON THE INSURED’S NONCOOPERATION)/NONCOOPERATION (INSURANCE LAW, DISCLAIMER, INSURER DID NOT DEMONSTRATE REQUIREMENTS FOR DISCLAIMER BASED UPON THE INSURED’S NONCOOPERATION

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