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Insurance Company Could Not Rely On Plaintiff’s Personal Injury Action to Recoup What It Paid Out on a Related Property Damage Claim—Not a Valid Subrogation Vehicle

The Third Department determined an insurance company’s (Erie’s) attempt to rely on plaintiff’s personal injury complaint as the basis of its subrogation claim for property damage was properly dismissed.  The insured’s house exploded due to a gas leak.  Next to the insured’s house was a garage owned by the insured.  Erie paid $50,000 for damage to the garage.  The Erie attempted to rely on the insured’s personal injury action to recoup the money paid out for the property damage:

“Subrogation is an equitable doctrine that allows an insurer to stand in the shoes of its insured to seek indemnification from third parties whose wrongdoing has caused a loss for which the insurer is bound to reimburse” … . To that end, an insurer seeking to enforce its right of subrogation generally has two options – “the insurer can bring an independent action against the wrongdoer in the name of its insured, the subrogor, or seek to intervene in an existing action between the insured and the wrongdoer” … . Neither path was pursued by Erie here; rather, Erie sought to use plaintiffs’ personal injury complaint “as a vehicle to assert [its] subrogation theory against . . . defendants.”As Supreme Court aptly observed, the principal flaw inErie’s methodology is that although plaintiffs’ complaint indeed recites that plaintiffs’ home exploded as a result of the natural gas leak, that pleading makes absolutely no reference to the property damage sustained to Pete’s Garage, nor does it “plead or otherwise spell out that damages are being sought for [the] property damage/loss” sustained thereto.  Although this Court has limited an insurer’s right to intervene in certain circumstances …, such circumstances are not present here.  Peterson v NYS Electric and Gas Corporation…, 516423, 3rd Dept 3-6-14

 

“Prompt Pay Law” Affords a Private Right of Action Against An Insurer Which Fails to Pay a Patient’s Undisputed Medical Claim

In a full-fledged opinion by Justice Austin, the Second Department determined the so-called “Prompt Pay Law” (Insurance Law 3224-a) affords an implied private right of action.  The law, therefore, can be enforced by a private lawsuit based upon its breach.  The defendant insurance company (First United) argued only the NYS Insurance Department could enforce the statute.

The Prompt Pay Law requires an insurer to pay undisputed claims within 30 days after receipt of an electronic submission or within 45 days after receipt by other means (see Insurance Law § 3224-a[a]). If a claim is disputed, the insurer is obligated to pay the undisputed portion of the claim, if there is any, and, within 30 days of receipt of the claim, notify the policyholder, covered person, or health care provider in writing of the specific reason that the insurer is not liable to pay the claim (see Insurance Law § 3224-a[b][1]). In the alternative, the insurer may request additional information necessary to determine its potential liability with respect to payment of the claim (see Insurance Law § 3224-a[b][2]). First United allegedly did neither. An insurer that fails to comply with the provisions of the Prompt Pay Law is obligated to pay the health care provider or the person submitting the claim the full amount of the claim, plus 12% interest per annum, to be computed from the date the claim was required to be paid (see Insurance Law § 3224-a[c][1]). * * *

Where a statute does not expressly confer a private cause of action upon those it is intended to benefit, a private party may seek relief under the statute “only if a legislative intent to create such a right of action is fairly implied’ in the statutory provisions and their legislative history” … . This inquiry involves three factors:” (1) whether the plaintiff is one of the class for whose particular benefit the statute was enacted; (2) whether recognition of a private right of action would promote the legislative purpose; and (3) whether creation of such a right would be consistent with the legislative scheme'” … .Only the third factor, which is generally the “most critical” … is disputed here. * * *

A review of the legislative history of the Prompt Pay Law reflects that the law was directed toward the protection of health care providers and patients from late payment of claims, and was not primarily designed to provide a mechanism for preventing harm to the public in general.  Maimonides Med Ctr v First United Am Life Ins Co, 2014 NY Slip Op 01441, 2nd Dept 3-5-14

 

Contradictory Information in Disclaimer Letters Did Not Invalidate the Disclaimer of Assault and Battery Coverage

Over a dissent, the Court of Appeals determined the insurance company, QBE, properly disclaimed coverage for an assault and battery claim against the insured bar, Jinx-Proof, despite contradictory language in the two disclaimer letters:

The courts below properly determined that QBE effectively disclaimed coverage for the assault and battery claims asserted in the underlying action. The first letter sent to Jinx-Proof stated that QBE would not defend or indemnify Jinx-Proof “under the General Liability portion of the policy for assault and battery allegations” and that Jinx-Proof did not have liquor liability coverage. The second letter stated that Jinx-Proof did have liquor liability coverage but that the policy excludes coverage for assault and battery claims. Specifically, the second letter stated:

“[W]e are defending this matter under the Liquor Liability portion of the [general commercial liability] coverage, and under strict reservation of rights for allegations of Assault and Battery. Your policy excludes coverage for assault and battery claims . . . Therefore, should this matter proceed to verdict, any awards by the Court stemming from allegations of Assault and Battery will not be covered under your Commercial General Liability policy.”

Although the letters contain some contradictory and confusing language, the confusion was not relevant to the issue in this case. The letters specifically and consistently stated that Jinx-Proof's insurance policy excludes coverage for assault and battery claims. These statements were sufficient to apprise Jinx-Proof that QBE was disclaiming coverage on the ground of the exclusion for assault and battery, and this disclaimer was effective even though the letters also contained “reservation of rights” language … . QBE Insurance Corporation v Jinx-Proof Inc, 25, CtApp 2-18-14

 

Disclaimer Based Upon Insured’s Non-Cooperation Was Timely—Must Allow Longer Period to Demonstrate Diligence In Seeking Cooperation

In a full-fledged opinion by Judge Pigott, the Court of Appeals determined that the insurers disclaimer based upon the insured’s failure to cooperate with the investigation was timely and enforceable:

The question whether an insurer disclaimed as soon as reasonably possible is necessarily case-specific. In some cases, very different from this one, the justification for disclaimer is “readily ascertainable from the face of the complaint in the underlying action” … or “all relevant facts supporting . . . a disclaimer [are] immediately apparent . . . upon . . . receipt of notice of the accident” … . In such cases, a disclaimer must be made rapidly. The present appeal, on the other hand, involves disclaimer for noncooperation by an insured. A determination as to whether such a disclaimer was made within a reasonable time is more complex because “an insured's noncooperative attitude is often not readily apparent”… . We have emphasized that “insurers must be encouraged to disclaim for noncooperation only after it is clear that further reasonable attempts to elicit their insured's cooperation will be futile” … .The primary reason that we allow a longer period for disclaimer for noncooperation lies in a well-established principle of our case law, which is intended to facilitate the full compensation of injured victims suing for damages. This is the requirement that an insurer may not properly disclaim for noncooperation unless it has satisfied its burden, described in the precedent as “a heavy one indeed,” of showing “that it acted diligently in seeking to bring about the insured's co-operation; that the efforts employed by the insurer were reasonably calculated to obtain the insurer's co-operation; and that the attitude of the insured, after his co-operation was sought, was one of willful and avowed obstruction”… . Country-Wide Insurance Company v Preferred Trucking Services Corp, 21, CtApp 2-18-14

 

Reversing Its Prior Decision in this Case, the Court of Appeals Determined the “Servidone” Rule Is to Be Followed in New York/An Insurer Which Has Breached Its Duty to Defend the Insured May Rely On Policy Exclusions to Escape Its Duty to Indemnify the Insured

In a full-fledged opinion by Judge Smith, over a dissent, the Court of Appeals reversed itself on reargument and adhered to precedent—Servidone Const Corp v Security Ins Co of Hartford, 64 NY 2d 419. Under Servidone, an insurer which breached its duty to defend can still rely on policy exclusions to escape the duty to indemnify:

In Servidone — a case in which, as in this one, the insurer was relying on policy exclusions in defending against a suit for indemnification — we stated the question as follows:

“Where an insurer breaches a contractual duty to defend its insured in a personal injury action, and the insured thereafter concludes a reasonable settlement with the injured party, is the insurer liable to indemnify the insured even if coverage is disputed?”… .

We answered the question in Servidone no. In K2-I [the initial ruling in the instant case], we held that “when a liability insurer has breached its duty to defend its insured, the insurer may not later rely on policy exclusions to escape its duty to indemnify the insured for a judgment against him” …. . The Servidone and K2-I holdings cannot be reconciled. * * *In short, to decide this case we must either overrule Servidone or follow it. We choose to follow it. K2 Investment Group LLC v American Guarantee & Liability Insurance Company, 6, CtApp 2-18-14

 

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Two-Year Time Limit On Bringing Suit Against Insurer for Cost of Replacement of Damaged Property Unreasonable If Replacement Cannot Reasonably Be Done Within Two Years

In a full-fledged opinion by Judge Smith, the Court of Appeals, in answering a question posed by the Second Circuit, determined a two-year time-limit on bringing suit against an insurance company was unreasonable because suit could not be brought until the damaged property was replaced. Therefore, as was true in this case, if the damage-repair takes longer than two years, the insured cannot sue for payment:

“[A]n agreement which modifies the Statute of Limitations by specifying a shorter, but reasonable, period within which to commence an action is enforceable” … . We conclude that the contractual period at issue here — two years from the date of “direct physical loss or damage” (i.e., from the date of the fire) — is not reasonable if, as the Second Circuit's question requires us to assume, the property cannot reasonably be replaced within two years.It is true, as the District Court pointed out, that there is nothing inherently unreasonable about a two-year period of limitation. In fact, we have enforced contractual limitation periods of one year … . The problem with the limitation period in this case is not its duration, but its accrual date. It is neither fair nor reasonable to require a suit within two years from the date of the loss, while imposing a condition precedent to the suit — in this case, completion of replacement of the property — that cannot be met within that two-year period. A “limitation period” that expires before suit can be brought is not really a limitation period at all, but simply a nullification of the claim. It is true that nothing required defendant to insure plaintiff for replacement cost in excess of actual cash value, but having chosen to do so defendant may not insist on a “limitation period” that renders the coverage valueless when the repairs are time-consuming. Executive Plaza LLC v Peerless Insurance Company, 2, CtApp 2-13-14

 

Insurance Company’s Failure to Submit Second Request for Verification of No-Fault Claim Precluded Tolling of 30-Day Payment Period

The Second Department determined that defendant insurance company’s failure to issue a second request for verification to the hospital which had submitted a no-fault claim precluded the insurance company from asserting the hospital’s failure to reply to the request for verification as a basis for not paying the claim within 30 days:

Upon the hospital’s failure to timely comply with the defendant’s initial request for verification within “30 calendar days after the original request [for verification]” (11 NYCRR 65-3.6[b]), the defendant was under a regulatory duty to issue a second request for verification within 10 days after the expiration of that 30-day period (see 11 NYCRR 65-3.6[b]…). In the absence of any such second request for verification, there is no merit to the defendant’s contention that the 30-day period within which it had to pay, deny, or request verification of the claim had been extended. The defendant “failed to submit any evidence that it mailed a second or follow-up request for verification at the end of the 30-day period subsequent to [its] mailing [of] the initial request for verification”… . Westchester Med Ctr v Allstate Ins Co, 2013 NY Slip Op 08616, 2nd Dept 12-26-13

 

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Prima Facie Proof Requirements for Entitlement to Payment of “No-Fault” Medical Expenses Clarified

In a full-fledged opinion by Justice Rivera, over the partial dissent by two justices, the Second Department resolved a conflict in its authority regarding what a medical provider must demonstrate to make out a prima facie case of entitlement to payment for medical treatment under the no-fault regime.  In Art of Healing Medicine PC v Travelers Home & Mar Ins Co (55 AD3d at 64), the Second Department wrote that “[t]he plaintiffs [ ] medical service providers failed to demonstrate the admissibility of their billing records under the business records exception to the hearsay rule”… . Based upon that language in “Art of Healing…,” several Appellate Term decisions “found that the plaintiff failed to establish its prima facie burden where it relied upon the affidavit of a biller who did not possess personal knowledge of the plaintiff’s business practices and procedures so as to establish that the claim forms annexed to the plaintiff’s moving papers were admissible under the business records exception to the hearsay rule…”.  In the instant case, the Second Department rejected that interpretation and reiterated that all a medical provider must demonstrate to make out a prima facie case is the submission of the proper billing forms and the failure to deny or pay the claim within the statutory period:

The requirement in Insurance Law § 5106(a) that a claimant must submit “proof of the fact and amount of the loss sustained” in order to trigger the 30-day period in which to pay or deny a claim refers to the contents of the billing forms, not the merits of the claim. * * *

The “how” evidentiary component of the plaintiff’s proof is met by, inter alia, the affidavit of a billing agent or an employee of the medical provider; that is, someone with personal knowledge of the plaintiff’s billing methods … . The billing agent will (1) attest that he/she personally sent the billing forms to the insurer, that the insurer received the same, and that the insurer failed to pay or deny the claim within the requisite 30-day period, or (2) set forth the procedures customarily utilized in the ordinary course of its business regarding the mailing/receipt of such forms and that the insurer failed to pay or deny the claim within the requisite 30-day period. As part of its prima facie showing, the plaintiff is not required to show that the contents of the statutory no-fault forms themselves are accurate or that the medical services documented therein were actually rendered or necessary. Stated another way, the plaintiff is not required to establish the merits of the claim to meet its prima facie burden. To the extent that Art of Healing imposes a “business record” requirement obliging the plaintiff to establish the truth or the merits of the plaintiff’s claim, we overrule Art of Healing. Viviane Etienne Med Care PC v Country-Wide Ins Co, 2013 NY Slip Op 08430, 2nd Dept 12-18-13

 

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Issuer of Excess Policy Was Required (by the Terms of the Policy) to Pay “All Sums,” Including Interest, Over and Above the Policy-Limit Paid Out Under the Primary Policy

In reversing the Appellate Division, the Court of Appeals determined that the issuer of the excess policy (HIC) was obligated to pay all sums, including interest, after the $1,000,000 policy limit was paid out under the primary policy.  The issuer of the primary was insolvent and the $1,000,000 primary policy limit was paid by the liquidator:

Applying the plain meaning of the primary and excess policies to the particular medical malpractice judgment against plaintiff at issue here, it is clear that the primary insurer’s liquidator fulfilled its obligations under the primary policy, thereby triggering HIC’s responsibility to pay the interest in excess of the primary policy’s $1,000,000 liability limit.  Upon entry of the initial judgment against plaintiff, the liquidator paid plaintiff $1,000,000 toward that judgment.  At that point, the liquidator was no longer required to pay interest under the “supplementary payments” provision of the primary policy because that further amount accrued only after the liquidator had already satisfied the liability limit of the primary policy in the manner specified by the “supplementary payments” provision.  Thus, the additional interest on the judgment, as amended, constituted a “sum[ ] in excess of the limits of liability of the Underlying Policy,” which is covered by the excess policy.  Accordingly, HIC had to pay the additional interest.  Ragins… v Hospitals Insurance Company, Inc, 234, CtApp 12-17-13

 

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Numerous Core Issues Discussed in Complicated Case Stemming from Mold in a Complex of Apartments Which Necessitated Termination of All the Leases

In perhaps the most complicated decision this writer has ever read, the Second Department reversed many of Supreme Court’s rulings and sorted out the defense and indemnification responsibilities for an astounding array of insurance companies.  The lawsuits arose from the intrusion of water and mold into a complex of rental apartments causing the termination of all the leases. The general contractor and a large number of subcontractors all had insurance policies issued by many different companies. Among the issues addressed: (1) “[C]ontract language that merely requires the purchase of insurance will not be read as also requiring that a contracting party be named as an additional insured”…; (2) Whether damage from water intrusion and mold is an “occurrence” within the meaning of the policy-language; (3) Whether the law of the insured’s domicile should apply; (4) The use of extrinsic evidence to determine an insurer’s duty to defend; and (5) Disclaimer based upon late notice.  QBE Ins Corp v Adjo Contr Corp, 2013 NY Slip Op 08238, 2nd Dept 12-11-13

 

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