Archive for the 'PA – Coverage Issues' Category

NO COVERAGE DUE FOR COVID-19 CLAIMS, NO BAD FAITH CLAIM POSSIBLE (Middle District)

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Middle District Judge Jones ruled that no Covid-19 coverage was due under an all-risk policy.

He found no “direct physical loss of or damage to property,” eliminating the possibility of coverage for business income losses or claims that the business closure resulted from a government order.  Further, even if covered, the claims were subject to the policy’s virus exclusion.

Thus, Judge Jones held plaintiff failed to make out its claims for breach of contract, declaratory judgment, and breach of the implied duty of good faith and fair dealing, and granted the insurer’s motion to dismiss those claims.  Although not a bad faith case, Judge Jones observed in a footnote, “[s]imilarly, Pennsylvania courts have held that if the insurer properly denied a claim, the policyholder is unable to state a bad faith claim.”

Date of Decision: February 8, 2021

Kahn v. Pennsylvania National Mutual Casualty Insurance Company, U.S. District Court Middle District of Pennsylvania No. 1:20-CV-781, 2021 WL 422607 (M.D. Pa. Feb. 8, 2021)

NO BAD FAITH WHERE NO COVERAGE DUE; NO BAD FAITH WHERE LAW IS UNSETTLED ON SCOPE OF COVERAGE; KVAERNER INTERPRETATION OF OCCURRENCE CAN APPLY TO PROPERTY DAMAGE OUTSIDE THE SCOPE OF THE CONSTRUCTION CONTRACT (Middle District)

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There can be no bad faith where no coverage is due, or where coverage is a close question based on unsettled law.

Court Applies Kvaerner to ALL Reasonably Foreseeable Damages Resulting from Faulty Workmanship

Middle District Judge Brann addressed an expanding body of case law in Pennsylvania’s Superior Court that would appear to require coverage for damages flowing from faulty workmanship, even if the faulty workmanship itself is not covered.  He rejected, however, the Superior Court’s interpretation of what constitutes a covered occurrence under the Pennsylvania Supreme Court’s 2006 Kvaerner decision.

[We have previously posted on Kvaerner in the context of coverage and otherwise, with two case summaries in 2019, here and here, this 2018 case summary, this 2014 summary, in 2013 on the Superior Court’s Indalex decision in relation to Kvaerner, and in this 2009 summary.]

Judge Brann relied on Third Circuit precedent emphasizing that all reasonably foreseeable damages resulting from faulty workmanship do not constitute an occurrence, whether that is damage to the product being constructed or damages to property beyond the scope of the construction contract resulting from that faulty workmanship.

Thus, e.g., in Judge Brann’s and the Third Circuit’s perspective, if a contractor improperly installs a roof, the roof leaks, and other parts of the building or personal property are damaged, there is no occurrence for this other damage to third party property, even though it is beyond the contracted work itself, if that other damage is reasonably foreseeable.  By contrast, the new Superior Court cases would find this third party damage outside the scope of the actual construction work to be a covered occurrence, even if reasonably foreseeable.

Judge Brann observes, “Despite the caselaw that has emerged from the Superior Court, the [District] Court notes that it is not bound by these decisions. As the Third Circuit has explained, although courts should ‘give due deference to the decisions of intermediate state courts…[s]tate appellate decisions…are not controlling.’ Thus, ‘while [courts] may not ignore the decision of an intermediate appellate court, [they] are free to reach a contrary result if, by analyzing other persuasive data, [they] predict that the State Supreme Court would hold otherwise.’”

In the present case, Judge Brann held no coverage due to replace a roof that had been improperly constructed. Further, there was no coverage due to areas of the roof damaged that were outside the scope of the contracted roof work, which also had to be replaced as a result of the faulty construction, as these third party property damages were reasonably foreseeable. Thus, he granted judgment on the pleadings in favor of the insurer as to coverage.

No Bad Faith Where no Coverage Due

On the insured’s bad faith claim, Judge Brann likewise granted judgment on the pleadings. First, he observed that the insurer properly denied benefits. Thus, he found there could be no bad faith because the insurer “certainly had ‘a reasonable basis for denying benefits under the policy,’ meaning that [the insured] cannot demonstrate bad faith.”

Judge Brann then added, “even if this Court were incorrect in its decision that [the insurer] owes no duty to indemnify [the insured], the duty to indemnify is, at the very least, debatable, in light of the differing conclusions reached by the Superior Court and the Third Circuit. Given that the caselaw in this area does not establish a clear duty … to indemnify …, it cannot be said that [the insurer] had no reasonable basis to deny benefits.”

Date of Decision:  January 26, 2021

Berkley Specialty Insurance Company v. Masterforce Construction Corp., U.S. District Court Middle District of Pennsylvania No. 4:19-CV-01162, 2021 WL 254002 (M.D. Pa. Jan. 26, 2021) (Brann, J.)

BAD FAITH CLAIM STATED WHERE COMPLAINT MAKES OUT CLAIM INSURER KNOWINGLY DENIED BENEFITS DUE (Philadelphia Federal)

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This case involves a discrepancy over whether an insured timely renewed his life insurance policy, two months before his death.  There was a dispute of fact over the date when the premium payment was mailed and received.

The carrier insisted the premium check was not mailed and received before the date necessary to maintain the policy. It deposited the insured’s payment check, but later returned the payment sum and deemed the policy lapsed on the basis the payment was outside the policy’s grace period. The beneficiary children, through their mother, alleged the check in fact was mailed and received within the grace period for premium payments. They sued for breach of contract and bad faith.

The insurer moved for judgment on the pleadings as to both counts.

First, the court denied judgment on the pleadings regarding the breach of contract claim. There was a dispute of fact over the mailing and receipt dates that could not be resolved via a motion for judgment on the pleadings.

Judge Slomsky then rejected the motion to dismiss the bad faith claim.

The plaintiffs alleged the insurer denied their claims without a reasonable basis, knowing that it had in fact received the insured’s premium payment during the grace period for continuing the policy. Further, the plaintiffs adequately alleged the insurer “knew of or recklessly disregarded the lack of reasonable basis because it knew [payment was timely] when it received and deposited the July Payment [from the deceased insured].”  Despite this knowledge, the insurer “refused to pay the Policy’s benefits and never issued a denial letter.”

In denying the motion, Judge Slomsky concluded that, “[a]t this stage, viewing the facts in the light most favorable to Plaintiffs, they are sufficient to raise an inference that [the insurer] refused to pay under the Policy in bad faith.”

Date of Decision: January 21, 2021

Mullin v. Reliastar Life Insurance Company, U.S. District Court Eastern District of Pennsylvania No. CV 20-1438, 2021 WL 210962 (E.D. Pa. Jan. 21, 2021) (Slomsky, J.)

NO BAD FAITH POSSIBLE WHEN CARRIER CONDUCTS A REASONABLE REVIEW, AND MAKES ITS DETERMINATION BASED UPON AN EXPERT REPORT (Philadelphia Federal)

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Like yesterday’s post, an insurer’s reliance on an expert report precluded bad faith.

The case involved first party coverage for a home heating oil spill.  The coverage issues involved whether the leak was caused by ongoing corrosion or was sudden and accidental, and/or or was subject to a pollution exclusion. The carrier denied coverage, and the insured brought breach of contract and bad faith claims. The insurer successfully moved for summary judgment on all counts.

No Coverage Due for Ongoing Corrosion and Under Pollution Exclusion

As to the corrosion issue, the insurer provided an unrefuted expert engineering report stating that long-term corrosion caused the leak. Thus, there were no dispute of fact on this coverage issue, warranting summary judgment for the insurer.

As to the pollution exclusion, the court did an exhaustive analysis of the case law on pollution exclusions and home heating oil.  Magistrate Judge Hey found, under the circumstances of this case, home heating oil qualified as a pollutant. “Here, Plaintiff contacted an environmental services firm about remediation and provided the court with the soil analysis identifying the same chemicals as were present in the soil in [prior precedent], and provided ample evidence that those chemicals were considered hazardous or pollutants.” Thus, “the record here presents more than sufficient evidence to allow the Court to apply the pollution exclusion to the facts of this case.”

No Bad Faith in Light of Expert Report

The court did not address the issue of whether the statutory bad faith claim had to be denied as a matter of law because no coverage was due. Rather, the court analyzed bad faith solely based on the quality of the insurer’s investigation.

Magistrate Judge Hey states, “[i]n order to determine whether an insurer acted in bad faith in conducting an investigation into whether an insured was entitled to benefits, courts have looked to the following: Judges of this court have held that an insurance company’s substantial and thorough investigation of an insurance claim, forming the basis of a company’s refusal to make or continue making benefit payments, establishes a reasonable basis that defeats a bad faith claim …. To defeat a bad faith claim, the insurance company need not show that the process used to reach its conclusion was flawless or that its investigatory methods eliminated possibilities at odds with its conclusion. Rather, an insurance company simply must show that it conducted a review or investigation sufficiently thorough to yield a reasonable foundation for its action.”

In this case, the court found the carrier “had a reasonable basis for its decision to deny Plaintiff’s claim based on the engineering report finding that the leak was caused by long-term corrosion, excluded by the policy, and that the heating oil was a pollutant based on environmental testing, government regulations and prior caselaw. Plaintiff has presented no evidence presenting a genuine issue of material fact in this regard.”

Thus, the insurer had a reasonable basis to deny the claim.

Biela v. Westfield Insurance Company, U.S. District Court Eastern District of Pennsylvania No. CV 19-4383, 2021 WL 181432 (E.D. Pa. Jan. 19, 2021) (Hey, M.J.)

NO COVID-19 BUSINESS LOSS COVERAGE DUE; NO BAD FAITH FOR DENIAL OF COVERAGE OR FAILURE TO INVESTIGATE (Philadelphia Federal)

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These two Covid-19 coverage cases ended in summary judgments against the insureds on their breach of contract and statutory bad faith claims.  Eastern District Judge Kenney decided both cases last Thursday (1/14/2021).

Case 1: Clear Hearing Solutions v. Continental Casualty

Covid-19 Business Coverage Issues

In Clear Hearing Solutions, the insured had two all-risk policies.  Plaintiffs were Pennsylvania entities, but they had hearing service stores closed in Maryland and North Carolina due to government shutdowns.  The insureds alleged they were entitled to “Business Income coverage, Extra Expense Coverage, Extended Business Income coverage, and Civil Authority coverage,” but the carrier denied coverage.

Judge Kenney observed that direct physical loss of property or damage to property were essential to all these coverages.  He followed the principles that “[t]he criteria for physical loss caused by a source unnoticeable to the naked eye is thus whether the functionality of the…property was nearly eliminated or destroyed, or whether the[ ] property was made useless or uninhabitable by that source.” (internal quotation marks omitted) The mere presence of the contaminating source material, however, “or the general threat of future damage from that presence, lacks the distinct and demonstrable character necessary for first-party insurance coverage.”

Judge Kenney states:

The Court agrees with and adopts the conclusion reached by another Court in this district. In 4431, Inc. et al v. Cincinnati Ins. Cos., the Court concluded that, “under Pennsylvania law, for Plaintiffs to assert an economic loss resulting from their inability to operate their premises as intended within the coverage of the Policy’s ‘physical loss’ provision, the loss and the bar to operation from which it results must bear a causal relationship to some physical condition of the premises.” No. 5:20-cv-04396, 2020 WL 7075318, at *11 (E.D. Pa. Dec. 3, 2020) (emphasis in original). There must also be an “element correlating to [the] extent of operational utility – i.e., a premises must be uninhabitable and unusable, or nearly as such.” Id; see also Brian Handel D.M.D. v. Allstate Ins. Co., No. 20-3198, 2020 WL 6545893 (E.D. Pa. Nov. 6, 2020) (finding Port Authority and Hardinger preclude a finding of “direct physical loss of or damage to” property where it remained inhabitable and usable, albeit in limited ways). In sum, while structural damage is not required to show “direct physical loss of” property, the source that destroys the property’s utility must have something to do with the physical condition of the premises.

The Clear Hearing insureds conceded there was no Covid-19 on the premises, and their losses resulted from government directed business closures.  “Because Clear Hearing expressly denies the existence of anything affecting the physical condition of its premises, its losses are a mere loss of use untethered to the physical condition of the property itself. Reading ‘direct physical loss of or damage to property’ to contemplate mere loss of use is not a reasonable interpretation because it renders two other Policy provisions superfluous or nonsensical.”

Judge Kenney then goes into a more detailed analysis as to why there is no covered physical damage or property loss from Covid-19, which are discussed in the opinion at length.

He further observes that simply because the policy lacks a virus exclusion, this does not create coverage by implication. “But ‘[a] loss which does not properly fall within the coverage clause cannot be regarded as covered thereby merely because it is not within any of the specific exceptions….’ And it is at least plausible that the physical manifestation of some type of virus could cause covered losses. That situation is just not present here.”

Judge Kenney also finds that the Maryland and North Carolina “government orders cannot constitute a covered cause of loss under either the Business Income and Extra Expense coverages or the Civil Authority Coverage provisions.”  Further, there was no genuine factual issue “as to whether the government orders were issued due to physical loss of or damage to nearby property,” and the insured could not show access to the premises was prohibited entirely for all purposes by these government orders.

Bad Faith Issues

[Note: We have observed numerous times over the years there is a strong argument that cognizable statutory bad faith claims in Pennsylvania require that the insured must have be denied an actual benefit, i.e., a payment of first party damages due or a refusal to defend and indemnify against third party claims due.  Thus, as repeated on this blog ad naseum, there is a genuine issue as to whether an independent statutory bad faith claim for poor investigation practices is cognizable when no coverage is otherwise due under a policy. For example, see this post from January 2020, this post from August 2020, and this post from earlier in August 2020.]

The Clear Hearing opinion states that statutory bad faith is an independent cause of action from a breach of contract action. If the statutory bad faith claim, however, “is premised solely on the denial of coverage, the claim must necessarily fail if a court finds that no coverage exists.” Judge Kenney adds, “[o]n the other hand, ‘if bad faith is asserted as to conduct beyond a denial of coverage, the bad faith claim is actionable as to that conduct regardless of whether the contract claim survives.’” Further, “[t]hat distinction has been accepted when, for example, an insured claims the insurer investigated his claim in bad faith in addition to a bad-faith denial of coverage.”

[Note: The legal support for these propositions goes back, in part, to the Third Circuit’s unpublished 2007 Gallatin Fuels decision, in which the court found bad faith was still possible even though there was not even a policy in effect at the time of the incident.  Here is a link to an article addressing the logic in Gallatin Fuels, and the effect the Pennsylvania 2007 Supreme Court decision in Toy v. Metropolitan Life should have had on Gallatin Fuels reasoning and authority, had the Gallatin Fuels Court looked to Toy, which was decided earlier in 2007.]

The bulk of Clear Hearing’s bad faith claims were based on coverage denials, and these claims were readily dismissed because no coverage was ever due. Judge Kenney then goes on to address the claim handling based bad faith arguments, accepting the possibility that statutory bad faith might still exist even when no coverage is due and no benefit has actually been denied.

Clear Hearing argued that there was bad faith based on the claim handling because Continental immediately denied the claim and did not conduct any investigation, while further failing to address or acknowledge the insureds’ interpretation of the policy language on direct physical loss.  Rather, Continental relied “on case law providing a restrictive interpretation of the term direct physical loss to deny its claim as part of a policy to limit the company’s losses during the pandemic.” (internal quotation marks omitted).

Judge Kenney rejected this argument:

To the extent that these allegations may be construed to extend beyond bad faith in the denial itself to bad faith in the investigatory process or process of denial, Clear Hearing has not met its burden. In the context of a claim for coverage based solely on government closure orders, and on Civil Authority orders where nearby property has not suffered direct physical loss of or damage to property and access to plaintiff’s property has not been prohibited, there is nothing to investigate: coverage does not exist on the face of that claim. Therefore, Clear Hearing has not shown bad faith in Continental’s lack of investigation or by denying Clear Hearing’s claim “in light of the current context of mass denials of COVID-19 related business interruption claims.” Discovery on this issue would not change that conclusion. Nor does Continental’s purported reliance on caselaw that this Court concludes correctly interprets “direct physical loss of or damage to” with respect to Clear Hearing’s claims indicate bad faith. Accordingly, Clear Hearing has not shown its entitlement to damages on its bad faith claim or an existence of a dispute of material fact as to Continental’s bad faith.

Case 2: Ultimate Hearing Solutions v. Twin City Fire Insurance

Plaintiffs were Pennsylvania entities with businesses located in Maryland, Delaware, Pennsylvania, and Virginia, which were subject to government closure orders due to Covid-19.  They likewise had all-risk policies, but with a different insurer than the Clear Hearing plaintiffs.  The Ultimate Hearing plaintiffs were represented by the same counsel as in the Clear Hearing case. These plaintiffs brought similar breach of contract and bad faith claims.

On the coverage, Judge Kenney applied the same reasoning found in Clear Hearing to conclude there was no covered direct physical loss or damage to property.

There were two differences, however, between the Ultimate Hearing and Clear Hearing all-risk policies. The Ultimate Healing policies included (1) limited coverage for fungi, wet rot, dry rot, bacteria, and viruses; and (2) a virus exclusion.

In rejecting limited virus coverage, Judge Kenney stated, “the Limited Virus Coverage clearly states that the Policy only covers ‘Direct physical loss or direct physical damage to Covered Property caused by … virus.’ Plaintiffs did not allege that the coronavirus was present at any of their insured properties. They also have not shown, as discussed above, physical loss or damage to their properties.”

Judge Kenney further rejected the argument that the limited virus coverage was illusory, because “Plaintiffs fail to acknowledge that this Limited Virus Coverage provision also applies to fungi, wet rot, dry rot, and bacteria, not just viruses. While it may be difficult to think of a hypothetical situation where a virus causes physical damage to a property, it is not difficult to imagine that wet rot, dry rot or fungi can cause damage that would satisfy the ‘direct physical loss or direct physical damage’ requirement. Further, while it may be difficult to imagine, Defendants did in fact identify a case where insured property was damaged due to a virus caused by a Covered Cause of Loss.”

Judge Kenney also found the virus exclusion precluded coverage.

The bad faith arguments were similar to those made in Clear Hearing, but without reference to the insurer’s improperly relying on caselaw to deny coverage. Rather, the argument was phrased as a refusal to consider the insureds reasonable interpretation of the policy language concerning direct physical loss.

Judge Kenney rejected the bad faith claim handling argument, stating as in Clear Hearing:

In the context of a claim for coverage based solely on the Closure Orders where there are no claims that the insured property or nearby property has been physically damaged and access to Plaintiffs’ property has not been entirely prohibited, there is nothing to investigate: coverage does not exist on the face of that claim. Therefore, Ultimate Hearing Solutions has not shown bad faith in Twin City’s lack of investigation or by denying Ultimate Hearing Solutions’ claim “in light of the current context of mass denials of COVID-19 related business interruption claims.” Discovery on this issue would not change that conclusion. Accordingly, Ultimate Hearing Solutions has not shown its entitlement to damages on its bad faith claim or an existence of a dispute of material fact as to Twin City’s bad faith.

Date of Decision:  January 14, 2021

Clear Hearing Solutions, LLC v. Continental Casualty Co., U.S. District Court Eastern District of Pennsylvania No. 20-3454, 2021 WL 131283 (E.D. Pa. Jan. 14, 2021) (Kenney, J.)

Ultimate Hearing Solutions II, LLC v. Twin City Fire Insurance Company, U.S. District Court Eastern District of Pennsylvania No. 20-2401, 2021 WL 131556 (E.D. Pa. Jan. 14, 2021) (Kenney, J.)

FAILURE TO PROVIDE UNDERWRITING FILE CANNOT CONSTITUTE BAD FAITH ABSENT MORE SPECIFIC FACTS SUPPORTING IT WAS WITHHELD IN BAD FAITH (Philadelphia Federal)

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Judge Baylson had previously dismissed in this matter, summarized here, but allowed the insured leave to amend.  The insured filed an amended complaint, and the carrier moved again to dismiss the bad faith claim.

The carrier had taken the position that there was no stacking available to the insured. Before suit, the insured asked the carrier for its underwriting file to confirm there were no UIM stacking benefits.  The insurer refused to produce that file absent a court order.

The insured argued his bad faith claims were not premised on UIM coverage disputes, “but rather upon Defendant’s misrepresentation of that coverage and refusal to disclose the underwriting agreement.” The insured alleged the carrier refused to produce the underwriting file “because it contained information that would demonstrate Defendant falsely represented the coverage amount.” This alleged “concealment and misrepresentation by the Defendant constitute[d] an act of bad faith.” Judge Baylson disagreed and dismissed the bad faith claim with prejudice.

A bad faith claim requires plaintiff showing by clear and convincing evidence that a benefit denial was unreasonable, and that the insurer knew it was unreasonable or recklessly disregarded that fact. A bad faith claim cannot meet the plausible pleading standard, however, by simply pleading the insurer denied a coverage request. Rather, an insured-plaintiff must plead “factual specifics as to the ‘who, what, where, when, and how’ of the denial,” to make a cases for reckless indifference.

Judge Baylson found the insured plaintiff here alleged “no factual content indicating that Defendant (1) lacked a reasonable basis to deny coverage or (2) that Defendant knew or recklessly disregarded the lack of reasonable basis. Rather, Plaintiff essentially asks the Court to infer—without providing any supporting facts—that Defendant’s sole motivation in withholding the underwriting file was to deceive Plaintiff.”

In Judge Baylson’s first decision, he had “addressed reasons other than bad faith that might explain why Defendant refused to provide the underwriting document.” Specifically, he observes that “underwriting files often contain an insurer’s evaluation of the risks along with other confidential business information, to be in line with a wide swath of rational and competitive business strategy.” (Internal quotation marks omitted.) The amended complaint fails to allege “any facts that plausibly suggest Defendant had no reasonable basis to deny Plaintiff stacked coverage, nor that Defendant knew or disregarded the lack of any such basis.”

Date of Decision: December 30, 2020

Dietz v. Liberty Mutual Insurance Company, U.S. District Court Eastern District of Pennsylvania No. 20-1239, 2020 WL 7769933 (E.D. Pa. Dec. 30, 2020) (Baylson, J.)

COURT BIFURCATES AND STAYS DISCOVERY ON BAD FAITH WHERE THAT CLAIM CENTERS ON COVERAGE DENIAL RATHER THAN CLAIM HANDLING (Philadelphia Federal)

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The insured denied coverage in this UIM case, and the insured sued for breach of contract and bad faith. The case centered on whether the household exclusion barred coverage. The insurer took the position the household exclusion applied and the insured disputed the insurer’s interpretation of Gallagher v. GEICO in taking that position. [Note: This 2019 Pennsylvania Supreme Court case held the household exclusion was void as a matter of law. The breadth of Gallagher’s application to other factual contexts is hotly debated in courts across Pennsylvania.]

The insurer successfully moved to bifurcate and stay discovery on the bad faith claim.

The court distinguished between bad faith actions based on claim handling failures and those based on coverage denials.  In this case, most of the bad faith allegations went to coverage, not claim handling. The court observed that “[t]hese allegations will become moot if it is determined that the Household Vehicle Exclusion applies and [the insurer] was not required to provide coverage to [the insured] under the Policy.”

Magistrate Judge Rice cited Magistrate Judge Carlson’s recent Dunleavy decision for the proposition “if an insurer properly denies coverage in accordance with the policy, then it could not have acted in bad faith by denying coverage,” and Judge Wolson’s decision in Live Face on Web, LLC for the principle that once the court concludes there is no contractual obligations to pay benefits under an insurance policy, the refusal to provide coverage “cannot have been unreasonable”.

In the same way, “if it is determined that the Household Vehicle Exclusion did not apply and [the insurer] breached the Policy by failing to provide coverage, the trier of fact on the bad faith claims can focus solely on [the insurer’s] motivations and intent in denying coverage. Thus, trying the breach of contract count first will narrow the issues to be decided in the bad faith count and result in efficiency and judicial economy.”

Magistrate Judge Rice also observed that the breach of contract claim centers on coverage and an exclusion that “will depend primarily on the terms of the policy, Pennsylvania law, causation, and … damages.” By contrast, “the bad faith claim concerns ‘more elusive concepts’ such as [the insurer’s] evaluation and investigation of the claim, motive, and response to [the insured]. … This evidence is irrelevant to the breach of contract count.” He observed that “’information concerning how an insurer investigated and evaluated a claim is simply immaterial to the issue of whether coverage is required under the policy.’”

In addition, “[b]ecause bad faith involves allegations of unreasonable and reckless behavior and requires a higher burden of proof, it also could confuse the jury and cause prejudice to [the insurer].”

Date of Decision: December 22, 2020

Gramaglia-Parent v. Travelers Home and Marine Insurance Company, U.S. District Court Eastern District of Pennsylvania No. CV 20-3480, 2020 WL 7624836 (E.D. Pa. Dec. 22, 2020) (Rice, M.J.)

INSURER COMPELLED TO PRODUCE “BEST PRACTICES” GUIDE (Western District)

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In this case, Western District Magistrate Judge Kelly ordered production of the insurer’s claim handling guidelines.

The insurer denied UIM coverage, claiming the insureds waived their benefits. The carrier conceded its UIM waiver forms did not comply with Pennsylvania law, but took the position it still properly denied the claim under the circumstances.  The insureds sued for breach of contract and bad faith.

The insured’s document requests sought “all written policies, claims and manuals, company manuals, operational guidelines, and/or any other policies, procedures, guidelines, manuals, and/or instructional/educational material pertaining to the handling of underinsured motorist claims ….” The insurer objected on the basis that these documents were confidential and proprietary, but that “if plaintiffs’ counsel will agree to sign a confidentiality order, [the insurer] will produce a copy of the Table of Contents for its claims manual and the plaintiffs can identify which chapter or chapters they believe they need to review.”

The carrier later stated there were no claim manuals, but rather the insurer maintained a “Best Practices” guide. The insurer produced part of its Best Practices guide, with redactions and removed pages, regarding liability, subrogation, and first party medical benefits. The redactions were not specifically identified and there was no privilege log.

The insured moved to compel greater production.

The carrier responded that “evidence of claims handling is irrelevant to this proceeding because the … claim was ‘never ‘handled’ since [the carrier] concluded there was nothing to handle.” It also took the position that neither liability nor the nature and extent of the injuries were in dispute, and the only issue was whether coverage was properly denied.

Separately, the carrier objected to production because such “production would otherwise cause it harm based on the nature of the plaintiffs’ counsel’s law firm; that is, a well-advertised law firm that represents ‘injured people.’” Apparently, the carrier was concerned that plaintiffs’ counsel would use its manual in future lawsuits, brought by different plaintiffs against the insurer.

In addressing the insureds’ motion to compel, the court first observed that claims manuals and training materials are “relevant [in bad faith cases] because the manuals contain instructions concerning procedures used by insurance company employees in handling UIM claims, like Plaintiffs’ claims herein. Though departures from established standards in handling a UIM claim would not alone establish bad faith, such information ‘is probative evidence for plaintiff to demonstrate bad faith.’”

The court rejected the insurer’s argument that it did not have to produce these materials because there had been no claim handling. “That [the insurer] failed to process the claim at all does not necessarily render guidelines as to how claims are ordinarily processed irrelevant and, at this stage of the proceedings, it cannot be said that the information sought is unrelated to the facts at issue.” The insureds had agreed that discovery could have some limits, and the insurer did not have to produce materials in the Best Practices guide “pertaining to rental vehicles, property damage, vehicle theft, and other sections unrelated to the evaluat[ion] and/or handling of an injury claim….”

Thus, the insureds “met their initial burden to establish the relevance of the requested material within the broad scope of permissible discovery and [the insurer] failed to adequately show that the information, limited to the handling of UIM claims for bodily injury, is irrelevant simply because it denied the claim.”

As to the second objection, the court found nothing in the Federal Rules of Civil Procedure imposing a discovery “limitation based on a law firm’s advertising budget or the nature of its legal representation of injured persons….” Any concern that these materials might be used in some future litigation could be addressed with plaintiff’s counsel in negotiating and drafting an appropriate confidentiality agreement.

Thus, the insurer had to produce the Best Practices guide, with only the redactions and limitations described above.

Date of Decision: December 9, 2020

Keeler v. Esurance Insurance Services, Inc., U.S. District Court Western District of Pennsylvania No. CV 20-271, 2020 WL 7239568 (W.D. Pa. Dec. 9, 2020) (Kelly, M.J.)

INSURER CAN GO BEYOND FOUR CORNERS OF COMPLAINT TO DETERMINE IF A PERSON IS AN INSURED IN THE FIRST INSTANCE, WHEN DEFENDING BAD FAITH CASE (Third Circuit, Pennsylvania Law)

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The Third Circuit addressed the central issue of whether the defendant was an insured, and how to analyze that factual issue in ruling on coverage and bad faith claims.

The named insured went with his girlfriend to a picnic, where they met up with the mother of the named insured’s child.  The girlfriend was also a named insured, but the mother was a stranger to the insurance contract. The mother decided to move the named insureds’ car, and struck plaintiff while driving the car. The injured plaintiff sued the two named insureds and the mother.

The carrier covered the named insureds, but took the position that the mother was not a permissive user and therefore was not an insured under the policy. The mother stipulated to a judgment and assigned her bad faith and breach of contract claims to the injured plaintiff, who sued the carrier.

The trial court granted summary judgment to the insurer, and the Third Circuit affirmed.

The Four Corners Rule does not Apply to Determining if a Party is an Insured for Duty to Defend Purposes

The Third Circuit first addressed the issue of whether the four corners rule encompasses determinations of whether a party is an insured in the first instance.

The issue has never been addressed by Pennsylvania’s Supreme Court.

The insurer argued it could not be bad faith to take the position the mother was not an insured, even if the complaint indicated otherwise, because the law on the issue is unsettled.  The carrier asserted it could use extrinsic evidence to show the mother was not an insured, and denied coverage on that basis. The Third Circuit agreed that “because Pennsylvania courts have not ruled on this issue, [the insurer] did not act in bad faith after it ‘reasonably determined that [mother] was not an insured under the Policy.’”

On the merits of coverage itself, the court concluded “that, when the insurer determines a claim is outside the scope of the insurance policy before a suit is filed, it has no duty to defend because it has effectively ‘confine[d] the claim to a recovery that the policy [does] not cover.’” Here, the insurer investigated the claim, and determined the mother was not an insured because she was not a permissive user.  “After that determination, the four corners rule no longer applied. [The insurer] did not have a duty to defend, and its actions do not show bad faith.”

Bad Faith Investigation

The court then went on to examine whether a bad faith claim could be stated solely on the basis that the insurer’s investigation was conducted in bad faith.  As repeated on this blog ad naseum, there is a genuine issue as to whether there is an independent bad faith claim for poor investigation practices when no coverage is otherwise due. For example see this post from January 2020, this post from August 2020, and this post from earlier in August 2020. A close examination in this case, however, shows the lack of investigation bad faith claim is actually intertwined with the coverage issue. Thus, this is not a case where a party is trying to prove bad faith even though no coverage is due.

Treating investigation based bad faith as a separate cause of action, rather than merely evidence of bad faith, the court observed “[g]ood faith in this context requires that an insurance determination be ‘made diligently and accurately, pursuant to a good faith investigation into the facts’ that is ‘sufficiently thorough to provide [the insurer] with a reasonable foundation for its actions.’” The mother argued the record showed she had “implied permission” to use the car, and the carrier acted in bad faith by unreasonably failing to recognize she had implied permission. The court disagreed, finding no adequate evidence to defeat summary judgment on the issue.

No Common Law Bad Faith Claim

“Finally, although the standard for common law bad faith diverges from statutory bad faith … the common law action for bad faith is a contract claim. Thus, because [the mother] was not an insured, she was not party to the contract, and she had no common law contract claim to assign….”

Date of Decision: December 8, 2020

Myers v. Geico Cas. Co., U. S. Court of Appeals for the Third Circuit No. 19-1108, 2020 WL 7230600 (3d Cir. Dec. 8, 2020) (Fisher, Restrepo, Roth, JJ.)

BAD FAITH CLAIM CAN PROCEED WHERE THE POLICY TERMS WERE IN DISPUTE, AND NO PARTY COULD PRODUCE THE ORIGINAL POLICY (Western District)

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This case involves a missing disability insurance policy.

The insured claimed he never received the original policy in 1990.  By the time of his disability claim 25 years later, the insurer likewise did not have an original, and could only produce “substitute” or “replica” policies.  The insured did have various application forms, which the court considered in ruling on the instant summary judgment motion.

Without going into painstaking detail here, the insured claimed he had a lifetime disability policy, and the carrier claimed the insured was only entitled to two years of payments after his disability.  The insured sued for breach of contract, tort, bad faith and violation of the Unfair Trade Practices and Consumer Protection Law (UTPCPL). The insurer moved for summary judgment on all counts.

The court first rejected the insurer’s breach of contract motion. While the substitute and/or replica policies could support the insurer’s position that it had paid all that was due, the insurer still had to prove that these policies accurately reflected the actual policy.  Thus, the insured’s testimony concerning the lifetime coverage he requested and was told he received vs. the insurer’s testimony that the substitute and/or replica policies were identical to the original policy all had to be decided by the trier of fact. Therefore, summary judgment on the contract action was denied. The court also considered the insured’s reasonable expectations under Tonkovic and Rempel to be open issues of fact.

As to the bad faith claim, the court first set out the pertinent legal principles and reiterated that the insured did not have to prove self-dealing or ill-will under Rancosky.  The court then denied the summary judgment motion on bad faith.

The insured raised numerous facts supporting bad faith.

  1. The insured alleged the carrier’s adjuster sarcastically commented that the insured claim conveniently fell just within the policy’s expiration limit.

  2. When asked for a copy of the policy, the insurer’s response was inconsistent. It first sent a “substitute policy” and then a “replica policy”. Both policies had missing pages and both were different than the policy he believed he had actually purchased.

  3. The insured contended the carrier’s “practice of not maintaining original copies of policies is further evidence of bad faith toward its insureds because this practice shifts the burden to the insureds to produce the terms of the policies.”

  4. The carrier “never informed [the insured] of the relevant limitations of the Policy, even when it offered the opportunity to purchase a new policy when he approached age 65.”

On the other hand, the carrier argued it had a reasonable basis to deny coverage, precluding bad faith.  The court responded that “while this may ultimately be proven, the Court cannot determine on a motion for summary judgment whether [the insurer] had a reasonable basis for its denial. Moreover, as [the insured] observes, [the insurer’s] behavior during the claim process constitutes evidence in support of his claim that it acted in bad faith.”

The court likewise denied summary judgment on the UTPCPL claim. The insured was successful in framing the argument as a case of deceptive conduct in issuing the policy, and not merely a failure to pay (which is not actionable under the UTPCPL).

The insured “indicated that representations were made by [the insurer’s] agent that he was purchasing a disability policy that provided ‘lifetime benefits up to age 65,’ that he justifiably relied on these representations and that he suffered damages because [the insurer] later took the position that the Policy did not provide this benefit because he did not become disabled until after he reached age 60. He has presented sufficient evidence to support a claim under the UTPCPL that must be weighed by the trier of fact.”

Summary judgment on the remaining claims was likewise denied.

Date of Decision: November 30, 2020

Falcon v. The Northwestern Mutual Life Insurance Company, U.S. District Court Western District of Pennsylvania No. CV 19-404, 2020 WL 7027482, (W.D. Pa. Nov. 30, 2020) (Dodge, M.J.)