A CLOSE CALL, BUT FACTUAL CHRONOLOGY TIED TO ALLEGATIONS OF UNREASONABLE DELAY SET OUT PLAUSIBLE BAD FAITH CLAIM (Middle District)
Stating it was a close call, Middle District Magistrate Judge Carlson found the following well-pleaded allegations sufficient to set forth a plausible bad faith claim, and recommended denying a motion to dismiss without prejudice to later bringing a summary judgment motion. District Judge Mariani adopted this report and recommendation as the opinion of the court.
Defendant … issued a policy of insurance No. K2495825 to Plaintiffs … covering their two automobiles ….
Defendant … charged and collected a premium for underinsured motorist coverage on said policy.
Plaintiffs … paid all premiums requested by Defendant….
The same policy was in full force and effect [at the time of the auto accident at issue].
On or about August 30, 2015, Plaintiff … was involved in a motor vehicle crash which directly caused him to sustain serious and severe life-threatening injuries some of which are permanent.
On August 30, 2015, Plaintiff … was insured for underinsured coverage in the amount of $250,000.00, with stacking (two cars), by Defendant … under policy K2495828.
As a result of the collision, Plaintiff … suffered severe and permanent injuries including, but not limited to, the following:
(a) neck sprain with severe pain and injuries to his cervical spine, more specifically identified as narrowing of disc space at the C4-C5, C5-C6 and C6-C7 with anterior and posterior osteophytes formation and narrowing of intervertebral foramina at the corresponding bilaterally with nerve root compression. Persistent multilevel degenerative spondylosis, degenerative bilateral facet edema at the C7-T1, bilateral foraminal stenosis at the C3-4, bilateral foraminal stenosis at the C4-5 and C5-6, bilateral foraminal stenosis with left foraminal disc protrusion at the C6-7, all of which pain radiates into his upper extremities;
(b) low back pain and injuries to his lumbar spine including degenerative disc disease with sharp shooting pain radiating into his left lower extremity and sciatica pain;
(c) radiculopathy and nerve injuries to the C8-T1 area;
(d) muscle spasms throughout his cervical, thoracic and lumbar spine;
(e) severe headaches;
(f) right hip pain;
(g) left ankle pain;
(h) right elbow pain; [*4]
(i) ongoing pain management, physical therapy and chiropractic treatment;
(j) ongoing and persistent pain aggravated by standing, sitting, walking, sexual activity, physical activities and elevating his arms;
(k) sleep disruption.
Defendant .. was promptly notified of Plaintiff[’s] … injuries.
As a result Defendant … after and only after litigation against its parent company … was initiated, began to pay and continues to pay medical payments to Plaintiff….
As a result of the aforesaid incident, Plaintiff … was offered the policy limits by the operator of the 3rd party vehicle.
Plaintiff … made a claim for underinsured motorist coverage with Defendant….
Plaintiff …. submitted all the pertinent medical records and bills to Defendant…, indicating the serious physical and economic injuries that he sustained as a result of the crash.
Defendant …refused payment to Plaintiff … of underinsured motorist benefits.
Plaintiff … has performed everything required of him under the policy and is entitled to underinsured motorist benefits from Defendant….
Defendant[‘s] … denial of underinsured motorist benefits was made without any reasonable basis of fact.
Defendant … acted in bad faith in that it did not have a reasonable basis for denying underinsured motorist benefits under the policy and the Defendant … knew and/or recklessly disregarded its lack of reasonable basis in denying that claim that Defendant:
(a) Failed to give equal consideration to paying the claim as to not paying the claim.
(b) Failed to objectively and fairly evaluate Plaintiff[‘s] … claim;
(c) Failed to raise a reasonable defense to not pay Plaintiff[‘s] … claim;
(d) Compelling Plaintiff … to institute arbitration to obtain underinsured motorist benefits;
(e) Defendant … engaged in dilatory and abusive claim’s handling;
(f) Unreasonably evaluating Plaintiff[‘s] … injuries and loss in the face of overwhelming evidence to the contrary;
(g) Failed to keep Plaintiff … fairly and adequately advised as to the status of the claim;
(h) Acting unreasonably and unfairly in response to Plaintiff[‘s] … claim;
(i) Failed to promptly provide a reasonable factual explanation of the basis for the denial of Plaintiff[‘s] … claim;
(j) Failed to conduct a fair and reasonable investigation and evaluation to Plaintiff[‘s] … claim;
(k) Defendant … violated the Unfair Claims Settlement Practice Act §146.5, 146.6, 146.7;
(l) Defendant … violated the Unfair Insurance Practice Act 40 P.S. §1171.5(a)(10) (ii) (iii) (iv) (v) (vi) (vii) (viii) (xi) (xii) (xiv).
The court found the complaint, “taken as a whole, goes beyond a mere boilerplate recital of the elements of the statute.” These allegations provided a factual chronology, and that “[despite providing [the insurer] with all pertinent medical records and bills, and fulfilling all of their policy obligations, the plaintiffs assert that [the insurer] has unreasonably refused to honor its policy obligations.” The complaint further intertwines these allegations with other bad faith averments, i.e., “unreasonable delay … in beginning to make medical payments”, and only making medical payments after suit was initiated against the insurer’s parent company, despite prompt notice of injuries well prior to suit.
While the averments are “spare,” they “go beyond the type of mere boilerplate allegations that courts have found to be too conclusory to sustain a bad faith claim.” Moreover, Magistrate Judge Carlson would not go beyond the pleadings to accept the insurer’s arguments for dismissal. The insurer asserted that the complaint should be interpreted as actually reflecting the insurer’s “prudent effort on its part to thoroughly examine and resolve a potentially meritless claim….” However, the court found “this argument invites us to go beyond the pleadings themselves and resolve essentially factual questions. This is a task which, in our view, may not be performed on consideration of a motion to dismiss, where we must simply assess the adequacy of the pleadings.”
Thus, the complaint could proceed, without prejudice to the insurer renewing its argument on summary judgment at the close of discovery.
Dates of Decision: July 19, 2019 and August 8, 2019
Vadella v. American States Ins. Co., U. S. District Court Middle District of Pennsylvania Civil No. 3:19-CV-73, 2019 U.S. Dist. LEXIS 121606 (M.D. Pa. July 19, 2019) (Carlson, M.J.) (Report and Recommendation), adopted in Vadellla v. American States Ins. Co., U. S. District Court Middle District of Pennsylvania Civil No. 3:19-CV-73, 2019 U.S. Dist. LEXIS 133764 (M.D. Pa. Aug. 8, 2019) (Mariani, J.)