Category: Uncategorized

5 Things Insurers DON’T Want From Their Coverage Counsel

I’ve always thought “bad” behavior was as good a teacher, if not a better one, than good behavior. This is no less true in the world of insurance coverage analysis than in other endeavors. With that in mind, here are five things insurers DO NOT want from their outside coverage counsel. They are instructive guideposts for insurers on what to avoid when working with outside coverage counsel.

Starting With An Answer And Working Backwards

This should be as self-evident as it is lethal — insurers are looking for what coverage counsel thinks, not what coverage counsel thinks the insurer wants them to think. Insurance coverage lawyers are sought out for coverage analysis because they are knowledgeable, trusted, and above all else, independent advisors. Insurers look to coverage lawyers who produce deliverables which are the product of thoughtful analysis of the policy language, the claims investigation and the facts, and the applicable jurisdictional statutory and/or common law.

I am grateful that in three decades of practice I have never had an insurance company client ever tell me, or even hint at, what they wanted me to conclude. This is not to say that I, and they, never have very early “gut reactions” or hunches as to what the answer to a coverage question might be. It is to say, however, that such early hunches have no place directing or determining the final work product. A “hunch” is fine, as long as it is kept in its place, and put through rigorous analysis and research which results in a final opinion. A hunch might be right, and it might not. What is important is that it is not exalted to the status of an answer without the necessary legwork and toil which tests and challenges it.

The “answer” to a coverage question should always be the result of coverage analysis, never the cause or the governor of it. Enough said.

Delay

The fog and smoke and fast pace of the insurance claims business makes for considerable uncertainly and unpredictability in terms of when insurance coverage questions might even arise, and, more importantly, when answers to those questions might be required. An insurer, for example, may be under the gun to make a decision to enter a defense of an insured, and to get a pleading filed ahead of a deadline.

Because of that, it is important that the insurer and coverage counsel be on the same page from the initial consult about when an answer to a coverage question is required. It may be a matter of days, or it may be a matter of weeks. What is important is that both the insurer and coverage counsel are working off of the same timetable as to when the final work product needs to be furnished.

Can unforeseen circumstances impact the delivery date of a coverage opinion? Of course they can (see fog, smoke, and unpredictability above). As soon as such difficulties arise, however, the insurer must be advised. Extensions to file answers to pleadings in underlying litigation, for example, can be secured, to provide some additional breathing room.

Insurers want to know when they will have an answer to a coverage question, and they don’t want to have to harangue coverage counsel for an overdue work product. The “when” of a coverage analysis must be the product of initial, and ongoing consultation between the insurer and coverage counsel.

Surprises

I have never had an insurer thank me for bad news. However, I have had insurers thank me a number of times for delivering bad news as early and as clearly as possible, along with suggestions and options which might lessen the impact of “bad” news relating to a coverage opinion. There is a lesson here, for certain.

Whenever possible, I like to schedule a quick status call with a client halfway between when a coverage opinion is requested, and when it is to be delivered. This provides a built-in early warning mechanism if a coverage question might be heading in a direction not originally anticipated, or if some development in claims investigation necessitates an answer which is not what might have originally been expected. (Better still, it is also a great opportunity to advise the insurer that there are as of yet no surprises).

Time is a gift. Coverage counsel should strive to give as much of it as possible to the insurer, especially if there is unexpected news. Almost by definition, the earlier a surprise is delivered to the insurer, the less of a surprise it becomes.

Incidentally, this proposition is equally true if unforeseen circumstances may require additional expense to the insurer, such as additional claims file or investigative materials which need to be reviewed before the final work product is provided. Insurers want to know sooner rather than later, and their first notice of unexpected expense should never, ever, be on an invoice.

Murkiness

If an insurer wanted to hear an overly general “maybe/maybe not” or excessive hedging on a coverage opinion, it could have saved itself the cost of an outside coverage opinion altogether and come to the same conclusion itself for free. It is true, of course, that coverage analysis is not an exact science. However, insurers do not want murkiness or generalities in the coverage opinions they request and obtain. They want guidance. And the art of guidance requires as much clarity as possible.

How is murkiness in coverage analysis to be avoided? Thoroughness is the first touchstone: A thorough analysis is much more likely to move coverage counsel off of the dreaded 50/50 opinion on outcome than is a cursory one. A complete and detailed review of the claims facts, the policy, and applicable law (including law from other jurisdictions if there is no law directly on point in the jurisdiction of assignment) is far more likely to get experienced coverage counsel to an expression of one likelihood versus another.

Likelihood and probability are far more useful to an insurer than a coin flip. At the end of the day, coverage counsel is expected to express a coverage opinion, not a coverage coin flip. A position must be taken, even if that position expresses probabilities, ranges of probabilities, and identifies “known unknowns” and even “unknown unknowns” which could affect the assessment. Follow up or supplemental coverage opinions can be provided, which leads us to our last black flag.

Lack of Follow Up / Follow Through

A coverage opinion is oftentimes non-static. That is, there may be variables which might not yet be filled in by the current claims investigation or facts not yet known which could have an impact on coverage counsel’s opinion. I never finish a coverage opinion without reminding/inviting the insurer for whom I am working to reach back out and advise if any additional facts have come to light which may change the coverage opinion in some way.

I also typically make at least one follow up call to my insurance company clients following the coverage opinion for this purpose, and also to make sure that there is nothing else they might require. For example, would they like some guidance as to a declination or reservation of rights letter? Should an examination under oath on a pivotal issue be taken? Would the insurer like guidance on the possible plusses and minuses of pursuing a declaratory judgment? In addition to being good business, such follow up is, more importantly, good client service.

Conclusion

In the final episode of the 1994 season of Seinfeld called “The Opposite,” the hapless yet somehow lovable George Costanza stumbles upon unfamiliar success by rejecting every instinct he has, and doing the opposite of what those instincts tell him. Insurers who seek out the opposites of the five black flags identified above from their coverage counsel will secure greater value in the coverage advice they obtain.

Additional Resources

  • For additional guidance to insurers on getting better, bulletproof coverage opinions, look here and here.
  • For additional guidance to insurers on whether to file declaratory judgment actions, look here.

AM Best Webinar – Remote Access: How Work and Lifestyle Changes are Transforming Insurance Claims

An AM Best Webinar

COVID-19 has accelerated the need for remote claims handling processes, which are greatly affecting today’s claims environment. A panel of insurance and legal professionals examine the recent evolution of the claims process and how virtual engagements, technological advancement, insurance fraud and other factors are impacting today’s landscape.

Panelists include:

  • Charles “C.J.” Haddick, Jr., Shareholder, Dickie, McCamey & Chilcote, P.C.
  • Randolph “Randy” Brause, Attorney, Leitner Tort DeFazio & Brause, P.C.
  • Fred Karlinsky, Shareholder, Greenberg Traurig LLP
  • James Barbieri, President and CEO, Claims Advantage Inc.

Access the webinar here: http://www3.ambest.com/conferences/events/eventregister.aspx?event_id=WEB732

Upcoming Webinar: The Impact of COVID-19 On Insurance Claims Practices, Presented By A.M. Best

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The COVID-19 pandemic and related shutdowns have opened up uncharted territory for insurance organizations and claims professionals. Beyond policy language, insurers must deal with timeliness, access, new workers’ compensation exposures, facility and workplace risks, and more. A panel of insurance claims professionals will examine the legal and logistical issues confronting the claims sector, how insurers are responding, and developments shaping the post-COVID-19 era.

Panelists

Charles E. (“C.J.”) Haddick, Jr.; Shareholder; Dickie, McCamey & Chilcote, P.C.
Frank A. Zacherl; Partner; Shutts & Bowen LLP
Randolph (“Randy”) Brause; Attorney; Leitner Tort DeFazio & Brause, P.C.
Bryan G. Baumann; Shareholder; Knox McLaughlin Gornall & Sennett, P.C.

For registration, contact John Czuba, Managing Editor – Best’s Insurance Professional Resources, at John.Czuba@ambest.com.

A.M. Best’s Insurance Law Podcast With C.J. Haddick: The Impact of COVID-19 On Business Interruption Claims

 

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In this month’s episode of Bests’ Insurance Law Podcast, John Czuba and I discuss COVID-19 and Business Interruption Coverage, along with early trends seen in the first wave of insurance coverage litigation involving COVID-19 claims.  You can listen to the podcast via the link below:

The Impact Of COVID-19 On Business Interruption Claims

Thank You For A Great Year!

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Thank you.

To the tens of thousands of visitors and readers of badfaithadvisor.com, a heartfelt thanks for your interest and loyalty in 2017, and a promise to continue to deliver content of vital interest to the insurance and law practice industries in 2018.

We are always interested in hearing from you, so please feel to drop a line to me anytime at chaddick@dmclaw.com.  If there are any topics you would like to see covered in the weeks and months ahead, please let us know that as well.

Best Wishes For A Happy and Prosperous 2018,

CJ Haddick

www.badfaithadvisor.com

Pa. Federal Judge Orders Westport To Produce Underwriting Manual, But Not Personnel Files, In Discovery

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PITTSBURGH, March 7 – A federal judge has granted an insured’s motion to compel the insurer’s underwriting manual in a bad faith case, but denied the motion as  to production of personnel files.

In Westport Ins. Co. v. Hippo, Fleming & Pertile, U.S. District Judge Kim Gibson decided the discovery dispute amidst a declaratory judgment action filed by Westport, and a bad faith counterclaim against Westport by the insured, the Hippo law firm.This case involves cross actions for declaratory judgments on a lawyer’s professional liability policy, and bad faith claims by the attorneys against the carrier. The attorneys moved to compel production of the insurer’s underwriting manual and the underwriting files, as well as the personnel files of three employees identified as having worked on the coverage file.

There was no clear case law on production of underwriting files, though the 2011 Consugar case decided by Judge Munley in the Middle District had some relevance. Thus, as with most discovery issues, the court looked at the particulars of the case before it.

The court found that production of the underwriting materials was proper. Although the insured did not bring any underwriting claims, the court observed that in supporting their bad faith claim, the attorneys argued that there were premium increases imposed by the insurer relating to commencement of the underlying litigation. Thus, “[g]iven the bad faith claim and the related allegations, the underwriting materials may well be relevant.” [Note: The opinion does not indicate whether the bad faith claims are under section 8371, common law contractual bad faith, or both. Thus, the question as to whether a premium increase can constitute the actionable denial of a benefit under a statutory bad faith claim is not clear.]

The insureds were not successful in obtaining the personnel files. They argued they were entitled to the information in the personnel files to gain knowledge about “the insurer’s corporate policy, standards, and procedures … relating to [the insurer’s] state of mind and relationship with its employees, and information regarding the relationship between the corporate policies and the training of the claims employees”

“Because there is a strong public policy against disclosure of personnel information, such requests are subject to a heightened relevancy standard.” Again, there was no clear case law, and the court stated it must look at the particular facts of the case. Relevant factors in the discovery of personnel files include “whether there is another way for the requesting party to obtain the information sought … whether there is other evidence suggesting the personnel files are likely to include relevant information … how broad the request is … and how closely the personnel files relate to the requesting party’s claims.”

The balance weighed against production. Although the “request is relatively narrow in that it asks for only the files of the employees who worked on its claim and has agreed to a number of redactions, the other factors do not meet the heightened relevancy requirement.” “The reasons supplied … for wanting the personnel files such as whether the claims employees had some incentive to deny its claim and the nature of the relationship between the company and its employees could likely be obtained through the depositions of those employees.” “Likewise, [the insured] has not presented any other evidence to support the[] theory that the personnel files are likely to include information relevant to their claims.” Thus, the insureds could not meet the heightened standards in obtaining personnel files.

 

 

 

 

Westport Ins. Co. v. Hippo, Fleming & Pertile (W.D. Pa. March 7, 2017)(Gibson, J.)

 

 

 

Claims Delay Not Unreasonable, In Bad Faith, Judge Rules

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SCRANTON, Pa., Jan. 31 — An auto insurer did not unreasonably delay processing of a claim, a Pennsylvania federal judge has ruled.   In Thomas and Colleen Meyers v. Protective Insurance Co., No. 16-1821, M.D. Pa., 2017 U.S. Dist. LEXIS 11338, a delay in the payment of an auto claim at issue in the case was found not so unreasonable as to constitute bad faith.

Thomas Meyers was insured by a hit-and-run vehicle while working as a delivery man on  Jan. 21, 2014.  He filed a claim alleging serious injury  with  Protective Insurance Co.,  for uninured/underinsured motorist benefits on April 23, 2014.  Meyers sought medical expenses and wage loss of more than $120,000.00 on Feb. 1, 2006.  He claims to have received no response from Progressive for more than three months.

On May 26, 2016, Meyers rejected a settlement offer from Protective in the amount of $225,000 .  Meyers later rejected an increased offer, and Protective hired counsel requesting additional time to review the claim.  Protective’s counsel required Meyers to complete four medical evaluations.

Meyers sued the Protective in the Lackawanna County, Pa., Court of Common Pleas, stating claims for breach of contract, common law, and  statutory bad faith pursuant to 42 Pa. C.S. §8371.  Protective removed the action to the U.S. District Court for the Middle District of Pennsylvania and moved to dismiss all claims including breach  of “fiduciary duty,” bad faith and a loss of consortium claim.

Judge A. Richard Caputo dismissed all fiduciary claims, holding, “[u]nder Pennsylvania law, an insurer owes a duty of good faith and fair dealing toward their insureds.  It is well-established, however, that there is no fiduciary duty owed to an insured in the context of an underinsured/uninsured motorist benefits.”

Judge Caputo also rejected the bad faith claims, including allegations that Protective’s failure to communicate constituted bad faith, finding such claims unsupported.  The judge found  that the insurer contacted the Meyerses four times requesting information and/or providing updates on the investigation between March 9, 2016, and May 24, 2016:

“Moreover, after the first settlement offer was rejected by Plaintiffs, Defendant, within only one week, proposed a new, higher, settlement offer.  Although Defendant often did not immediately respond to Plaintiffs’ communications, an allegation of ‘failure’ to communicate is inconsistent with reality.  Defendant’s communications may be described as tardy, but I cannot impute bad faith or even unreasonable delay, especially in light of the fact that Defendant made a settlement offer within three-and-a-half months after receiving Plaintiffs’ estimate of damages.  Although ‘[d]elay is a relevant factor in determining whether bad faith had occurred,’ [Kosierowski v. Allstate Ins. Co., 51 F.2d 583, 588 (E.D.Pa.1999)], I am unable to find precedent supporting the proposition that an insurance company’s investigation of a claim lasting three-and-a-half months is unreasonably lengthy. . . “[t]here is also no evidence that Defendant failed to objectively and fairly evaluate Plaintiffs’ claims, or that the settlement offer was so inadequate as to constitute bad faith.”

Judge Caputo also did not find Protective’s settlement offers unreasonably low:

“First, given that the damages package provided by Plaintiffs included a ‘medical lien and wage loss documentation in an amount in excess of $122,000,’ a settlement offer that is higher by nearly $100,000 than the proposed damages package is not unreasonable, and ‘bad faith is not present merely because an insurer makes a low but reasonable estimate of an insured’s damages.’  Secondly, Plaintiffs’ assertion of a verdict potential is an opinion as to the value of their claim, not an objective measure of it, and because such an assertion is nothing more than a legal conclusion, it must be disregarded.  Simply put, Plaintiffs’ subjective belief as to the verdict potential of their claims cannot constitute evidence of bad faith on the part of Defendant because Defendant’s subjective belief as to the value of the claim may reasonably, and permissibly, differ.”

The judge granted Protective’s 12(b)(6) motion, and gave the Plaintiffs 21 days to amend their complaint.

Thomas and Colleen Meyers v. Protective Insurance Co., No. 16-1821, M.D. Pa., 2017 U.S. Dist. LEXIS 11338

 

Faulty Construction Not Covered Loss Under Nationwide Builders’ Policy, Pa. Federal Judge Rules

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PHILADELPHIA, Nov. 16  — Two homebuilders insured by Nationwide Mutual Insurance Company accused in an underlying lawsuit of poor workmanship are entitled to no coverage, U.S. District Judge Michael M. Baylson ruled earlier  this week, because such workmanship did not constitute a fortuitous  “occurrence” which would trigger coverage under the policy.

William Tierney III sued  Robert and Hannelore Bealer, owners of Affordable Homes for foundation cracks and water leakage problems they built for Tierney in Pennsylvania State Court.   The complaint alleged that a May 2014 flooding of the home’s basement was due to faulty construction.   In response to Bealers’ requests for defense and indemnity in that case, Nationwide declined, citing no triggering  occurrence under policy, despite the Bealers’ claims that the problems were actually caused by superseding events including heavy storms and shifting ground.

The Bealers sued Nationwide for coverage in 2015, and the suit was removed to Federal Court.

Judge  Baylson, citing Pennsylvania law requiring analysis of the underlying complaint only, found that Nationwide was within its rights to deny coverage under the language of the policy:

“The Bealers’ alternative explanation for the cause of Tierney’s property damage is outside the scope of this analysis because it is not pled in the underlying complaint. . . Tierney’s factual allegations are that a failure to properly design and construct the property caused the damage at issue. These are faulty workmanship claims, and the Bealers’ attempts to reframe them as based on an ‘occurrence’ due to the ‘degree of fortuity’ involved in the intervening factors that allegedly led to the damage, are unavailing.”

Bealer v. Nationwide (E.D. Pa., No. 16-3181, Nov. 16, 2016)(Baylson, J.)

Inclusion of Adjuster Not Sufficient To Defeat Removal Jurisdiction In Bad Faith Case

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DALLAS, Oct. 6  — Ruling that the insured failed to shoe that an  adjuster could be directly liable for the claims alleged, a federal judge in Texas denied the insured request for remand of a removed bad faith case.

In  Ministerio Internacional Lirios del Valle v. State Farm Lloyds, et al., No. 16-1212, N.D. Texas; 2016 U.S. Dist. LEXIS 137453, the plaintiff sued State Farm Lloyds in the 160th Judicial District Court of Dallas County, Texas, over a property damage claim.   The suit included claims for breach of contract, breach of the duty of good faith and fair dealing and violations of the Texas Insurance Code.  The complaint included allegations that adjuster Aaron Galvan, who conducted an investigation denied the claim on grounds that the damage was uncovered, was liable.

State Farm Lloyds removed the case to the U.S. District Court for the Northern District of Texas, arguing the adjuster was not properly named as a defendant.  The plaintiffs moved for remand, and Judge Sidney A. Fitzwater denied the motion, holding:

“Defendants have met their heavy burden of demonstrating that there is no reasonable basis to predict that Ministerio might be able to recover against Galvan. . . Galvan is an adjuster, and ‘[a]n adjuster “cannot be held liable under this section [of the Texas Insurance Code] because, as an adjuster, he does not have settlement authority on behalf of the insurer…[the adjuster had] no obligation to provide a policyholder a reasonable explanation of the basis in the policy for the insurer’s denial of a claim, or offer of a compromise settlement of a claim.”

The judge also found that Galvan could not be held liable because the sections of the Texas Insurance Code relied upon by the Plaintiff applied to specifically listed ‘insurers,’ and Galvan was  “not an insurer.”

Ministerio Internacional Lirios del Valle v. State Farm Lloyds, et al., No. 16-1212, N.D. Texas; 2016 U.S. Dist. LEXIS 137453 (October 4, 2016, Fitzwater, J.)

Editor’s Note:  joinder of individual adjusters is a common tactic used by insureds to attempt to defeat federal removal jurisdiction, because it provides a “same state” defendant as the plaintiff.  While cases across the country have gone both ways, the individual liability of an adjuster is highly questionable under standard agency principles, if he or she is acting in the course and scope of his or her employment.

 

Concurrent Clause Exclusion Bars Sewer Backup Claim

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FRANKFORT, July 26 — A Kentucky appeals court ruled that a concurrent cause exclusion barred coverage provided under a Sewer and Drain Back-Up endorsement  in a policy issued by Maryland Casualty Co.  to a building owner and eye car practice.   The court affirmed summary judgment for the insurer in the case.

Eye Doctor Caroline L. Hendy, Insight Properties LLC and Eye Deal Eye Care II PLLC were insured by Maryland Casualty.  On Nov. 30, 2010 extensive damage was done to the insureds’ office building following heavy rains.  The doctor discontinued her practice for nearly 5 full days, and furnished an engineers’ report which attributed the damage to a collapsed drainage tile on a neighboring property which was under construction.

On March 7, 2011, the insureds sued Maryland Casualty in state court for negligence and bad faith  after the insurer declined coverage on grounds of the concurrent clause exclusion.  While the policy provided coverage for sewer backup, the policy also contained flood and surface water exclusions, and a concurrent cause exclusion which, Maryland Casutalty asserted, made the sewer backup coverage inapplicable to the loss.

Maryland Casualty was granted  summary judgment by the trial court, which found that the concurrent causes of heavy rain and surface water from overflow of a nearby creek likely contributed to the loss and the insureds’ damages.  The court held that the surface and flood water exclusions applied, regardless of any other contributory or concurrent event.

The Kentucky appeals court affirmed summary judgment for Marlyand Casualty, holding that the sewer backup coverage provision was essentially irrelevant  when the trial court determined that flood or surface water contributed to the loss:

“When viewing the record in a light most favorable to Appellants and resolving all doubts in their favor, we cannot conclude that the trial court erred in finding that there were no genuine issues of material fact and that [Maryland Casualty] was entitled to a Judgment as a matter of law. The policy language is not ambiguous and expressly provides an exclusion from covered loss for damages resulting from ‘flood, surface water . . . [or] overflow of any body of water.”

Dr. Caroline I. Hendy, et al. v. Maryland Casualty Co., No. 2015-CA-001030, Ky. App.; 2016 Ky. App. Unpub. LEXIS 502