存档“ PA”–延迟(被保险人)类别

没有坏信念的依据是:(1)报价和储备金的比较; (2)违反UIPA; (3)低于所需的定居要约; (四)未能提高和解要约的; (5)未能协商; (6)分期付款的时间;或(7)索赔手册(西区)

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In Western District Magistrate Judge Dodge’s 可能 2020 opinion 在 this case, the court allowed this UIM 恶意 claim to survive a motion to dismiss. That decision is 总结在这里.  Her present opinion addresses the 在 surer’s summary judgment motion on 恶意.

的stipulated facts show, among other things, the 在 sured’s 在 juries, that the tortfeasor’s carrier paid $50,000, that the 在 sured demanded full UIM policy limits of $500,000, that the 在 surer set a $25,000 reserve 和 offered $10,000 to settle the claim fully, 和 that there was a dispute among medical experts about the scope of future treatment.  的record showed that the 在 surer’s claim adjustor reviewed new 在 formation from the 在 sured on a number of occasions 和 found no basis to revise his damage analysis behind the $25,000 reserve figure.

After a considerable time period, the 在 sured’s counsel did demand partial payment of the $10,000, saying this was undisputed, but never provided a full counter demand to the $10,000 offer because the course of medical treatment remained open.  的insurer eventually agreed to pay the $10,000, but the record appears ambiguous as to how each side 在 terpreted the conditions of that payment.

Although the earlier motion to dismiss resulted 在 dismissal of claims asserting a private right of action under the Unfair Insurance Practices Act (UIPA), the 在 sured asserted there were technical violations of the UIPA that could be considered 在 ruling on a statutory 恶意 claim.

的court identified the following 恶意 claims:

  1. 的insurer allegedly “failed to re-evaluate the UIM claim when presented with new 在 formation 和 then make a higher offer despite raising the amount of its reserves.”

  2. 的insurer “failed to make a timely partial payment of $10,000 even though that amount was undisputed.

  3. 的insurer “violated the UIPA 和 its own claims-handling policies 在 at least two respects—by failing to notify [the 在 sured] of its position that his alleged contributory negligence reduced the value of his claim, 和 failing to respond to an offer within ten days.”

Poor Judgment is Not 信仰不良

Magistrate Judge Dodge stated that “neither an 在 sured’s disagreement with the amount offered on a UIM claim nor a citation to negligent mistakes made by the 在 surer 在 handling the claim is sufficient to demonstrate 恶意.”

她期待着霍纳克法官最近对斯图尔特的判决, 总结在这里,授予保险公司即决判决“原告行人遭受了价值200万美元但被保险公司调查的伤害,将索赔额定为125,000美元,将准备金定为55,000美元,并提出了25,000美元”和麦克维里法官在2013年做出的Schifino判决, 总结在这里, where a “$10,000 在 itial offer on UIM claim valued at $60,000 did not constitute 恶意 和 although [the 在 surer’s] conduct was ‘not free from criticism 在 its 在 itial handling of the claim … this conduct is more 在 dicative of poor judgment than 恶意.’”

预留储备金不能用作备用项

地方法院法官道奇(Dodge)也谈到了有关储备金的法律,指出“拨出储备金并不等于承认责任”。 “准备金只是保险公司为支付未来潜在负债而预留的金额,”和“准备金的设置是对保险公司根据索赔承担的风险的估计…[但是]法院不愿意制定一项规则,要求保险公司在准备金确定后立即提出要约。”因此,“恶意并不取决于要约是否少于准备金……。”

的Alleged Failure to Increase an Offer is Not 信仰不良

的court rejected the claim that the 在 surer had raised reserves while failing to reevaluate the claim. In fact, the claim handler had not raised reserves even after receiving new 在 formation from the 在 sured, but kept the reserves at the same figure after evaluating that new 在 formation.

的adjustor’s claims notes omitted $45,000 在 medical expenses at two different dates, which were 在 his original evaluation. 的insured claimed this demonstrated 恶意 在 evaluating the claims. 的adjustor testified “that this was simply a mistake ‘because if you look at the doctor’s notes there’s no difference 在 what I already knew.’ Thus, this evidence suggests that [the] adjustor made an error when he recorded or updated 在 formation 在 his notes. This would amount to negligence, not 恶意. Importantly, it is undisputed that [the adjustor] concluded 在 each evaluation that a reserve setting of $25,000 was appropriate 和 his assessment of the potential value of the UIM claim did not change.”

Further, simply because the $10,000 offer was lower than the reserves did not prove 恶意, nor was it even “evidence of 恶意.” There also was no evidence the adjustor concluded the UIM claim’s value “was far 在 excess of the amount he set as a reserve or that his offer was unreasonable.”

的court distinguished the well-known Boneberger case on grounds that case was about 在 tentionally devious claim handling practices used to create artificially low values. It was not about simply making offers that were much lower than the claimed value.

Magistrate Judge Dodge then discussed case law recognizing the principle that low but reasonable estimates cannot support 恶意 claims. She looked to the Third Circuit’s 2019 Rau decision, 总结在这里。此外,她还看了康蒂法官(Conti)的卡塔(Katta)意见, 总结在这里, 在 observing factors weighing against 恶意, such as: the uncertainty of the claim’s value; “the offer was not unreasonably low because an 在 itial offer below the alleged amount of loss does not constitute evidence of 恶意”; the 在 surer’s willingness to 在 crease its offer 和 the 在 sured’s refusal to negotiate down from a policy limit demand; 和 the 在 sured’s failure to provide additional 在 formation to the 在 surer as to why its offer should be 在 creased.

的court quoted Judge Conti at length: “It is troubling that plaintiff seeks to proceed with his 恶意 claim despite having made no effort to engage 在 negotiations with defendant. Plaintiff was under no duty to negotiate, but courts have recognized that stonewalling negotiations is a relevant consideration 在 determining whether an 在 surer acted 在 恶意. …. If plaintiff’s 恶意 claim were to proceed, future plaintiffs could survive summary judgment on 恶意 claims by simply filing suit after receiving an offer that the plaintiff believes is too low. 的mere fact that defendant’s 在 itial offer was lower than plaintiff’s unsubstantiated claim of lost wages, 在 absence of 任何 other substantive evidence of 恶意, 在 cluding unreasonable delay, 在 tentional deception, or the like, is not sufficient to constitute 清晰而令人信服 evidence.”

在本案中,被保险人从未提出过抗辩或在10,000美元的初始要约后尝试进行谈判,也从未脱离保单限额要求。而且,如上所述,理算人的理赔和理赔评估也不是没有道理的。

Partial Payment Issue not a Basis for 信仰不良

Magistrate Judge Dodge cited Third Circuit precedent that a failure to make partial payment could only reach the level of 恶意 “where the evidence demonstrated that two conditions had been met. 的first is that the 在 surance company conducted, or the 在 sured requested but was denied, a separate assessment of some part of her claim (i.e., that there was an undisputed amount). 的second is, at least until such a duty is clearly established 在 law (so that the duty is a known duty), that the 在 sured made a request for partial payment.” She observed Pennsylvania’s Superior Court has followed this standard.

在本案中,没有对部分索赔进行单独评估,也没有进行任何部分评估,导致商定了无争议的部分应付款。被保险人最初拒绝了一个要约,但后来要求付款,但被保险人不承认他接受或拒绝了这个要约。相反,被保险人的律师要求承运人“开具10,000美元的汇票,作为UIM福利的部分付款,直到可以立案且问题可以完全解决为止。”此外,即使支付了10,000美元,双方也不同意支付的含义。

Magistrate Judge Dodge concluded the “agreement to pay to Plaintiffs the amount of its previous offer to settle the UIM claim does not represent evidence of 恶意.” While it might be generally correct to characterized the $10,000 as undisputed “there were no communications about this amount representing a separate assessment of some component of [the] claim.” 更多over, 任何 delay 在 paying the $10,000 fell on the 在 sured.

“Thus, to the extent that Plaintiffs continue to assert that the failure [] to make a more timely partial payment represents 恶意, 任何 such claim fails as a matter of law. Plaintiffs cannot assert that [the 在 surer] acted 在 恶意 by offering to make a partial payment—which it was not required to do—and not offering it again sooner after Plaintiffs rejected it.”

UIPA Violations Cannot Form the Basis of a 信仰不良 Claim

的parties agreed there is no private right of action under the UIPA. 的insured, however, wanted to use UIPA violations as evidence of statutory 恶意. 的court rejected that effort.

Magistrate Judge Dodge stated that since the seminal Terletsky opinion 在 1994, “federal courts have uniformly rejected plaintiffs’ attempt to rely on UIPA violations to support 恶意 claims.” Contrary to the 在 sured’s arguments that some federal cases hold otherwise, she states that “for the past 26 years, case law 在 federal courts on this issue has been consistent.”  Magistrate Judge Dodge cites, among other cases, the Third Circuit’s opinion 在 浸出,吉布森法官的2019年 霍瓦斯的意见, Fisher法官2014年Kelman判决 (在西区受邀时)Kosik法官,2007年 厄尔曼决定孔蒂法官在2007年发表的疏忽性意见.

[我们2019年5月2日的帖子 总结了法院在考虑UIPA和《不正当索赔和解实践》法规时采取的不同方法。]

No 信仰不良 Based on Insurer’s Own Manuals

地方法院法官道奇(Dodge)发现,这不是保险人的手册和指南建议采取积极的理赔处理和诉讼策略以阻止被保险人的合法理赔的情况。 “在这种情况下,记录中没有证据表明[保险人的手册]助长了不正当的战术或行为;恰恰相反。”

的court also rejected the argument that the 在 surer acted 在 恶意 by violating its own claim handling policies. “The issue here is not whether [the 在 surer’s] claims handling policy is admissible, but whether it provides 任何 support for Plaintiffs’ 恶意 claim. It does not.”

In sum, partial summary judgment was granted on the 恶意 claim.

决定日期:2020年12月10日

克莱因诉Unitrin汽车和家庭保险公司,美国宾夕法尼亚州西区地方法院,第2:19-CV-01426,2020年,WL 7263548(W.D。Pa .. Dec. 10,2020)(道奇,M.J。)

宾夕法尼亚州高等法院地址在简易判决背景下对涉嫌不利的指控进行指控(宾夕法尼亚州高等法院)(非前提)

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We do not often see Pennsylvania’s state courts addressing “conclusory” allegations 在 恶意 cases. In this case, the Superior Court makes clear that conclusory assertions cannot forestall summary judgment on a 恶意 claim.

的employee plaintiffs/insureds demanded underinsured motorist coverage under the employer’s policy.  They asserted that there were $1,000,000 在 UIM limits. 的carrier countered that the employer had selected 和 signed off on a $35,000 UIM coverage limit, 和 the 在 surer ultimately paid the $35,000.  的trial court agreed with the carrier on the facts of record that coverage was only $35,000, 和 granted summary judgment on the breach of contract claim. 的Superior Court affirmed, finding the employer’s UIM sign-down enforceable 和 effective.

As to the 恶意 claim, the trial court found “there can be no dispute that [the 在 surer] had a reasonable basis for denying the … claim for coverage beyond $35,000, as we have already determined the trial court did not err 在 concluding that the UIM policy limit was $35,000.” 的panel then looked at the 恶意 claim based upon the 在 surer’s timeliness 在 dealing with the claim. This appears to be an argument there was a 恶意 delay 在 paying the $35,000 admittedly due.

的insureds argued the 在 surer failed “to promptly offer 任何 payment,” engaged “in dilatory 和 abusive claims handling,” acted “unreasonably 和 unfairly by withholding underinsured motorists benefits justly due 和 owing,” subordinated “the 在 terests of its 在 sured 和 those entitled under its 在 sured’为其自身的金融货币利益承担责任”,并导致被保险人花钱提出索赔。

的Superior Court again affirmed the trial court’s granting the 在 surer summary judgment, favorably citing the trial court’s reasoning.

First, the trial court rejected the 在 sureds’ Nanty-Glo argument. Further, the 在 sureds “provided no evidence to support their 信仰不良 claim beyond conclusory assertions.” 的record showed the 在 sureds made a $900,000 demand on what the 在 surer (correctly) believed was a $35,000 policy.  的record also revealed the 在 surer was attempting to get 在 formation from the 在 sureds to resolve the claim, 和 that the carrier tendered the $35,000 limit multiple times, which offers were refused or ignored.

的Superior Court favorably quoted the trial court on how to address conclusory 恶意 allegations 在 responding to a summary judgment motion. 的trial court had relied on Pennsylvania Supreme Court precedent 在 reaching its conclusion:

“在没有证据支持承担举证责任的问题的情况下,允许不动产的当事人避免即席判决,这违反了《宾夕法尼亚州民事诉讼规则》 1035的精神。我们已经指出,简易判决程序是冲破诉状并评估证据,以查看是否确实需要进行审判。我们在英联邦拥有一个简易判决规则,以便免除对以下案件的审判(或在某些情况下,在案件中有争议) party lacks 证据的开始 to establish or contest a material issue…。强迫当事方以执行简易判决规则为幌子,对毫无根据的主张进行审判,是对该规则的歪曲。 [强调已添加]

因此,我们认为,一个不动产的当事方必须就其案件必不可少的一个问题提供充分的证据,并在该问题上承担举证责任,以便陪审团可以作出有利于他的裁决。”

在这种情况下,高级法院裁定原告“缺乏‘证据的开始’关于[保险人]如何进行扩张性和滥用性索赔处理,并服从其被保险人和受保人的利益’涵盖其自身的金融货币利益。”被保险人没有提供足够的证据证明有关延误的证据,也没有证据表明招标解决的任何延误是不合理的,或者是明知或or顾后果地无视延误是不合理的。

的underlying dispute over whether coverage was $1,000,000 or $35,000, 和 the 在 sureds 在 sistence on pursuing large six figure demands, contributed to the circumstances of 任何 delays.

决定日期:2020年9月11日

Beach v. 的Navigators Insurance Company,宾夕法尼亚州高等法院,第1550号MDA 2019,2020 WL 5494530(2020年9月11日,超级Ct。Pa)(Musmanno,Panella,Stabile,JJ。)

在任何可能的情况下,保险人都没有合理的依据来进行其行为; UIPA和UCSP法规没有建立不良信仰主张的依据(费城联邦)

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This UIM 恶意 claim 在 volved allegations of delayed 在 vestigation 和 settlement payment. 的insurer moved for summary judgment, which Eastern District Judge Robreno granted.

的court observed that 任何 reasonable basis to deny coverage defeats a 恶意 claim, 和 consultation with counsel can establish a reasonable basis for the 在 surer’s actions. Negligence or poor judgment do not make out a 恶意 case. Further, “[a]n 在 surer who 在 vestigates legitimate questions of 在 surance coverage is not acting 在 恶意, 和 no 在 surer is required ‘to submerge its own 在 terest 在 order that the 在 sured’s 在 terests may be made paramount.’”

更多over, although 恶意 can be proven through unreasonable delays 在 paying on a claim, “’a long period of time between demand 和 settlement does not, on its own, necessarily constitute 恶意.’” For example, if the 在 surer’s delay is tied to its need for further 在 vestigation, this is not 恶意.

Judge Robreno’s opinion sets forth a meticulous recitation of the factual history. 的key factual issues were the length of time 在 reaching a settlement 和 the 在 vestigation 在 to what portion of the 在 sured’s 在 juries were attributable to the accident at issue vs. a separate auto accident 在 the preceding year.

In analyzing these facts, the court observed that the 在 sureds’ principal argument was that the 在 surer took 15 months to make a settlement offer. However, the court found this was “not a per se violation of § 8371, 和 courts have found no 恶意 在 cases where 在 surers took the 相同的时间长度 评估索赔。” (强调原文)

Drilling down with specific calendar calculations by relevant event, Judge Robreno found the length of time attributable to the 在 surer’s own delay was around 9 months. This was only half of the nearly 18-month period between the first petition to open a UIM file 和 filing suit. Further, during its 在 vestigation, the 在 surer had “repeatedly asked … for additional medical documentation, repeatedly communicated with Plaintiffs’ Counsel, 和 provided updates on the progress of the 在 vestigation. In the light most favorable to Plaintiffs, no reasonable jury could find by 清晰而令人信服 evidence that Defendant lacked 任何 调查的合理依据。” (强调原文)

UIPA 和 UCSP regulations not a basis for 恶意 here

在最后的脚注中,罗布雷诺法官拒绝了被保险人根据《不公平保险惯例法》(UIPA)或《不公平索赔和解惯例》(UCSP)的规定提出索赔的努力。

He states, “While recognizing that they do not provide private causes of action, Plaintiff also cites to the Pennsylvania Unfair Insurance Practices Act, 40 Pa. C.S. § 1171, 和 the Pennsylvania Unfair Claims Settlement Practices regulations, 31 Pa. Code § 146, which each require prompt 和 reasonable responses from 在 surers 在 response to a claim, as further evidence of Defendant’s 恶意 conduct. … However, ‘a violation of the UIPA or UCSP is not a per se violation of the 恶意 standard.’ …. Further, both statutes apply to behavior performed with such recurrence as to signify a general business practice. See 31 Pa. Code § 146.1; 40 Pa. C.S. § 1171.5(a)(10). Because Plaintiffs only identify an isolated 在 stance of Defendant’s alleged 恶意 conduct 在 their argument that Defendant violated both statutes, neither is persuasive 在 showing Defendant lacked 任何 延迟原告主张的合理依据。” (强调原文)

决定日期:2020年3月19日

Bernstein诉Geico Casualty Co.美国宾夕法尼亚州东区地方法院民事诉讼编号2020年美国区19-1899。雷克西斯47798(E.D. Pa。Mar. 19,2020)(J.Robreno)

 

没有坏信念:(1)合理的低赔付率; (2)未能全额支付未保留的信仰; (3)附加调查不会改变结果; (4)保险延迟索赔处理(西区)

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In this UIM 恶意 case, the court set out a detailed claims handling history. It shows an active claims handler, conflicting expert reports, 和 what appears to be a genuine dispute over the scope of the 在 sured’s 在 jury. 的central discrepancy is between permanent disability vs. no medical record of serious 在 jury.

的court granted summary judgment on 恶意, finding the 在 sured could not meet the 清晰而令人信服 evidence standard. It specifically addressed four issues 在 reaching this conclusion.

  1. 和解报价过低吗?

的insured claimed losses 在 excess of $2,000,000. 的UIM 在 surer offered $25,000. As the tortfeasor’s carrier paid $100,000, this meant the UIM carrier valued the claim at $125,000.

的court set out the relevant law. Low but reasonable offers are not 恶意, but “low-ball offers which bear no reasonable relationship to an 在 sured’s actual losses can constitute 恶意….” A carrier can reasonably rely on expert opinion when 在 vestigating claims. In this context, 在 surers “can rely on IMEs of qualified health professionals who examine claimants 在 a usual 和 customary manner.”

First, the court found the claims handler’s well documented file showed an IME was warranted. Next, the court examined the claims handler’s review of the 在 sured’s economic expert’s report of over a $2,000,000. 的court found that multiple medical reports provided the claims handler with a reasonable basis to question the economic expert’s critical assumption of permanent disabled. “Thus, with no other evidence to establish [the 在 sured’s] economic losses other than [the economic expert’s] report that assumes total disability, no reasonable juror could find 恶意 by 清晰而令人信服 evidence from [the] $25,000 settlement offer to [the 在 sured].”

  1. 储备金

储备金 were set at $55,000. 的insured asserted the 在 surer should have offered the $55,000, rather than $25,000. 的court stated that an 在 surance company must set reserves aside when placed on notice of a possible loss arising under its policy. “However, the failure of a carrier to offer its full settlement authority does not constitute 恶意.” In the present case, “because the Court finds no sufficient evidence of 恶意 as to the $25,000 settlement offer, there is likewise no 恶意 在 [the 在 surer’s] reserve for this UIM claim.”

  1. 调查的充分性

To prove 恶意 在 vestigation, the 在 sured “must show that the outcome of the case would have been different if the 在 surer had done what the 在 sured wanted done.” 的putative 在 vestigative failures here would not have changed the result.

Thus, even if the claims handler had reviewed the economic loss reports with her own economic experts, sought medical authorizations, or spoken to treating physicians or the tortfeasor’s lawyer, this additional 在 vestigation would not have altered the IME opinions that there was no permanent 在 jury, 和 that 任何 在 juries had resolved. These IMEs provided a reasonable basis to contest value. “Therefore, [the 在 sured] cannot meet his burden to show that a reasonable juror could find by 清晰而令人信服 evidence that [the 在 surer] would have evaluated [the] claim differently had it conducted an earlier or different 在 vestigation as argued by plaintiff’s counsel.”

  1. 不必要的调查延误

“In order for an 在 sured to recover for 恶意 from delay, an 在 sured must demonstrate that ‘the delay is attributable to the defendant, that the defendant had no reasonable basis for the actions it undertook which resulted 在 the delay, 和 that the defendant knew or recklessly disregarded the fact that it had no reasonable basis to deny payment.’”

的court first observed that much of the delay 在 this matter was caused by the 在 sured. There were delays 在 providing 在 formation 和 producing documents to the 在 surer. 的insured also changed his damage theory during the claims handling process, which led to 在 surer to require additional evaluations. Thus, “no reasonable juror could conclude by 清晰而令人信服 evidence that [the 在 surer] acted 在 恶意 在 the timeline of its 在 vestigation….”

决定日期:2020年2月19日

斯图尔特诉GEICO保险美国宾夕法尼亚州西区地方法院2:18-CV-00791-MJH,2020美国区。 LEXIS 28459(于2020年2月19日在宾夕法尼亚州W.D.注册)(霍兰,J.)

感谢Dan Cummins律师的出色 侵权谈话博客 引起了我们的注意。

 

2018年5月不良信仰案件:(1)拒绝给予好处(2)不足的调查和(3)不合理的延迟作为法定不良信仰的潜在依据(费城联邦)

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This post 在 cludes two opinions from consecutive days issued by the same judge 在 the Eastern District. In these two opinions, the court sets forth various standards for pursuing potential statutory 恶意 claims, 在 cluding (1) benefit denial; or (2) unreasonable 在 vestigations; or (3) delays 在 either (a) the claim handling process or (b) paying benefits due. As noted before on this blog, there is an issue whether statutory 恶意 can exist for poor 在 vestigation or claim handling practices where no benefit was due.

CASE 1

In the first case, the 在 surer denied disability benefits. 的insured sued for breach of contract 和 恶意. 的bad faith claim was based on two theories: (1) unreasonable denial of benefits 和 (2) improper claim handling during the 在 vestigation. 的court denied the motion to dismiss the coverage based 恶意 claim for denying benefits, but granted the motion to dismiss the 恶意 claim based on an 在 adequate 在 vestigation.

否认受益不良信念

的court’s 恶意 analysis began with basic statements of statutory 恶意 law:

  1. “To establish 恶意 under 42 Pa.C.S. § 8371, a plaintiff must demonstrate that the 在 surer (1) lacked a reasonable basis for denying benefits 和 (2) knew or recklessly disregarded its lack of a reasonable basis.”

  2. “In the 在 surance context, 恶意 denotes a ‘frivolous or unfounded’ refusal to pay policy proceeds, which imports a dishonest purpose 和 a breach of a known duty, such as good faith 和 fair dealing.”

  3. “To defeat a claim of 恶意 an 在 surer need not show that the 在 surer was correct; rather, an 在 surer must demonstrate that it had a reasonable basis for its decision to deny benefits.”

  4. “A reasonable basis is all that is required to defeat a claim of 恶意.”

  5. “On the other hand, ‘an unreasonable 在 terpretation of the policy provisions as well as a blatant misrepresentation of the facts or policy provisions will support a 恶意 claim.’”

调查不足的信念

These principles, however, were not the sole means to define 恶意. 的court cited case law for potential 恶意 conduct that went beyond these basic parameters, beginning with the proposition that “[s]ection 8371 also encompasses a broad range of other conduct 在 cluding 在 adequate 在 vestigations.”

Concerning “inadequate 在 vestigation” 恶意, the court stated the following:

  1. “法院裁定,保险人必须'在拒绝向被保险人支付保单收益之前,对索赔进行适当的调查。'”

  2. “'保险公司进行的调查不足或未能就承保问题进行充分的法律研究时,可能会发生恶意。””

  3. 但是,保险人不必证明其调查得出了正确的结论或其调查是完美的;相反,它必须只是表明其调查“足够彻底,足以证明其拒绝索赔的决定是正确的。””

的insured’s amended complaint based her 恶意 claims on two distinct theories: “(1) a denial of benefits predicated either on an unreasonable 在 terpretation of the terms 和 conditions of the Policy or on imposition of requirements that do not exist 在 the Policy; 和 (2) a failure to conduct a reasonable or adequate 在 vestigation 在 to the nature 和 extent of either Plaintiff’身体状况或原告’s occupation.”

的court refused to dismiss under the first theory, finding that factual issues remained on the coverage questions. However, it did dismiss the 恶意 claim under the second theory. Although the plaintiff had added some allegations to support her 在 adequate 在 vestigation claim, “[t]hese additional allegations fail to successfully move Plaintiff’s 恶意 claim from the realm of mere possibility to that of plausibility.”

修改后的投诉的展览显示,除其他外,该保险公司已经考虑了被保险人的医疗信息以及有关其职业职责的声明。此外,被保险人多年来没有报告其残疾,这种延误及其后果完全是她的责任。当法院总结其驳回意见时:“尽管被告’s 在 vestigation may not have been perfect, the allegations of the Amended Complaint do not raise a plausible inference that it was so deficient as to rise to the level of 恶意.”

决定日期:2018年5月22日

Wiessmann诉西北地区共同人生案。公司美国宾夕法尼亚州东区地方法院民事诉讼编号2018年6月16日至16日,美国区LEXIS 86103(美国宾夕法尼亚州2018年5月22日)(Goldberg,J.)

CASE 2

的second case 在 volved UIM breach of contract 和 恶意 claims. 的insurer moved for summary judgment on the 恶意 claim. In carrying out its 恶意 analysis, the court observes the same principles quoted above concerning denial of benefits, burden of proof, 和 在 adequate 在 vestigation, but also adds more detailed principles concerning delay as a basis for 恶意.

与第一项裁决类似,法院最初遵循基本的恶意原则:“在宾夕法尼亚州,‘bad faith’在保险案件中被定义为‘any frivolous or unfounded refusal to pay proceeds of a policy. … Bad faith must be demonstrated by 清晰而令人信服 evidence, ‘a burden that applies even on summary judgment.’ … To establish 恶意 under 42 Pa.C.S. § 8371, a plaintiff must demonstrate that the 在 surer (1) lacked a reasonable basis for denying benefits 和 (2) knew or recklessly disregarded its lack of a reasonable basis. … In the 在 surance context, 恶意 denotes a ‘frivolous or unfounded’ refusal to pay policy proceeds, which imports a dishonest purpose 和 a breach of a known duty, such as good faith 和 fair dealing. … While mere negligence or bad judgment are 在 sufficient, a showing of reckless disregard will suffice to establish 恶意.”

不合理的延迟不良信念

其次,与第一个案件一样,法院指出“第8371条不限于保险人’s 恶意 在 denying a claim. An action for 恶意 may extend to the 在 surer’s 在 vestigative practices.” 的court then observes standards for another measure of 恶意 not detailed 在 the first opinion: “A 恶意 在 surance practice can also 在 clude an unreasonable delay 在 handling or paying claims. … Thus, even when ‘an 在 surance claim has been settled 和 paid, Pennsylvania’s 恶意 statute provides 在 surance claimants a means of redressing unreasonable delays by their 在 surers.’”

的court sets forth the following principles concerning 恶意 delay claims:

  1. “To establish a claim of 恶意 based on the 在 surer’如果延迟支付索赔,原告必须证明(1)延迟归因于保险人; (2)保险人没有造成延误的合理依据; (3)保险人知道或不顾后果地无视延误的合理依据。”

  2. 的plaintiff bears the burden of establishing delay by 清晰而令人信服 evidence.”

  3. A long period of time between demand 和 settlement does not, on its own, necessarily constitute 恶意.”

  4. “[I]f delay is attributable to the need to 在 vestigate further or even to simple negligence, no 恶意 has occurred.”

的court uses examples from prior case law to show specific time periods that did not constitute 恶意 delays. In one precedent, “a delay of fifteen months to resolve a claim—during which the 在 surer took the 在 sured’通知索赔后九个月的存款,等待一年后才投保’s deposition 和 waited fourteen months to obtain a vocational assessment—was not an unreasonable length of time so as to rise to the level of 恶意, even though the 在 surer could have completed its 在 vestigation with greater speed”. In another, “even if all delay were attributable to the 在 surer, a period of approximately thirteen months between notification of UIM claim 和 resolution of claim through arbitration would not, without more, be sufficient to establish bad faith”.

In applying these principles, the court lays out a detailed factual history of the 在 surer’s claim handling during the adjuster’s 在 vestigation, 在 cluding the history of communications between the adjuster 和 the 在 sured’s attorney 和 requests for various documents 和 records. Despite this detailed factual record, however, the 在 sured solely relied on his complaint’s averments to oppose summary judgment. These amounted to conclusory allegations that could not meet the 清晰而令人信服 evidence standard.

Independently, the court found “the undisputed evidence reveal[ed] no 恶意 在 vestigation or delay on Defendant’的一部分。”最后,法院指出,“任何拖延都应归因于被告双方’有充分的理由调查原告和原告’s own delays 在 providing the requested 在 formation. Based on this undisputed record, no reasonable factfinder could determine that Defendant acted 在 恶意 在 在 vestigating 和/or evaluating Plaintiff’s UIM claim.” Thus, the court granted summary judgment on the 恶意 claim.

决定日期:2018年5月23日

威廉姆斯诉自由共同保险宾夕法尼亚州东区美国地方法院民事诉讼,第17-3862号,2018年美国区。 LEXIS 86356(美国宾夕法尼亚州2018年5月23日)(Goldberg,J.)

 

 

2018年3月不良信仰案件:过失不是不良信仰;记录违背错误信念的秃鹰指控(联邦费城),则不能对判决进行失败

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In this UIM case, the actual record warranted summary judgment for the 在 surer, despite allegations of 恶意 to the contrary.

的insured submitted a UIM claim for 在 juries sustained to his elbow. 的insured recovered $100,000 from the tortfeasor’s 在 surer, 和 then requested maximum UIM benefits of $200,000. Three weeks before the accident, the 在 sured had 在 jured the elbow when he fell at his home.

的insured’s counsel 在 itially attempted to contact a claims specialist who no longer worked for 在 surer. Nearly four months later, the 在 surer responded that that this adjuster no longer worked there, but the UIM claim was being transferred to another claims specialist immediately. 的insurer did immediately begin processing the claim, 和 continually requested additional medical records from the 在 sured, to no avail.

的insured filed suit for 恶意 和 breach of contract, 和 the 在 surer moved for summary judgment on the 恶意 claim, which was granted for the following reasons:

Negligence is not 恶意.

  1. 的insured argued 恶意 在 delaying the UIM 在 vestigation for four months. 的Court ruled that 在 light of the fact that the 在 itial demand letter was sent to the wrong person, the delay 在 opening the claim amounted to mere negligence, not 恶意.

的record contradicts the 在 sured’s alleged bases for 恶意.

  1. 的insured argued a failure to tender reasonable UIM benefits. 的Court rejected this argument, stating that a partial valuation of the claim had neither been made nor requested by the 在 sured.

  2. 的insured argued the 在 surer used dilatory tactics 和 failed to 在 vestigate the claim. 的Court found this “patently false,” because the record showed the 在 surer continually communicated with the 在 sured 和 retained three separate physicians who all concluded the 在 sured suffered no additional elbow 在 jury due to the auto accident.

  3. 的insured argued the claim was frivolously denied. 的Court rejected this argument, citing the thorough 在 vestigation conducted by the 在 surer.

决定日期:2018年3月6日

史密斯诉LM General Insurance Co。,民事诉讼编号2018年2月17日雷克萨斯(Lexis)35773(E.D. Pa。Mar. 6,2018)(帕佩特,J.)

2017年8月不良信仰案件:没有因被保险人混淆索赔处理流程并拒绝与保险人合作而感到不满(费城联邦)

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This 95-page opinion granting the 在 surer summary judgment provides an extremely detailed review of the facts, 和 considerable exposition of 恶意 case law concerning 在 vestigation 和 claims handling.

如意见中所述,被保险人拥有她出租给大学生的多个出租物业。从2005年开始,她从保险公司购买了业主财产保险。 2014年,房客搬进了房产,并向乡镇警察警告了恶劣的情况。

的police report catalogued broken windows, buckled hardwood floors, water damage, ceiling damage, removed 和 damaged fixtures 和 doors, detached ceiling lights 和 smoke alarms, peeling paint, an overgrown lawn, broken appliances, trash, 和 mice droppings. 的tenants then broke their leases, citing a breach of the implied warranty of habitability.

A township code official 在 spected 和 photographed the properties 和 prepared a list of code violations. 的official posted violation notices, 和 revoked the 在 sured’s student rental licenses. 的insured notified both the 在 surer 和 her 在 surance broker, 和 made a claim for the property damage 和 lost rent.

的insurer mistakenly filed the 在 sured’s communication 在 a preexisting file related to another claim with the same 在 sured. However, an employee of the 在 surance broker immediately called the 在 sured to request more facts relevant to the claim. 的insured did not pick up the call 和 did not return the voicemail.

的township later brought a code violation action against the 在 sured 在 the Court of Common Pleas, as well as for the 在 sured’s failure to allow mandated property 在 spections over several years. 的insured then reached out to the 在 surer, 和 repeatedly claimed that her earlier communications went unanswered.

的insured’s story changed, however, after the 在 surer produced evidence of phone calls 和 emails from claims adjusters. 的insured conceded that she did 在 fact speak to someone, but she only “sort of” recalled the conversation.

Even after the rental license revocations, the 在 sured again rented properties to two other college students. Similar physical problems arose, 和 the new tenants were likewise unable to reside at the properties. 的township locked the 在 sured out of the properties.

Throughout this period, the 在 surer’s claims handlers continually attempted to communicate with the 在 sured to gather more facts concerning the 在 sured’s claim. 的insured received an email stating “‘it is imperative that I make voice to voice contact with you to get accurate loss facts regarding the claim that you submitted’ since ‘the claims process is reliant on the 在 formation that is shared between ‘you’ the 在 sured 和 ‘me’ the claims adjuster.’”

Several days after the 在 sured received that email, the adjuster had a telephone call with the 在 sured, but the 在 sured said she could not speak with the adjuster due to ongoing litigation. 的insured then hung up the phone.

的insurer took the position that the policy did not provide coverage for property damage, lost rents or the township’s suit against the 在 sured.

的insured sued the 在 surer for breach of contract, 恶意, 和 alleged violations of Pennsylvania’s Unfair Trade Practices 和 Consumer Protection Law (“UTPCPL”). 的Court granted the 在 surer’s motion for summary judgment on the breach of contract claim, stating that the 在 surance policies were not “all risk” policies whereby coverage is automatically triggered 在 the event of loss.

Furthermore, the 在 sured failed to show that the losses occurred suddenly 和 accidentally, 和 the 在 sured had no reasonable expectation of coverage. 的court also found that the 在 surer had no duty to defend the 在 sured 在 the state court action. Additionally, the court granted the 在 surer summary judgment on the UTPCPL claim, finding no fraud or misrepresentations to the 在 sured with regard to the policies.

As to the 恶意 claim, the 在 sured alleged that the 在 surer 在 tentionally delayed opening a claim, delayed commencing its 在 vestigation, 和 that it lacked a reasonable basis for refusing to pay the 在 sured benefits under the policies.

的Court found that there existed no 清晰而令人信服 evidence that the 在 surer acted 在 恶意. 的Court stated that “the record makes clear that [the 在 surer’s] delays are attributable to mistake, possible confusion between [the 在 surer] 和 [the broker,] 和 [the 在 sured’s] obfuscation 和 refusal to cooperate with [the claims] representatives.”

的Court further opined that the 恶意 claim must fail because the evidence shows the 在 surer conducted an adequate 在 vestigation 和 had a reasonable basis for denying coverage. Any delays on the part of the 在 surer were attributable to the 在 sured’s “repeated failures to provide the 在 formation necessary to open a claim….”

的Court granted the 在 surer’s motion for summary judgment 在 its entirety.

决定日期:2017年4月6日

Doherty诉Allstate Indem。公司,第15-05165号,2017年美国地区。 LEXIS 52795(美国宾夕法尼亚州2017年4月6日)(Pappert,J.)

上诉后维持了这一决定。

Doherty诉Allstate Indem。公司美国上诉法院第三巡回庭,2018年第17-1860号。 LEXIS 13900(3d Cir.2018年5月25日)(Fuentes,Greenaway,Rendell,JJ。)

 

2017年6月不良信仰案件:索赔处理流程中没有不良信仰延误(费城联邦)

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This summary judgment opinion 在 volved a 恶意 dispute based on alleged delay 在 claims handling 在 the course of an appraisal process valuing property loss. 的court had earlier dismissed the 在 sureds’ breach of contract claim, but had allowed the 恶意 claim to proceed.

的court first observed that 在 its earlier decision, the dispute over the claim value was not the basis for a breach of contract claim, where the 在 sureds could not show the actual breach of a contractual duty.

In allowing the 恶意 claim to proceed, the court had “expressly found that the amended complaint limited the 恶意 claim to the delay 在 the appraisal process,” not value. Thus, it rejected the 在 sureds’ current effort to assert 恶意 for undervaluing of the claim, which the court found “irrelevant.”

的court summarized the law concerning delay 和 恶意. “[A] 恶意 在 surance practice can 在 clude an unreasonable delay 在 handling or paying claims.” “Thus, even when ‘an 在 surance claim has been settled 和 paid, Pennsylvania’s 恶意 statute provides 在 surance claimants a means of redressing unreasonable delays by their 在 surers.’”

To establish a claim of 恶意 based on the 在 surer’s delay 在 paying the claim, the plaintiff must show that (1) the delay was attributable to the 在 surer; (2) the 在 surer had no reasonable basis for causing the delay; 和 (3) the 在 surer knew or recklessly disregarded the lack of a reasonable basis for the delay.”

It is “[t]he plaintiff [who] bears the burden of establishing delay by 清晰而令人信服 evidence.” “A long period of time between demand 和 settlement does not, on its own, necessarily constitute 恶意.” Further, “’[i]f delay is attributable to the need to 在 vestigate further or even to simple negligence, no 恶意 has occurred.’”

的court closely analyzed the history of the parties’ conduct of the appraisal process. 的court found the first alleged delay of 5 weeks 在 acknowledging the appraisal demand was de minimis, 和 could not lead a reasonable jury to find 恶意.

更多over, after acknowledging the demand, the 在 surer’s appraiser reached out to the 在 sureds’ appraiser, but the 在 sureds’ appraiser stated he could not begin work until he had a signed agreement with the 在 sureds. Once he had that signed agreement, the two appraisers then executed a joint declaration 和 began their 在 spections. This could not be the basis for a 恶意 claim.

的court also rejected the argument for 恶意 during a subsequent 5-month period during the appraisal process. Both appraisers carried out 在 vestigations during the first three months of this period. 的insurer’s appraiser also had lab tests done regarding asbestos remediation, 在 vestigated the HVAC system, 和 conducted extensive research 在 response to the 在 sureds’ claim for engineering 和 architectural fees, which 在 volved multiple 在 terviews with the plaintiffs’ engineer 和 architect.

此后长达一个月的时间流逝,其中一部分包括保险人同意被保险人的鉴定人前往佛罗里达参加其母亲的葬礼。他回来后,两位评估师再次讲话,并将申诉书提交给了公断人。

总而言之,原告无法负担确定推定的“延误是不合理的,只能归因于[保险人],或者[保险人]没有合理的依据来造成任何此类延误”。任何据称的延误都是“法律和保险工作的一部分。”

的eight months at issue from the time of demand to the time of the umpire’s meeting was “relatively minimal,” 和 during “that period, both parties’ appraisers were actively conducting 在 vestigations, with much of the actual delay attributable to plaintiffs’ own adjuster.”

的court granted summary judgment for the 在 surer.

决定日期:2017年6月8日

Dagit诉Allstate财产&伤亡保险公司,第16-3843号,2017年美国地区。 LEXIS 87971(于2017年6月8日编入宾夕法尼亚州)(O'Neill,Jr.,J.)

2017年6月不良信仰案件:由于在索赔处理期间缺乏行动而造成的不良信仰,导致无法获利(中区)

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This property loss case provides a good summary of basic 恶意 law leading 在 to its analysis of the facts, 和 then some strong language on bringing a 恶意 claim where the 在 sured’s own conduct led to the delays at issue.

报价法院:

“To succeed on a 恶意 claim, a Plaintiff must demonstrate “(一)保险人缺乏合理的拒绝给付依据; (2)保险人知道或不顾后果地无视其合理的依据。” Verdetto诉State Farm Fire 和伤亡公司,837 F.Supp 2d。 480,484(博士后2011年),确认 510美联储Appx。 209,2013 W.L. 175175(3d.Cir.2013)(引述Klinger诉State Farm Mutual Insurance Company,115 F.3d 230,233(3d。Cir。1997)。此外,原告必须以明确和令人信服的证据表明恶意。Polselli诉Nationwide Mutual Fire Insurance Company, 23 F.3d 747,751(3d。Cir。1994)。一家保险公司若要证明其有拒绝或延迟支付理赔的合理依据,则无需证明其调查得出了正确的结论或结论Krisa v。Equitable Life Assurance Company,113 F.Supp 2d。694,704(MDPa。2000),不需要保险公司表明以下事实:“它得出结论的过程是完美无缺的,或者它采用的调查方法消除了与结论不符的可能性。”ID。取而代之的是,保险公司必须证明其进行了充分彻底的审查或调查,以为其行动奠定合理的基础。 ID。“The ‘clear 和 convincing’标准要求原告出庭‘证据是如此清晰,直接,有说服力且令人信服,以至于可以毫不犹豫地就被告是否有恶意行事而定罪。””J.C. Penney Life Insurance Company诉Pilosi,393 F.3d 356,367(3d。Cir。2004)。”

In this case, the 在 surer paid “no less than $347,000” for real 和 personal property loss from fire, with a remaining dispute over $17,000 for landscaping issues. That contract dispute could not be resolved on summary judgment. However, the 恶意 claim was resolved on summary judgment, where the court found it “unthinkable” on the facts that a jury could find 恶意.

的bad faith claim centered on the timing of making payments for personal property loss (which had been ultimately paid to the policy limits). 的court observed that the analytic framework for measuring claims of delay 在 making such payments began with the terms of the 在 surance policy itself. Unambiguous policy language placed most responsibility for the timing 和 amount of payments on actions required of the 在 sureds. In this case, the 在 sureds did not provide required documentation for over a year.

的court analyzed the history 和 concluded: “In short, Plaintiffs’ failure to perform their reporting duty under the contract impeded, wittingly or unwittingly, [the 在 surer’s] 在 vestigation of their claim. Thus, the delay 在 payment for the value of their personal property was a direct result of Plaintiffs’ failure to perform their contractual duties 和, as such, may not serve as an appropriate basis for a finding of 恶意 on Defendant’s part. Stated another way, Plaintiffs may not now seek to profit due to their lack of action.”

决定日期:2017年5月30日

特纳诉国家农场火灾& Cas. Co., 第3:15-CV-906号,2017年美国地区。 LEXIS 81922(医学博士宾夕法尼亚州2017年5月30日)(J.Conaboy)

 

 

2017年5月不良信仰案件:延迟与不良信仰不是一致的;未事先声明誓言,因为事先在基础案件中有存款;不违反SE的技术法规违规(中区)

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A UIM claimant alleged 恶意 based upon: “misstatement of … coverage limits, alleged delay 在 claims processing, 在 sistence upon a sworn statement under oath …, persistence 在 collecting medical records 和 failure to comply with 在 surances regulations regarding periodic status notices to 在 sureds as evidence of 恶意.”

的insurer wanted summary judgment on the 恶意 claim, which the court granted, stating: “that, while both parties 在 dulged 在 occasional missteps 在 the process of reviewing 和 litigating this claim, the essentially uncontested evidence does not meet the demanding, precise 和 exacting legal standards prescribed under Pennsylvania law for a 恶意 在 surance processing claim.”

的court observed the “well-established” principle “that it is not 恶意 for an 在 surance company to ‘conduct a thorough 在 vestigation 在 to a questionable claim.’” Insurers can be successful 在 defending against 恶意 claim by showing that there were “red flags” warranting further 在 vestigation.

Thus, delay alone does not equate to 恶意: “the mere passage of time does not define 恶意. Rather, an 在 ference of 恶意 only arises when time passes as part of a pattern of knowing or reckless delay 在 processing a meritorious 在 surance claim.”

的court observed that 在 surers 在 UIM cases need to deal with the claim against the underlying tortfeasor, which 在 this case went on for a number of years. Further, the 在 sured did not place the 在 surer on notice of the UIM claim until nearly 5 years after the accident. Once the claim was made, the parties engaged 在 an ongoing process to attempt to resolve the dispute.

此外,尽管承运人原本确实误报了承保范围,但这是可以理解的错误,已得到纠正,仅造成短暂的延误。

In addition, there was nothing untoward 在 seeking a sworn statement 在 light of multiple circumstances, 在 cluding, e.g., 在 complete medical 在 formation. 的court did not accept the argument that no sworn statement was needed because the 在 sured had been deposed two years earlier 在 the underlying litigation. Further, as stated, each party engaged 在 some missteps 在 exchanging medical 在 formation, 和 the 在 surer was justified 在 seeking further medical 在 formation after having obtained some records.

Next, 在 evaluating the claim the underlying tortfeasor only settled years after the accident, 和 for a sum less than policy limits; a factor going to the UIM 在 surer’s ability to evaluate the claim. 的insured had originally demanded over double the UIM policy limits to settle, 和 then policy limits.

的final argument 在 volved alleged violations of Pennsylvania’s Unfair Claims Settlement Practices Act 和 the Unfair Insurance Practices Act, specifically concerning the regulatory requirement to provide 45 day updates on the status of 在 surance claims.

的court recognized that a “violation of these 在 surance rules can be considered when examining a 恶意 claim under §8371.” 的court then went on: “However, it is also clear beyond peradventure ‘that a violation of the UIPA or the UCSP is not a per se violation of the 恶意 standard.’”

Applying these principles, the court concluded: “This case aptly illustrates why technical violations of these state 在 surance regulations cannot be equated with 恶意. 的record before us amply reveals active, extensive 和 on-going communications …. Our review of the substance of these multiple communications … reveals that even when the communications are viewed 在 a light most favorable to [the 在 sured], these communications do not support a claim of 恶意 shown by 清晰而令人信服 evidence.”

的court then observed: “Given that the communications, 在 their substance, do not allow for a finding of 恶意 here, it would be anomalous to conclude that the fact that the communications did not meet the technical frequency requirements mandated by 在 surance regulations, standing alone, established a 恶意 claim 在 this case.”

决定日期:2017年4月10日

Ridolfi诉State Farm Mut。汽车。英斯公司,第15-859号,2017年美国地区。 LEXIS 54267(医学博士,宾夕法尼亚州,2017年4月10日)(卡尔森,新泽西州)