存档“ PA”–解决相关问题的类别

没有对被保险人或仅因估价纠纷导致的主动索赔处理未披露的关于其他保险承保范围的错误信念

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受伤的原告人拥有四辆汽车的UIM保险。通过堆叠,UIM的承保金额为60,000美元。被保险人同意以$ 50,000赔偿他的索偿。

达成和解后,原告提请承运人注意,他的继子对同一承运人也有汽车政策。原告的立场是,由于他们居住在同一个家庭中,因此按照Stepon的政策,他是被保险人。如果为真,这将使UIM的潜在承保范围从60,000美元大幅增加至160,000美元。

但是,继子的政策列出了其他家庭住址。继父告诉该承运人这不准确,因此对继子进行了调查’的地址随之而来。承运人最终同意为UIM提供额外的100,000美元承保,但没有找到增加诉讼和解费用50,000美元的事实依据。

保险人的估价索赔处理

法院从记录中接受了承运人的事实陈述。被保险人两次与承运人就索赔额达成协议,只是后来改变航向并增加了他的需求。承运人没有争论这些逆转,而是“重新开放,重新评估并继续以迅速,合理的方式与原告进行谈判。”而且,承运人这样做是“尽管[原告’s]一年多来一直拒绝参加SUO(经宣誓的陈述),并且拒绝提供发布医疗记录的授权,而这两项都是[保险人]有权获得的调查工具。”

法院还同意,被保险人仅给承运人“过短的时间窗口以响应他的要求,并拒绝给予任何延期。 …然而,[保险人]继续与原告合作,并向他解释[保险人]需要什么,[保险人]为什么需要它,以及[关于]他的索赔决定的依据。”

保险公司在受伤后数年获得了独立的医疗检查,得出的结论是没有增加赔偿金额的依据。这项评估是在被保险人一再表示要接受额外手术的时候进行的,这是增加索赔额的基础’的价值。截至该案的记录创建时间,该手术尚未进行。

塞尔科内法官表示,保险公司“合理地评估了原告UIM的索赔……并合理地认为,如果原告确实接受了手术,那么该索赔可在那时再次进行重新评估。”

据称未能确定Stepson的地址

The 恶意 claim focused on the 在 surer’继子的保单以及他自己的保单也涵盖了涉嫌未披露被保险人的情况。这又归结为事故发生时继子实际居住的地方,以及保险人对继子有什么了解’承保继子的住所’s auto policy.

记录显示,继子是用其亲戚父亲的家庭住址来申请保险的,而不是继父的住所。此外,继子上没有任何表情’的承销文件,表明继子是原告而不是亲生父亲。经过大量调查后,保险人同意原告是继子保单下的被保险人,因此接受了继子实际上是原告而不是其亲生父亲的住所。然而,如上所述,保险人拒绝在任何实际的额外手术及其评估之前增加其结算金额。

信仰不良 Analysis

The 在 sured sued for breach of contract 和 恶意. The 恶意 claim was based on the notion that it was the carrier, not the stepfather, that had a duty to disclose the additional $100,000 在 coverage under the stepson’s policy. Thus, the plaintiff alleged the carrier misled the stepfather-insured 在 to thinking there was only $60,000 在 coverage, 和 this created a basis for a statutory 恶意 recovery.

The 在 surer successfully moved for summary judgment on this 恶意 claim.

Judge Cercone found “[t]he matter presented to defendant 和 this court falls far short on the showing needed to permit the finder of fact to arrive at a finding of 恶意.” The stepfather did nothing more than 在 sinuate the carrier: (1) should have been more astute 在 determining the stepson’s actual address, (2) questioned the stepson on his address, (3) discovered 在 consistencies 在 his address, which (4) “would have 和 should have detected that [stepson] lived with plaintiffs,” 和 then (5) would have necessarily resulted 在 the carrier realizing that the stepson’s policy should have been added to the stepfather’适用的政策限制。

The court rejected this speculative narrative as falling far short of the kind of reckless or 在 tentional misconduct needed to prove 恶意. The putative failure to uncover the extra $100,000 在 coverage was at most negligent, 和 “an 在 surer’s mere negligence or bad judgment is not 恶意.”

更多over, the court clearly did not believe there was even negligence 在 this case. Judge Cercone described plaintiff’s effort to convert the stepson’s underwriting history “into an unfounded 和 unreasonable basis for failing to detect [stepson’s] actual residence [as] nothing more than an attempt to 在 sinuate an evidentiary basis for a finding of 恶意.” The plaintiff failed to identify any procedure the carrier failed to follow 在 concluding the stepson’s address to be with his biological father, which was the address submitted by the stepson 和 his biological father when originally obtaining the policy, 和 the address used on the policy.

法院称此案实际上是一场估值争议。

如上所述,保险人的理赔处理是合理的。它考虑了多个要求以重新评估索赔,即使在解决之后也是如此。它还同意增加100,000美元的承保范围,“一旦[stepson的]实际地址…获知…并得到核实,就不会出现有意义的延迟”

Cercone法官指出:“ [在此背景下,人们普遍猜测,参与其中的[保险人]校长从事某种行为,目的是为了增进[保险人]对原告的信托义务的财务利益,或者他们鲁ck地追求了能够做到的行为。如上所述,原告试图建立缺乏诚意的行为严重不足,而且还不够。”保险人没有发现任何东西’的索赔处理“即使在遥远的地方也会引起自我交易的阴影。”

塞科内法官发现“没有证据表明被告没有在调解过程中真诚地调查,估价和与原告进行谈判,也没有停止这样做。”

总而言之,塞科内法官指出:

简而言之,原告未能提供足够的证据以使他们对不诚实的保险业务索赔提出有利的调查结果。原告的证据与被告在寻找家庭保单持有人期间未发现[继子]的政策以及[原告] UIM的主张有关,无法承担原告试图承担的重担。 [保险人]直接要求原告确定居住在其家庭中的任何家庭成员所欠的汽车。当他们要求时,他们没有发现甚至暗示[stepson]和他的汽车。反映出在[Stepson's]保单中使用的地址的证据看起来与兑现其被保险人的陈述和开票要求一致,并且在任何情况下都没有提供明确和令人信服的证据表明被告人采取了自我交易或其他类似措施为了制止其在调整和谈判[原告] UIM索赔中的诚意义务。”

决定日期:2020年11月30日

Bogats诉State Farm Mutual汽车保险公司,宾夕法尼亚州西区美国地方法院,第2号:18CV708,2020年,WL 7027480(W.D。Pa。Nov. 30,2020)(J.Cercone)

(1)根据MVFRL的规定,不进行WANTON行为,以免造成重大损害和超级利益; (2)在没有法定错误信念的情况下(i)MVFRL规则的不良信念法规; (ii)仅存在估值争议; (iii)合理的调查; (4)BIAS索赔仅是主语(费城联邦)

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Plaintiff was 在 jured 在 an auto accident 和 made both PIP claims 和 underinsured motorist (UIM) claims. She found the carrier’s settlement offers 和 negotiations wholly 在 adequate, 和 brought statutory 恶意 claims, 和 claims for damages under the Motor Vehicle Financial Responsibility Law (MVFRL) seeking treble damages 和 super 在 terest for the 在 surer’s allegedly “wanton” conduct concerning her medical benefit claims.

MVFRL索赔

法院认为,在违反合同理论的情况下,被保险人可以继续其PIP索赔。但是,根据75 Pa。C.S.§1797(b)(4),MVFRL提出的三倍损害赔偿和12%利息的索赔被驳回,没有任何损害。帕普特法官裁定原告未提出抗辩“wanton”行为,是根据本法规获得非凡补救措施的依据。

The 在 surer also asserted the MVFRL count actually alleged a breach of the duty of good fair dealing, 和 moreover constituted an improper effort to get relief under the 信仰不良 Statute. It asked the court to strike certain averments related to this putative backdoor 恶意 claim.

法院驳回了这一论点:“尽管Count II似乎根据MVFRL提出了索赔……它也似乎针对…据称违反了隐含的合同义务履行与她的PIP承保有关的诚实行为的索赔。 …因为[被保险人]可能会因违反其政策的PIP承保义务而提出索赔,并且因为“不赞成采取罢工动议,通常会被拒绝,除非这些指控与争议没有任何关系,并且可能对其中一项造成偏见”各方,“法院不会对她关于第二计数中的诚实守信和公平交易的指控提出指控。”

MVFRL索赔 和 the 信仰不良 Statute

The court then addressed the statutory 恶意 claim.

The court first observed that unless the 在 surer’s “conduct falls outside of the scope of § 1797 of the MVFRL, 75 Pa. C.S. § 1797, 和 在 volves a 恶意 abuse of the process challenging more than just the 在 surer’s denial of first party benefits, the MVFRL preempts any statutory 恶意 claim concerning … PIP benefits.” The court made clear, “To the extent that the gravamen of [the] 恶意 claim is the denial of first party medical benefits 和 nothing more, [the 在 surer’s] alleged conduct is within the scope of § 1797 of the MVFRL 和 therefore [she] is precluded from bringing such a claim.”

However, “[s]ection 8371 恶意 claims remain cognizable when the basis of a benefits denial does not relate to the reasonableness 和 necessity of treatment, or when an 在 surer’s conduct is obviously not amenable to resolution by the procedures set forth 在 Section 1797(b).”

Dispute Over Valuation not 信仰不良

被保险人称保险人推迟了索赔,并否认了其价值。法院认为这些指控并不等同于保险人实际上否认UIM或PIP的指控。相反,在估值方面存在争议。

Analyzing the matter as a valuation dispute, Judge Pappert found the 在 sured did not allege “facts sufficient to show [the 在 surer’s] valuation is unreasonable.” The 在 sured’s subjective beliefs as to her claim’s value “is not 在 dicative of 恶意 because … subjective belief as to the value of the claim may reasonably, 和 permissibly, differ.”

Rather, “[t]o state a 恶意 claim, [an 在 sured] must do more than call [the 在 surer’s] offers low-ball.” These kind of conclusory 和 subjective allegations “suggest nothing more than a normal dispute between an 在 sured 和 在 surer.”

Low but Reasonable Offers Not 信仰不良

恶意不存在“仅仅是因为保险公司对被保险人做出了低而合理的估计’的损失。”也不拒绝“立即接受对政策限制的要求… without more, amount to 恶意.”

保险人有合理的理由拒绝索赔/没有充分的偏差索赔

接下来,帕珀特法官驳回了以下观点:被保险人充分辩护保险人缺乏合理的依据以否认索赔的价值。保险人要求病历并进行了IME。它根据该信息评估了被保险人的伤害。

The court did not give weight to conclusory allegations the doctor performing the IME was “a biased IME doctor” 和 “well-known as [someone] who provides so-called Independent Medical Examinations exclusively for 和 apparently to the liking of 在 surance companies….”  Further, that the plaintiff’s own doctor said she needed surgery did not, by itself, support a 恶意 claim. The 在 surer was not unreasonable 在 relying  on the IME doctor’s assessment that the symptoms requiring surgery were unrelated to the accident at issue.

“In the absence of any supporting facts from which it might be 在 ferred that [the] 在 vestigation was biased or unreasonable, this type of disagreement 在 an 在 surance case is not unusual, 和 cannot, without more, amount to 恶意.”

The court, however, permitted plaintiff to amend the statutory 恶意 claim “to the extent it is not preempted by the MVFRL 和 to the extent she is able to allege facts stating a plausible claim for relief.”

决定日期:2020年10月2日

Canfield诉Amica Mutual Insurance Co.美国宾夕法尼亚州东区地方法院,CV 20-2794,2020年,WL 5878261(美国宾夕法尼亚州,2020年10月2日)(帕珀特,J。)

不良信念索偿已成定局;法院拒绝分叉或切断的动议(费城联邦)

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In this underinsured motorist 恶意 case, Eastern District Judge DuBois denied both a motion to dismiss on ripeness grounds, 和 an alternative motion to server or bifurcate.

投诉称,侵权人的赔偿额为50,000美元,原告/被保险人的UIM赔偿额为500,000美元。侵权人同意以47,000美元和解,UIM承运人同意。原告涉嫌严重和永久性伤害,并向UIM提出索赔。

具体来说,被保险人声称他们遵守了所有保单条款和条件;保险人未提供任何UIM利益或提出任何和解要约;保险人未对索赔进行任何调查;保险公司通过“连续且系统地未能传达任何和解或拒绝给付的要约”玩弄“猫和老鼠”的游戏,至少在九次上误导了原告关于可能的和解,并且“故意忽略了[原告]对保险不足的驾驶人福利。”

可以进行恶意投诉

First, Judge DuBois rejected the argument that the 恶意 claim was not ripe until the breach of contract claim was actually decided. Among other things, the court stated: “Success on a statutory claim for 恶意 does not necessarily depend on the success of the underlying breach of contract claim.” Relying on a 1996 Eastern District decision, the court quotes: “A claim for 恶意 brought pursuant to § 8371 is a separate 和 distinct cause of action 和 is not contingent on the resolution of the underlying contract claim. A plaintiff may succeed on its 恶意 claim even if it fails on the underlying breach of contract claim. Additionally, courts 在 terpreting § 8371 have consistently entertained multi-count complaints containing both unresolved 在 surance contract disputes 和 恶意 claims.”

法院还依据未公布的第三巡回法院的裁决, Gallatin Fuels,Inc.诉Westchester Fire Insurance Co.,理由是“’[a]发现被保险人最终没有义务承保原告’的索赔本身并不能使被保险人’s actions reasonable’ 在 hindsight.” Judge DuBois concludes: “Therefore, so long as the underlying contract claim is ripe, the 恶意 claim is also ripe.”

After finding the claim ripe, the court finds plaintiffs can proceed on their 恶意 claim. “Plaintiffs allege defendant acted 在 恶意 by failing to properly 在 vestigate their 在 surance claim, engage 在 settlement discussions, 和 communicate with them. This is ‘a separate 和 distinct’ cause of action from plaintiff’s claim that defendant breached the terms of the policy 在 failing to pay UIM benefits. … As such, a finding that defendant does not owe plaintiffs UIM benefits would not mandate a finding that defendant did not act 在 恶意 在 handling the 在 surance claim.”

[注意: This opinion does not address the impact of the Pennsylvania Supreme Court’s decision 在 玩具诉大都会人寿保险公司 在 determining to what extend a statutory 恶意 claim can proceed, if at all, when there is no duty to pay any benefits under the policy. 更多over, we have previously observed that Gallatin Fuels never addressed Toy. These issues have been discussed many times on the 博客, most recently 这里.

特别值得一提的是杜波依斯法官在2019年的裁决 巴克诉GEICO, which appears to emphasize, 和 confirm, the denial of a benefit as a predicate to statutory 恶意 claims. Among other things, the Buck opinion looks to Toy as a leading authority, 和 not Gallatin Fuels. The Buck opinion 在 cludes language, 在 quotes below, stating:

“Even assuming that the 恶意 denial of the benefits claimed by plaintiff was properly alleged 在 the Complaint, plaintiff’s argument fails because plaintiff does not allege the denial of any benefits within the meaning of the statute. ‘[B]ad faith’ as it concern[s] allegations made by an 在 sured against his 在 surer ha[s] acquired a particular meaning 在 the law.’”

“Courts 在 Pennsylvania 和 the Third Circuit have consistently held that ‘[a] plaintiff bringing a claim under [§ 8371] must demonstrate that an 在 surer has acted 在 恶意 toward the 在 sured through ‘any frivolous or unfounded refusal to pay proceeds of a policy.’”

The Buck plaintiff could not state a claim because “[n]one of the ‘benefits’ that defendant allegedly denied plaintiff concern the refusal to pay proceeds under an 在 surance policy. To the contrary, plaintiff concedes that he ‘does not allege 恶意 for refusal to pay benefits.’”

Buck observes that cases have held “’section 8371 is not restricted to an 在 surer’s 恶意 在 denying a claim. An action for 恶意 may also extend to the 在 surer’s 在 vestigative practices.’” This means, however, that 恶意 claims “’need not be limited to the literal act of denying a claim.’”

Rather, “the essence of a 恶意 claim must be the unreasonable 和 在 tentional (or reckless) 剥夺利益.” “Thus, plaintiff must allege the 剥夺利益 to state a claim under § 8371.”]

In the present case, there seems to be no question that UIM coverage is provided, but only whether the plaintiff’s damages reach 在 to the UIM coverage level or stop below $50,000. The 在 surer does not appear to challenge whether a plausible 恶意 claim has been pleaded with adequate factual allegations, but only that the 恶意 claim should not be allowed to proceed because it is not ripe. The court concludes that the UIM 恶意 claim is ripe 和 can proceed.

分叉或断绝的动作

The Procedures 和 Standards Governing Contract 和 信仰不良 Claims do not Favor Bifurcation or Severance.

Judge Dubois first rejected the argument that the claims should be severed or bifurcated because they will be governed by different procedures 和 standards. First, the carrier 在 correctly argued that the contract 和 loss of consortium claims go to a jury while 恶意 is decided by the judge. While true 在 Pennsylvania state court actions, 恶意 claims can go to the jury 在 federal court cases. Next the court rejected the notion that the jury would be confused 在 applying the preponderance of the evidence standard to the contract claim 和 clear 和 convincing evidence standard to the 恶意 claim. Judge Dubois also rejected the argument that the facts at issue on the two claims were entirely distinct.

“For example, one of plaintiffs’ assertions 在 the 恶意 claim is that defendant failed to conduct an adequate 在 vestigation 在 to plaintiffs’ 在 juries. This requires 在 quiry 在 to two facts (1) the extent of plaintiffs’ 在 juries, 和 (2) the extent of defendant’s 在 vestigation 在 to those 在 juries. The breach of contract claim also requires 在 quiry 在 to the extent of plaintiffs’ 在 juries. A separate trial on the 恶意 claim would require plaintiffs to present much of the same evidence to the second jury, ‘duplicating 在 many respects the presentation to the first jury.’ 对于所有各方而言,这将是昂贵且费时的。由于权利要求之间的事实重叠,在这种情况下进行一次审判会更加方便。因此,便利因素不利于遣散或分叉。”

没有偏见,因为工作产品原则仍然有效。

As to prejudice, the 在 surer focused on protecting work product. Judge Dubois states: “On this factor, defendant contends that allowing discovery 和 trial for the claims to proceed simultaneously would prejudice defendant because discovery 在 the 恶意 claim would require defendant to disclose the claim adjustor’关于案情的精神印象,结论和意见,这是在违约案件中找不到的证据。 …在索赔理算人的工作产品受到保护的范围内,被告’的说法令人信服。”

Judge Dubois joins the vast majority of opinions finding the attorney client privilege 和 work product doctrine do not fall by the wayside simply because an 在 sured brings a 恶意 claim: “The Federal Rules of Civil Procedure 和 longstanding judicial precedent protect work product from disclosure—protections that do not disappear merely because work product prepared 在 anticipation of litigation over one claim may also be relevant to a second claim. Allowing the claims to proceed simultaneously simply means [defendant] will be called upon to prove its entitlement to work product protection….”

司法经济有利于单一行动

关于司法经济:

“被告’s argument as to this factor is that, should plaintiffs fail on their breach of contract claim, the 恶意 claim will be moot. As explained above, that is an 在 correct statement of the law. Plaintiffs’ 恶意 claim is based, 在 part, on defendant’未能调查原告’的保险索赔并就其索赔与原告进行沟通。 ‘发现[保险人]最终没有责任掩盖原告’的索赔本身并不能使[保险人’事后采取合理的行动。 Gallatin Fuels,Inc.,244 F. App’x在434-35。被告根据该政策最终是否应归还原告利益,这与被告是否适当处理了索赔有所不同。” [请参见上述说明,分别是Toy诉Metropolitan和Buck诉GEICO。]

“To the contrary, a single trial promotes judicial economy because it avoids duplication of effort by the parties across multiple trials. Although the contractual 和 恶意 claims present distinct legal issues, the underlying facts overlap. Therefore, “[b]ifurcation would essentially double the life of this action requiring a second discovery period, more dispositive motions, more pretrial motions, 和 a completely separate trial,” much of which would concern the same factual basis. … Accordingly, the judicial economy factor weighs against severance or bifurcation.”

决定日期:2020年9月11日

邓利维诉包容之家&汽车保险公司,美国宾夕法尼亚州东区地方法院,CV 20-1030,2020年,WL 5501200(美国宾夕法尼亚州,2020年9月11日)(杜波依斯,J。)

“权宜之计”条款破坏了不良信念和解索赔; 4年限制条件适用于基于合同的坏信索赔(费城联邦)

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被保险人案件的实质是,保险人在被保险人不知情或未得到允许的情况下,也没有进行充分调查的情况下,针对被保险人解决了索赔。保险公司从100万美元的保单中向受保人救护车中受伤的人支付了99.5万美元。被保险人断言承运人多付了定金,导致保费增加导致200,000美元的损失。

The complaint did not 在 clude any reference to statutory 恶意, 42 Pa.C.S. § 8371. Thus, the court found that the sole “bad faith” claim at issue was a breach of the contractual duty of good faith 和 fair dealing.

The 在 surer moved to dismiss based on section 8371’s two-year statute of limitations. Since this is a contract based 恶意 claim, however, the statute of limitations is four years, 和 that argument was rejected.

至于是非曲直,承运人明确声明保单语言,条件是它可以解决它认为适当的任何索赔或诉讼。因此,它拥有完全的权力来解决任何数量的政策限制。被保险人认为这是“荒谬的”,但没有提供任何权力来支持其立场。

The court ruled for the 在 surer, observing: “Pennsylvania law disfavors 恶意 claims where a policy grants the 在 surer discretion to settle 和 where such settlement is within policy limits. However, ‘in limited circumstances,’ ‘a claim for 恶意 may …尽管有“视作权宜之计”规定,但仍被指控对保险公司…如果这种解决方式违反了当事方的意图和期望。”在这里,法院认为“在适当情况下和解”的用语等同于权宜之计。

The court cited two precedents where a deems expedient provision undermined the possibility of a 恶意 claim. In the first, there was no evidence the parties did not freely negotiate policy terms. As to the second, the Third Circuit 在 terpreted “’deems expedient’ clauses broadly—so broadly as to allow 在 surers to settle claims subject to such clauses ‘for nuisance value of the claim’ or even where a ‘suit …没有提出针对被告的有效主张。’”

在目前的情况下,被保险人不认为认为权宜条款没有自由谈判。而且,即使保险公司可以做更多的工作来调查基础索赔,“其政策中的“认定权宜”条款为[保险人]提供了解决的选择……仅仅是因为它宁愿和解而不是对其索赔进行进一步调查。”

Thus, the 恶意 claim was dismissed with prejudice.

决定日期:2020年7月22日

Healthfleet救护车公司诉Markel Insurance 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20-2250。 LEXIS 129185(ED.Pa.2020年7月22日)(J.Beetlestone)

TOY V. METROPOLITAN LIFE是否提供绑定的先决条件,要求在法定信念范围内(西部地区)适用宾夕法尼亚州法律,否决法院的利益

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就像最近 中区弗格森决定, the opinion 在 this case involves good news 和 bad news. First, the court addresses head on whether statutory 恶意 must be predicated on a 剥夺利益, or can be 在 dependently sustained based upon a variety of poor claims handling practices. That’s good for those seeking clarity on this issue. The bad news is that, like Ferguson, this opinion never addresses head on the 2007 Pennsylvania Supreme Court decision 在 玩具诉大都会人寿保险公司.

由于我们有 在此Blog上多次阐述, the Toy decision strongly appears to require the denial of a benefit as a predicate to bringing a statutory 恶意 claim, meaning a refusal to pay proceeds due under the policy, unreasonably delaying payment of proceeds due under the policy, or refusing to pay for a defense due under the policy. Under Toy, other types of poor conduct 在 claims handling go to evidence of statutory 恶意, without being actionable 恶意 standing alone. See this 2014年文章进行了更详细的讨论.

In the present case, an excess carrier paid $19,000,000 to settle a malpractice suit, contingent on its right to recoup that payment. The 在 sured objected. The 在 surer brought suit to recover the money, 和 the 在 sured counterclaimed for breach of contract, common law contractual 恶意, statutory 恶意, 和 for a declaratory judgment.

The court denied the 在 surer’s motion to dismiss the counterclaims, 和 the 在 surer brought a motion for reconsideration on whether the 恶意 claim was adequately pleaded, 和 whether the damage claims were too speculative 和 contingent to stand. Both motions were unsuccessful. [We only address the 恶意 claim.]

法院的重点是宾夕法尼亚州最高法院的 2017 Rancosky决定 为解决可诉的法定恶意索赔是否要求“原告必须指控保险人拒绝了该保单下的利益”这一问题。…[并且]只有拒绝支付利益或延迟支付利益成为有效的拒绝才可以构成对利益的拒绝,足以根据第8371条提出索赔。”法院指出,兰科斯基多数人并未解决该问题,但韦奇法官的兰科斯基同意书“列举了几种类型的行为,包括不当的索赔处理,对被保险人不予回应以及其他类似行为,这可能导致§8371的要求,并且该清单比拒绝或延迟支付给付金更广泛。”尽管多数人未采纳该同意,但由于多数人未明确表示反对,地区法院“仍然坚信宾夕法尼亚最高法院如果面临该问题……将裁定[被保险人]表示要求。”

[注:但是,根据上述评论,宾夕法尼亚州最高法院在2007年确实解决了该问题。 承运人简介 在 dicates that it argued Toy stood for the proposition “that ‘bad faith’ under § 8371 is strictly limited to ‘those actions an 在 surer took when called upon to perform its contractual obligations of defense 和 在 demnification or payment of a loss.’” The carrier further argued that Rancosky did not overrule or limit this principle, 和 if anything reaffirmed it. The District Court clearly rejected the notion that Rancosky limited statutory 恶意 claims to the 剥夺利益, but never addressed whether Toy did so.]

因此,重新审议的动议被驳回。法院认为,被保险人声称“不正确的索赔处理,未对被保险人作出回应以及可能导致§8371索赔的其他类似行为”而提出索赔,完全独立于任何拒绝付款或延迟的行为。在支付福利。

决定日期:2020年1月23日

Ironshore Specialty Insurance Co.诉Conemaugh Health System美国宾夕法尼亚州西区地方法院,案件编号: 3:18-cv-153,2020美国区LEXIS 11060(2020年1月23日在美国宾夕法尼亚州吉布森(Gibson,J.)

Two recent examples of cases finding that statutory 恶意 claims must be based upon a 剥夺利益 are 杜布瓦斯法官的2019年Buck裁决科尔尼法官的2019年无聊裁决。 在她的 2019 Purvi决定, Judge Beetlestone states that, with limited exceptions, “the essence of a 恶意 claim must be the unreasonable 和 在 tentional (or reckless) 剥夺利益…。” (强调原件)。

除少数情况外,信仰不当需要拒绝福利;没有单独违反善意行动(费城联邦)

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用下面的摘要来解释: Though courts have extended the concept of 恶意 beyond an 在 sured’s denial of a claim 在 several limited areas, the essence of a 恶意 claim must be the unreasonable 和 在 tentional or reckless 剥夺利益.

被保险人与保险人之间的纠纷以237,000美元解决。在和解后的起草过程中,保险人在和解协议中加入了一个条款,使被保险人的抵押权人成为和解支票的收款人。被保险人提出异议,但承运人对此作出回应,要求其包括收款人。它拒绝在没有抵押权人的情况下签发和解支票,并且当事双方都处于争执状态。

被保险人对承运人提起新诉讼,寻求在不包括抵押权人的情况下执行和解协议。被保险人违反了合同要求,另外还违反了与和解协议有关的诚信义务和公平交易。承运人采取行动取消了真诚和公平交易。

法院驳回了这一点,即遵循这一原则,违反了诚实信用和公平交易的规定已包含在合同索赔之内,并且不能陈述明确的诉讼因由。 “这种包容发生在‘the actions forming the basis of the breach of contract claim are essentially the same as the actions forming the basis of the 恶意 claim.’” Here, both counts arose out of the refusal to remove the mortgagee from the settlement payment.

The court also noted there was no separate tort claim for 恶意 在 Pennsylvania.

Finally, the court rejected the notion that the good faith count could survive if treated as a statutory 恶意 claim. It observed that the case arose from an alleged breach of a settlement agreement, not a violation of the 在 surance policy. The issue 这里 was the 在 surer’s 在 cluding the mortgagee on the payment check, not the denial of a benefit, i.e., the carrier was ready 和 willing to make a payment under the policy.

法院指出:

至关重要的是,尽管原告确实声称[承运人]“拒绝按照保险单的规定在60天内支付结算金额”,但从原告自己的陈述中可以清楚地看出,原告的意思是: “拒绝付款”等于原告’s refusal to accept a settlement check naming the mortgagee as a payee, rather than a 剥夺利益 under the policy. Though “Courts have extended the concept of ‘bad faith’ beyond an 在 sured’s denial of a claim 在 several limited areas,” … “the essence of a 恶意 claim must be the unreasonable 和 在 tentional (or reckless) 剥夺利益…。”因此,第8371条“不适用于仅基于合同条款的争议。” ……很明显,原告没有发现宾夕法尼亚州法院或解释宾夕法尼亚州法律的法院发现第8371条涉及此处争议的和解纠纷的情况。原告人二’因此,由于未提出索赔,驳回了经修订的投诉。

决定日期:2019年11月18日

Purvi,LLC诉Nat’l Fire &海上保险公司 美国宾夕法尼亚州东区地方法院民事诉讼编号19-4250,2019美国区。 LEXIS 199469(于2019年11月18日在美国东部时间)(Beetlestone,J.)

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. The 在 sured sued for breach of contract 和 恶意. The 恶意 claim was based on two theories: (1) unreasonable 剥夺利益 和 (2) improper claim handling during the 在 vestigation. The 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

The 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. The 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。””

The 在 sured’s amended complaint based her 恶意 claims on two distinct theories: “(1) a 剥夺利益 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.”

The 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

The second case 在 volved UIM breach of contract 和 恶意 claims. The 在 surer 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 剥夺利益, 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‘任何轻率或无根据的拒绝支付保单收益的行为。 …恶意必须以明确而令人信服的证据来证明,“即使在简易判决中,这种负担也是如此。”… 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.” The 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.’”

The 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. 原告承担着通过明确而令人信服的证据来确定延误的责任。”

  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.”

The 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”.

在运用这些原则时,法院列出了保险人在理算人调查期间处理索赔的详细事实历史记录,包括理算人与被保险人之间的通讯历史以及各种文件和记录的请求。尽管有如此详细的事实记录,但是,被保险人仅依靠其投诉的平均值来反对即决判决。这些都是无法达到明确和令人信服的证据标准的结论性指控。

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5月不良信仰案件:关于UIM索赔处理和和解谈判的实质性问题,防止对一方的简易判决(宾夕法尼亚州西部)

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被保险人在车祸中头部严重受伤之后,UIM开始采取这种行动。索赔处理过程跨越了两年半的时间。被保险人要求提供100,000美元的保额限额,而保险公司最初提出要支付17,000美元。最终,保险人支付了保单限额。

The 在 sured sued for 恶意, among other claims. The 在 sured alleged 恶意 在 the delay of payment of benefits. Both parties moved for summary judgment on 恶意. The Court found genuine issues of material fact existed on 恶意, precluded relief to either party.

法院认为,被保险人的律师在提出索赔后近两年没有要求解决索赔,一旦提出,保险人便立即采取行动。法院进一步认为,陪审团可以断定最初的$ 17,000报价是合理的,因为被保险人承认在索赔处理过程中某一时刻她的特殊赔偿金仅为$ 15,000,并且作证说“头部受伤特别难以评估”。 。 。 。 。”

但是,法院也拒绝了保险人的即决判决,因为陪审团可以得出结论,支付给养恤金的不合理拖延,而17,000美元的报价是低价报价。陪审团可以发现,保险人在提出申请到被保险人的律师要求18个月后和解之间,没有进行有意义的调查或试图和解。此外,有人可能会争辩说17,000美元是低价报价,因为保险公司对索赔的估价在46,800美元至61,800美元之间。

[It is 在 teresting to compare this result to New Jersey’s fairly debatable standard on 恶意, where an 在 sured’s 在 ability to obtain summary judgment on 恶意 means there can be no 恶意.]

决定日期:2018年5月7日

Parisi诉State Farm Mut。汽车。英斯有限公司美国宾夕法尼亚州西区地方法院,民事诉讼第16-179号,2018年美国区。 LEXIS 76246(W.D. Pa.2018年5月7日)(吉布森,J。)

2018年4月不良信仰案件:没有不良信仰的地方,保险人在合理的基础上提出了和解提议(宾夕法尼亚州高级法院确认了费城常见的抗辩)

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在发生车祸后,被保险人向保险公司提交了UIM索赔。在对有关事故的证据以及被保险人的病历进行了初步审查之后,保险公司提出了$ 15,000的赔偿要求。保险公司随后将报价提高到20,000美元,然后是25,000美元。保险公司的最终估值为28,000美元,但由于最终被保险人明确表示他不会以低于50,000美元的价格结算,因此保险公司未与被保险人就最终增加的估值进行联系。

An arbitration panel awarded the 在 sured $45,000, 和 he sued for 恶意. The 在 sured argued the 在 surer acted 在 恶意 because its final settlement offer was only about 50% of the arbitration award, 和 because the 在 surer failed to notify him of the last 在 creased $28,000 valuation.

审判法院判决保险人即决判决,认为这些事实不足以证明保险人的报价缺乏合理依据。法院认为,保险人的“报价不是随意的低价要约,而是对有关索赔的相关信息进行认真分析的结果。”

在未公布的判决中,高级法院根据审判法院的合理意见予以确认。

决定日期:2017年8月17日和2018年4月4日

Boleslavsky诉Travco Ins。公司 费城普通上诉法院,2015年10月,第886号(2017年8月17日)(安德斯,J。),

肯定的

Boleslavsky诉Travco Ins。公司宾夕法尼亚州高等法院,第1227号EDA 2017年,2018年。取消发布LEXIS 1065(2018年4月4日,超级加利福尼亚)(Gantman,McLaughlin,Platt,JJ。)

2018年3月的不良信仰案件:第三次诉讼未涉及诉讼行为可能构成不良信仰的原因,因为在发行时的行为在第一例中并非不良的信仰行为(宾夕法尼亚州第三巡回法院)

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The 在 sured alleged 恶意 based on the 在 surer’s 在 troduction 和 reliance on allegedly biased expert testimony 在 this underinsured motorist case. The District Court had dismissed the claim, after an extensive analysis on when litigation conduct might constitute 恶意。第三巡回法院确认,但未解决该问题。

The parties entered a high/low settlement agreement during the course of a jury trial, i.e., if the 在 sured won he could get up to $300,000, but no less than $100,000 if he lost. The jury awarded $1.6 Million, but that sum was molded to $300,000. The agreement released all 恶意 claims existing up to the date of the agreement, but did not release post-agreement 恶意 claims.

The 在 surer relied upon two experts’ reports 和 testimony before the jury. The 在 sured later brought a 恶意 action based upon the 在 surer’s use of its expert reports 和 testimony during the trial process 和 after the date of the high/low agreement. He alleged that the 在 surer acted 在 恶意 by 在 troducing 和 relying upon the biased testimony of its experts; by “failing to make an honest, 在 telligent settlement offer”; 和 by “seeking to have the 恶意 claim dismissed with prejudice.”

The Third Circuit observed that 恶意 is based upon the frivolous or unfounded refusal to pay proceeds under a policy, under a two criteria test: (1) that it was unreasonable to deny benefits; 和 (2) that the 在 surer knew or recklessly disregarded the absence of a reasonable basis to deny benefits. The big issue addressed at the District Court level was how to evaluate litigation conduct under the 信仰不良 Statute. The Third Circuit found it did not have to reach that issue because the complaint’s allegations (including expert reports 和 depositions as exhibits) did “not identify any misconduct, much less 恶意” conduct.

It was alleged contradictions 在 the experts’ testimony that formed the basis of the 恶意 claim. The Court found no 在 consistencies 在 the first expert’s report 和 testimony, 和 found that the report was more limited 在 scope than the 在 sured asserted. Similarly, the Court found no contradictions 在 the second expert’s report. Thus, “[b]ecause the statements made by [the medical experts] are not contradictory, [the 在 surer’s] 在 troduction of 和 reliance on their testimony cannot rise to the level of 恶意, even under [insured’s] suggested legal standard.”

再一次,在指出宾夕法尼亚州最高法院关于诉讼行为何时可能受到《不良信仰法规》约束的先例之后—尽管它已经在高等法院和第三巡回法院得到了一定程度的解决—法院表示,“不需要提出这个问题,因为所指控的事实显然并不意味着知道有偏见的专家作证。”

决定日期:2018年2月27日

荷马诉全国共同保险公司案。,美国上诉法院第三巡回法院,第16-3686号,2018年LEXIS 4859(3d Cir.2018年2月27日)(Fishman,Hardiman,Roth,JJ。)