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iNews Issue: 38 | April 2012 |
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Concurrent Coverage Questions
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Below is a recent question posed by one of our Insurance Carrier clients that may be instructive for all. "I have a case where two carriers have concurrent coverage. Our limits are 50/100 and the other is a 25/50. If a settlement is reached for the injured party would that be based on the combined limits or a 50/50 split if it was within our limits? Insurance Carrier A has retained Defense for the insured, and Insurance Carrier B is acting as excess. If either one of us obtains a release are both released? Also, how would it work if we settled the claim for $20,000. Would we then be able to require Insurance Carrier B to pay us back their portion of that settlement?" Our response was "There is no short answer to that one." As for the release, you should require that all insured defendants are listed on the release (Insurance Carrier A policyholder/driver and Insurance Carrier B driver/policyholder). The answer to the sharing of the settlement costs depends on the reading of the "Other Insurance" clauses in both Insurance Carrier A's policy and the Insurance Carrier B policy. Generally, where the terms regarding payment obligations in two or more policies conflict, "insurers must contribute in the proportion their policies bear to the limit of coverage at that level." Jefferson Ins. Co. of N.Y. v Travelers Indem. Co., 92 N.Y.2d 363, 372, 703 N.E.2d 1221, 681 N.Y.S.2d 208 [1998]; see Lumbermens Mut. Cas. Co. v Allstate Ins. Co., 51 N.Y.2d 651, 655, 417 N.E.2d 66, 435 N.Y.S.2d 953 [1980]; Castricone v Riggi, 259 A.D.2d 815, 816, 686 N.Y.S.2d 175 [1999]). Insurance Carrier A policy indicates: "If other valid and collectible vehicle liability coverage applies, then we will pay the proportion of damages payable that our applicable limit bears to the sum of our applicable limit and the limits of all applicable valid and collectible liability coverage that applies to the accident. However, the liability coverage provided by this policy applies as excess coverage over any other valid and collectible coverage provided for a non-owned car or a temporary substitute car." First question: Is this involving a non-owned car or a temporary substitute car? Second inquiry is: Do you have the Insurance Carrier B policy---as we would need to see their "other insurance clause." Where the same risk is covered by two or more policies, each of which was sold to provide the same level of coverage (as is the case here), priority of coverage (or, alternatively, allocation of coverage) among the policies is determined by comparison of their respective "other insurance" clauses (see Great N. Ins. Co. v Mount Vernon Fire Ins. Co., 92 NY2d 682, 686-687, 708 NE2d 167, 685 NYS2d 411 [1999] [hereinafter, Great Northern], citing State Farm Fire & Cas. Co. v LiMauro, 65 NY2d 369, 482 NE2d 13, 492 NYS2d 534 [1985]; see also Jefferson Ins. Co. of N.Y. v Travelers Indem. Co., 92 NY2d 363, 372, 703 NE2d 1221, 681 NYS2d 208 [1998]). An "other insurance" clause "limit[s] an insurer's liability where other insurance may cover the same loss" (15 Couch on Insurance 3d § 219:1). This may be accomplished by providing that the insurance provided by the policy is excess to the insurance provided by other policies, in which case the "other insurance" clause is known as an excess clause (15 Couch on Insurance 3d § 219:33; 22 Holmes' Appleman on Insurance 2d § 140.2 [B] [1]). Alternatively, an "other insurance" clause may limit the insurer's liability by providing that, if other insurance is available, all insurers will be responsible for a stated portion of the loss; an "other insurance" clause of this kind is known as a pro rata clause (15 Couch on Insurance 3d § 219:27-219:28; 22 Holmes' Appleman on Insurance 2d § 140.2 [A]). In this case, the applicable "other insurance" clause of Insurance Carrier A is a pro rata clause. It is well established under New York law that, where one of two concurrently applicable insurance policies contains an excess "other insurance" clause and the other contains a pro rata "other insurance" clause, the excess clause is given effect, meaning that the coverage under the policy containing the excess clause does not come into play, and the carrier's duty to defend is not triggered, until the coverage under the policy containing the pro rata clause has been exhausted (see General Acc. Fire & Life Assur. Corp. v Piazza, 4 NY2d 659, 669, 152 NE2d 236, 176 NYS2d 976 [1958]; Harleysville Ins. Co. v Travelers Ins. Co., 38 AD3d 1364, 1367, 831 NYS2d 625 [2007], lv denied 9 NY3d 811, 877 NE2d 651, 846 NYS2d 601 [2007]; Firemen's, 233 AD2d at 193; see also International Bus. Machs. Corp. v Liberty Mut. Fire Ins. Co., 303 F3d 419, 429 [2d Cir 2002] [applying New York law]; Great Northern, 92 NY2d at 687; Pav-Lak Indus., Inc. v Arch Ins. Co., 56 AD3d 287, 288, 866 NYS2d 671 [2008]; Tishman Constr. Corp. of N.Y. v American Mfrs. Mut. Ins. Co., 303 AD2d 323, 324, 757 NYS2d 535 [2003]). By contrast, where each policy contains an excess "other insurance" clause, so that giving each policy's clause effect would leave the insured without primary insurance, the clauses are deemed to cancel each other out, and the insurers are required to cover the loss on a pro rata basis (see Great Northern, 92 NY2d at 687; Jefferson Ins. Co., 92 NY2d at 372; LiMauro, 65 NY2d at 373-374; Federal Ins. Co. v Atlantic Natl. Ins. Co., 25 NY2d 71, 75-76, 250 NE2d 193, 302 NYS2d 769 [1969]). (see State Farm v. LiMauro 65 N.Y.2d 369 Court of Appeals 1985).
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Appellate Decisions of Interest |
| Congratulations to Al Galatan of our office for a victory on appeal in Matter of Allstate Ins. Co. v Stricklin decided on March 13, 2012 by the Appellate Division, Second Department (2012 NY Slip Op 01812). In this proceeding our office filed an appeal to the order of Supreme Court, Suffolk County which granted a petition to stay arbitration. The facts involved a hit and run accident on March 2, 2009 in which Marcus Stricklin, a passenger in a vehicle insured by Allstate, claimed injuries. Allstate filed the petition to stay the uninsured motorist arbitration, claiming the adverse vehicle was in fact insured by our client, Auto One. At a framed-issue hearing concerning the possible identity of the hit-and-run vehicle, Stricklin testified that, within "about five minutes" after the accident, an unidentified individual handed him a piece of paper on which the license plate number of the car which fled the scene allegedly was written. Stricklin further stated that this individual told him that he "went down the road and retrieved the plate number." While Stricklin was "headed into the ambulance" which had arrived at the accident site, he gave the piece of paper to a police officer. Stricklin never observed the plate number of the other vehicle. The plate number and identifying information was included in the subsequently prepared police accident report. The lower court admitted the uncertified police report into evidence even though no police officer testified, and concluded that "there is another tortfeasor for which there is coverage."
On appeal, the Appellate Division agreed with our argument, "the police accident report was not admissible under the present sense exception to the hearsay rule. To be admissible under this exception, a statement must be made "substantially contemporaneously" with the witness's observations, and the declarant's description of the relevant events must be "sufficiently corroborated by other evidence" (People v Brown, 80 NY2d 729, 734). As stated by this Court in the case of Matter of Phoenix Ins. Co. v Golanek (50 AD3d 1148, 1150): "After [the eyewitness] wrote [the plate] number on a piece of paper, [he] was no longer relying upon a present sense of the number, but was relying entirely on the contents of [his] own writing [and thus] . . . the police accident report generated sometime later did not reflect a present sense impression rather than a recalled or recast description of events that were observed in the recent past' (People v Vasquez, 88 NY2d 561, 575 [1996])." Consequently, without the police report in evidence, there was no proof of the involvement of the Auto One insured in the hit and run accident and therefore, the Appellate Court reversed the lower court and denied the petition to stay Arbitration.
Read full decision here. _____________________________________________________
 "Can you smoke pot in your car on a public street and not be charged with a crime?"
If you asked the same question in 1977 and 2012 do you think the majority answer would differ based on the year the question was asked?
Attitudes about marijuana use were much different 40 years ago when we were in college. Back then, it seemed everyone used recreational marijuana and even Judge Ginsburg, a nominee of President Reagan to the U.S. Supreme Court, admitted to continued pot smoking as a professor at Harvard after college and law school. The public could forgive a few joints in college but the continued use when he was a practicing lawyer and professor caused him to withdraw the nomination. Recreational marijuana possession was decriminalized in 1977. The New York State legislature restructured marijuana possession offenses with the intent to reduce criminal culpability for the possession of a small quantity of marijuana for personal use in a private place (such as in the home), making such conduct a violation when it had previously been a misdemeanor. Penal Law §221.10(1) was also created keeping marijuana use a misdemeanor if used in a "public place." "[A] person is guilty of criminal possession of marijuana in the fifth degree when he knowingly and unlawfully possesses marijuana in a public place, as defined in section 240.00 of this chapter, and such marijuana is burning or open to public view."
The New York State Court of Appeals addressed the meaning of the statute, Penal Law §221.10(1), on March 27, 2012 in People v. Samuel Jackson (2012 NY Slip Op 2252). Here the defendant argued he could not be charged with a crime as he was not in a "public place" when he was found with marijuana in his car on a public street. Under Penal Law § 240.00(1), a "public place" is "a place to which the public or a substantial group of persons has access, and includes, but is not limited to, highways, transportation facilities, schools, places of amusement, parks, playgrounds, and hallways, lobbies and other portions of apartment houses and hotels not constituting rooms or apartments designed for actual residence."
The Court of Appeals found in favor of the People on this issue, "Although acknowledging that the marijuana possession offenses were restructured to reduce penalties for private marijuana possession or use in some circumstances, the dissent and defendant would extend the 1977 reforms well beyond the private conduct the Legislature intended to address, encompassing behavior that can fairly be described as occurring in public."
Read more here. _____________________________________________________
A question of Threshold Injury.
Kendra Cividanes was exiting from the back of a city bus on May 28, 2008 when she stepped into a hole and badly sprained her ankle (no fracture found). In a suit against the Transit Authority, can the defendant move to dismiss the case for lack of serious injury under Insurance Law §5102(d)? Judge Soto of Bronx County, Supreme Court denied the motion in May of 2010, finding the injuries did not arise out of use and operation of a vehicle and the Transit Authority appealed the decision to the Appellate Division First Department. In Cividanes v. Manhattan and Bronx Surface Transit Operating Authority, decided on March 22, 2012 (2012 NY Slip Op 2179), the Appellate Court affirmed the denial of the serious injury threshold motion. In Walton v. Lumbermens Mut. Cas. Co.(88 NY2d 211 1996), the Court of Appeals indicated the essential question in determining whether an injury is covered by the No-Fault Law is whether the plaintiff's injury arises out of the "use or operation" of the vehicle. In Walton, the plaintiff, a truck driver, was injured while delivering goods to a supermarket. He backed his employer's tractor trailer up to the supermarket's loading dock, got out of the truck, and opened the rear cargo door. The supermarket provided an apparatus called a "levelator" to facilitate delivery and, after the plaintiff raised the levelator to the same height as the truck bed and attached plates from the levelator to the truck, a ramp was created that enabled him to transfer goods from the truck to the levelator. After placing the goods onto the levelator, he could then lower the levelator to the height of the loading dock and transport the goods to the loading dock. While using the levelator and standing on it with a load of products, the levelator tipped over and threw him to the ground, causing him injuries. The Court of Appeals found that the truck was not the proximate cause of Walton's injuries; they arose out of the operation of the levelator.
In Cividanes, the First Department stated, "the proximate cause requirement of the No-Fault Law is not established merely because injuries occurred during the occupancy of or while entering or exiting a vehicle. Adopting this approach would be tantamount to equating proximate cause with the term "occupying" a vehicle. However, more than occupancy is required to establish a causal link between a motor vehicle and a claimant's injuries. Instead, what Walton requires for the No-Fault Law to apply is that the motor vehicle itself be the instrumentality which produces the injuries." Compare this result with Manuel v. New York City Transit Authority (82 AD3d 1059 2011), where the plaintiff alleged that he was injured when he fell in a hole in the street while exiting from a bus. After a trial on the issue of liability, the jury found that the defendant was negligent, and that its negligence was a substantial factor in causing the plaintiff's accident, and that the plaintiff was not negligent. The Second Department ordered a new trial, because the issue of whether the plaintiff sustained a serious injury within the meaning of the No-Fault Law should have been submitted to jury. In the Second Department, the No-Fault Law applied because the negligent operation of the bus was the proximate cause of plaintiff's injuries, where, in Cividanes, the plaintiff's theory of liability was that the accident resulted from the bus driver's positioning of the bus next to a hole in the street when he pulled into the bus stop. The Court also found it significant that the plaintiff was not completely outside of the bus when the accident occurred.
Read full decision here .
_____________________________________________________ Denial of Peer Review at Issue
Judge Cheree A. Buggs of Queens County Civil Court issued a decision on March 20, 2012 on a No-Fault matter involving a "Substitute PEER" report in Physician Park Slope Medical and Surgical Supply, Inc a/a/o Jaime Espin-Pullas v. Met Life Auto & Home (03857-09) on March 12, 2012.
In failing to follow the Appellate Term, which expressly allowed the testimony of a substitute PEER review physician, Judge Buggs in finding for the provider stated, "This Court has the greatest respect for the higher court, and has given much sober thought to its rulings that an expert whose testimony is offered at trial to substitute for the preparer of the peer review report should be allowed to testify; however, based on the foregoing, this Court cannot follow precedent without further guidance on the evidentiary issues which have remained expressly unaddressed". This decision is troubling to the No-Fault defense bar as the Court precluded the introduction of the "Substitute PEER" report on evidentiary grounds despite the precedent of Park Slope Medical and Surgical Supply, Inc. as Assignee of Ira Franklin v. Progressive Insurance Company (34 Misc 3d 129(A) 2011 Appellate Term, Second Department).
"Defendant's expert medical witness, who was not the expert who had prepared the peer review report upon which defendant's denial of the subject claim was based, should have been permitted to testify as to her opinion as to the medical necessity of the supplies at issue in this case, which testimony would be limited to the basis for the denial as set forth in the original peer review report" (Radiology Today, P.C. v Progressive Ins. Co., 32 Misc 3d 144[A], 2011 NY Slip Op 51724[U] [App Term, 2d, 11th & 13th Jud Dists 2011]; Dilon Med. Supply Corp. v New York Cent. Mut. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52454[U] [App Term, 2d & 11th Jud Dists 2007]; see also Psychology YM, P.C. v Geico Gen. Ins. Co., 32 Misc 3d 130[A], 2011 NY Slip Op 51316[U] [App Term, 2d, 11th & 13th Jud Dists 2011]). Urban Radiology, P.C. v Tri-State Consumer Ins. Co. (27 Misc 3d 140(A)) decided on June 8, 2010 by the Appellate Term, Second Department held, "The fact that defendant's peer reviewer considered medical records from plaintiff, as well as from other providers who treated the assignor in forming his opinion as to the medical necessity of the relevant services, does not warrant a contrary result.... Consequently, plaintiff's argument that defendant failed to establish the reliability of the underlying medical records in support of its claim that the treatment provided was not medically necessary is irrelevant." It looks like another trip to the Appellate Term, whose docket is filled with No-Fault appeals, is warranted on this case. Park Slope Med v Progressive, (2012 NY Slip Op 50349) was decided on February 21, 2012 by the Appellate Term with what one would have thought is a clear direction, "Defendant's expert medical witness, who was not the expert who had prepared the peer review report upon which defendant's denial of the subject claim was based, should have been permitted to testify as to her opinion as to the medical necessity of the supplies at issue in this case, which testimony would be limited to the basis for the denial as set forth in the original peer review report."
Read full decision here.
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