Archive for the ‘Insurance Practices’ Category

The Flying Insurance Adjuster—Implications of Insurers’ Use of Drones

Thursday, May 14th, 2015

By Hilary Rowen, San Francisco

Insurers perform property inspections in connection with underwriting to determine if the property meets their standards for issuing coverage, and to determine the appropriate premium classification. Insurers inspect damaged property to evaluate the extent of the damage, whether the damage resulted from a covered cause of loss and to estimate the cost to repair or replace the insured property.

In the future, inspections of buildings and other insured property by insurers may be done through still photos, videos or data from more sophisticated sensors obtained by an unmanned aircraft. Rather than having inspections done by a person peering up from the ground, on a ladder or walking through a field, the inspections will be done by a person looking at photos taken by a drone or reviewing a computer analysis of data collected through drone-mounted sensors.

Several property-casualty insurers, including State Farm, USAA and AIG, have recently received approval from the Federal Aviation Administration (FAA) to test and use drones in insurance underwriting and claims operations. However, to date, the approvals that the FAA has issued to insurers contain restrictions that effectively limit the insurers to testing drones for use in inspections under limited conditions. Deployment of drones in insurers’ operations will not “take off” until the FAA’s recently issued draft regulation governing commercial use of drones is adopted.

The Regulation of Drones by the FAA: Entering a Period of Rapid Change

After being subject to criticism for its stringent restrictions on commercial use of drones, the FAA announced in March 2015 that it would streamline its process of reviewing “Section 333 exemption” filings for use of drones weighing less than 55 pounds (25 kilograms) in commercial operations. (Section 333 of the FAA Modernization and Reform Act of 2012 authorized the Secretary of Transportation to determine requirements for commercial use of unmanned aircraft systems.) In March the FAA also exempted entities with approved Section 333 exemptions from filing flight plans for each drone use, provided that the drone is flown below 200 feet. The FAA’s move to speed Section 333 approvals and to lift some of the restrictions on commercial drone use is likely to increase insurers’ interest in the use of drones for a wide range of property inspection purposes.

Restrictions in Section 333 Exemption Approval Issued to Insurers

Today, even with the recent changes, the FAA approvals of commercial use of drones have significant restrictions. Although lightweight drones may weigh less than 5 pounds, the operator must have a pilot license (which, under the FAA’s recent relaxation of commercial drone requirements, can be a recreational or sports pilot license). A second observer must be present for all drone flights. The drones can only be operated within line-of-sight of both the pilot and the observer.

Perhaps most significantly for insurers’ use of drones, the FAA’s approvals of insurers’ Section 333 exemption applications contain the following restrictions:

1. A drone cannot be flown within 500 feet of any structure or vehicle without the permission of the owner or person in control of the structure or vehicle; and
2. A drone cannot be operated within 500 feet of a person other than the operator and observer, unless the people within 500 feet are inside a structure that would protect them from debris in the event that the drone crashes.

These limitations impose significant restrictions on testing property inspection drones in real-life situations in urban and suburban areas. The FAA is testing whether to relax some of these restrictions.

On May 6, the FAA announced three drone initiatives: one will allow a drone manufacturer to survey crops in rural areas with drones flying outside of the pilot’s direct line-of-sight; a second initiative will allow a railroad to inspect rail infrastructure beyond line-of-sight in isolated areas; the third initiative will allow CNN to test the use of drones for news-gathering in populated area, under the current line-of-sight restrictions. None of the FAA initiatives involves insurer operations.

The Proposed FAA Regulation

The FAA issued a proposed unmanned aircraft system regulation for comment in February 2015. Under the proposed regulation, a new unmanned aircraft system (“UAS”) airman certificate would be created and the requirement that operators of drones hold traditional pilot licenses would be eliminated. The currently required observer would be optional. The line-of-sight requirement would be modified to provide that either the operator or the observer, if one is present, must maintain eye contact with the drone, rather than the current requirement that both the operator and a mandatory observer maintain a line-of-sight view of the drone.

As perhaps the most significant change with respect to insurers’ use of drones, the proposed regulation eliminates the requirement that drones remain at least 500 feet from structures, vehicles and people, although drones may not be flown directly over people other than the operator and observer. Under the proposed regulation, the operator is responsible for taking measures to mitigate risk to persons and property in the event that the operator loses control of the drone. The Notice of Proposed Rulemaking for the proposed regulation provides an example of a mitigation measure: Where the drone is operating in a residential area, the operator could ask that people in the area of operation remain inside while the drone is flying.

The proposed UAS regulation creates a separate and more relaxed set of requirements for drones weighing less than 4.4 pounds (2 kilograms) that fly at low speeds and at low altitudes. Operators of these very small drones would need to obtain a “microUAS” operator certificate from the FAA. Unlike the larger drones weighing up to 55 pounds, microUAS drones could be operated directly over people.

The proposed regulation requires that any accident involving injury to persons or property (other than the drone itself) be reported to the FAA.

It is unclear when the FAA regulation on the commercial use of small drones will be issued and whether it will be significantly modified based on comments from interested parties. However, the FAA is under pressure to create a regulatory environment more favorable to commercial use of drones, in part because testing and deployment of small drones is moving to other countries with less restrictive requirements.

The Evolution of Insurers’ Use of Drones

It is likely that insurers’ use of drones will move from the testing stage to operational use within the next few years. Possible developments include:

On-Site Inspections Will Be Severed From Data Evaluation

As a general matter, the person performing an insurance underwriting or claims inspection will have the expertise to evaluate the state of the property. The person on-site will usually provide a written assessment of the state of property in underwriting inspections, or the extent of damage, nature of the damage and the likely cause of the damage in claims inspections. These reports typically will include photographs and, sometimes, videos as documentation of the findings. However, the assessment is made by the on-site inspector.

As insurers start utilizing drones in inspections, it is likely that the expertise needed to perform a given underwriting or claims inspection will be split among several individuals. The on-site “inspector” will need to hold an FAA drone operator license and will need to have sufficient insurance training to collect the data relevant to the underwriting or claims evaluation. The drone operator will not need the substantive expertise in building construction and maintenance currently needed for underwriting inspections or the expertise in extent of damage, loss causation and other issues currently needed for claims inspection. Some insurers may outsource the drone inspections to companies that specialize in flying drones, rather than have drone operators on staff. Instead of having experienced claims personnel in the field, insurers will likely perform the analytic portion of the inspection remotely, using personnel who rarely, if ever, go into the field.

Drone Inspections Will Collect Different Data Than Current In-Person Inspections

In contrast to a human on a ladder checking for dry rot with a screwdriver, drones in the near future will not have capabilities to physically probe buildings or take samples. The type of sophisticated instrumentation utilized in space probes will not be practical for drones used for insurance inspections.

While on-site physical inspections will remain an option for insurers, it is likely that as inspection operations change in response to increased use of drones, physical inspections will become a rarity only performed in unusual circumstances where physical sampling is essential.

Current inspections, whether of buildings, crops or other insured property, tend to utilize visible light. The Mark 1 human eyeball, supplemented by photos and, sometimes, videos, is the primary inspection tool. Devices such as infrared detectors generally are only employed where there is some indication of a problem.

It is possible, although by no means certain, that insurance inspection drones will routinely collect data using non-visible light sensors. This could lead to more sophisticated analyses of the condition of buildings and the extent of damage. With a wider range of data, insurers may increasingly utilize computer algorithms to evaluate the inspection data. The use of a range of drone-mounted sensors may prove to be an effective substitute for a diminished reliance on physical probing of buildings.

Impact of the Relaxed FAA MicroUAS Requirements

If the proposed FAA regulation is promulgated with the relaxed requirements for drones weighing less than 4.4 pounds, insurers—and many other commercial users of drones in urban and suburban areas—may favor micro drones. Where it is not practical to get pedestrians, neighbors and other bystanders under cover before launching a lightweight drone, there will be significant incentives to use drones below the 4.4-pound threshold. Absent a set of “safe harbor” guidelines from the FAA regarding what set of precautions, other than moving everyone other than the operator and the observer under cover, is reasonable, commercial users of drones will probably favor microUAS.

It is unclear whether inexpensive microUAS will be able to carry sensors more sophisticated than a camera, given the 4.4-pound weight limit. Many current microUAS use the relatively inexpensive ultralight camera technology in smartphones. However, there is no comparable off-the-shelf source for ultralight, non-visible light sensors. Insurers alone would not be able to generate enough demand for such equipment. In the future, it is possible that there will be enough demand from all commercial uses for microUASs to spur the development of such sensors. Alternatively, the FAA may create an intermediate

category between drones weighing 4.4 pounds and drones weighing 55 pounds that allows less stringent deployment requirements for drones that can carry somewhat heavier payloads than the microUASs.

Drones and Disaster Response by Insurers

Much of the discussion of insurers’ use of drones has focused on handling disaster claims. It has been suggested that use of drones in damage assessments after disasters will allow insurers to handle claims more quickly. This is likely to be true in some disaster scenarios, but not all.

Large-scale disasters, whether hurricanes, earthquakes or Western wildfires, often strain insurers’ claims adjusting resources, even with the reassignment of claims inspection personnel from other regions of the country and the use of independent adjusters. Drones may alleviate at least part of the post-disaster claims resource crunch. As claims inspections increasingly are performed remotely, the need to redeploy claims personnel will diminish and the insurer’s ability to handle a surge in claims in one geographic region will improve. However, a limited supply of drones and qualified drone operators may simply replace a limited supply of claims adjusters as a key post-disaster claims adjusting resource issue.

Potential Issues Relating to Insurers’ Use of Drones

Any change in insurer underwriting or claims handling practices is likely to trigger charges that the insurer is treating policyholders and claimants inappropriately. Potential issues arising from insurer use of drones include:

Failure to Properly Inspect and Investigate a Claim

A shift from in-person inspections to remote inspections based on drone-collected data will inevitably lead to allegations that a claim was improperly denied due to the failure of the drone to collect necessary information or the misinterpretation of the data by a remote claims center. In many ways, these likely future complaints are not materially different from garden-variety challenges to in-person claims inspections. However, it is possible that regulators could impose a requirement that drone inspections be supported by in-person inspections whenever there is a challenge to the drone-collected data, at least where the in-person inspection does not pose a risk to the adjuster. It is unclear whether such a requirement would deter insurers from utilizing drones in adjusting claims; although if challenges became frequent, the cost of duplicate inspections would reduce the use of drones.

Flawed Computer Algorithms for Underwriting and/or Claim Damage Evaluation

If the use of drones is combined with the use of computer algorithms to assess the drone-collected data, there may well be challenges to the accuracy of computer-driven claims review. Challenges to computer models used to estimate replacement costs and other uses of computer programs in claim adjusting have been common in recent years. These lawsuits typically have been brought as class actions. Future litigation over computer algorithms used to assess drone-collected data are also likely to be framed as class actions, increasing insurers’ potential exposure.

Conclusion

Use of drones in insurance inspections will start as a fairly minor supplement to the traditional in-person inspection, primarily used to examine inaccessible portions of structures and other property. As lightweight sensors and the computer software needed to evaluate drone sensor data are developed, drones may trigger a more fundamental reorganization of insurers’ property inspection operations—with the collection and evaluation functions severed from each other.

Whether this more seismic shift occurs will depend both on technological developments and on the legal infrastructure for commercial use of drones. It is a fairly safe bet that the technology will be developed. The only question is whether the legal infrastructure creates an environment in which widespread use of drones makes sense for insurers.

This article was originally published in the Bloomberg BNA’s Daily Report for Executives on May 14, 2015.

Challenges for the London Insurance Market

Thursday, April 30th, 2015

By Duncan Strachan, Sedgwick London

The London insurance market is in a fight to remain competitive and maintain its role as a leading market international insurance and reinsurance business.

A strong preference is emerging for commercial entities around the world to place business with a local carrier instead of in London. At the same time, there is increased competition from other insurance markets for those risks, particularly where they cannot be placed locally.

Economic growth in the emerging economies of Asia, Latin America and Africa has driven increased local demand for insurance and reinsurance since 2010, and it is in these locales that the London market has struggled to develop market share.

There has been a slight decrease in the share of commercial lines being placed in London. There also has been a drop in London’s share of the global reinsurance market. As well as competition from Zurich and Bermuda, hubs are strengthening in Singapore, Hong Kong, and Miami to address regional demand for reinsurance.

The main reasons for the increase in the use of local market carriers are: increased capacity and expertise, a perception that they have a better understanding of how things are done locally, and a willingness to offer more favourable terms and conditions. There is also the issue of local regulations restricting access to the market for foreign insurers and reinsurers. These factors have led global insurers and reinsurers to take things into their own hands, by setting up local operations to ensure they can compete for business that is no longer coming to London.

However, in more specialised lines of business, such as energy, general liability, financial institutions, and aviation, customers rank expertise and financial security over price and the speed at which claims are paid. This is where London retains an advantage, thanks to its concentration of specialised underwriters, brokers and, of course, service providers. The high level of capital available also means that the London market is less vulnerable to soft market conditions and able to absorb large claims.

London’s expertise and reputation for innovation means it is well-positioned to build on its position as the first choice for large and complex risks. The subscription market also puts London at an advantage when it comes to providing solutions for high risk exposures. Where the London market needs to improve is in selling its unique expertise to emerging markets.

Colorado Supreme Court Holds that the Notice-Prejudice Rule Does Not Apply to Date-Certain Notice Requirement in Claims-Made Policies

Wednesday, February 25th, 2015

By Eryk Gettel, Sedgwick San Francisco

Like many jurisdictions, Colorado’s notice-prejudice rule generally provides that an insured who fails to provide timely notice of a claim does not lose policy benefits unless the insurer establishes that the late notice prejudiced its interests.  Friedland v. Tranvers Indem. Co., 105 P.3d 639, 643 (Colo. 2005).  In Craft v. Philadelphia Indemnity Insurance Co., 2015 WL 658785 (Colo. Feb. 17, 2015), the Colorado Supreme Court held that this rule does not apply to date-certain notice requirements in claims-made policies.

Dean Craft was the principal shareholder and president of Campbell’s C-Ment Contracting, Inc. (CCCI).  Craft agreed to sell a portion of his CCCI shares to Suburban Acquisition Company (Suburban), and later sold his remaining shares back to CCCI.  Suburban and CCCI sued Craft for alleged misrepresentations and fraud regarding the stock sales.

At the time he was sued, Craft was unaware that CCCI had purchased a D&O policy from Philadelphia Indemnity Insurance Company (Philadelphia).  The policy required the insured to notify Philadelphia “as soon as practicable” after becoming aware of a claim, but “not later than 60 days” after the policy period expired.  The policy period was November 1, 2009 to November 1, 2010.  Craft did not report the matter to Philadelphia until March 2012 (more than one year after the policy had expired), and settled the underlying litigation in June 2012.  Philadelphia ultimately denied coverage for Craft’s legal fees and the underlying settlement because Craft had not complied with the policy’s notice provision.

Craft sued Philadelphia in Colorado State Court for breach of contract, breach of the implied covenant of good faith and fair dealing, and statutory violations.  Philadelphia removed the case to federal district court, and then successfully moved to dismiss the coverage action on the basis that Craft did not notify Philadelphia of the claim within 60 days of the policy’s expiration date.  After appealing the district court’s decision, the Tenth Circuit certified the following questions to the Colorado Supreme Court:  (1) whether the notice-prejudice rule applies to claims-made liability policies as a general matter; and (2) whether the rule applies to one or both types of notice provisions in claims-made policies.  Because the parties agreed that the prompt notice requirement was not at issue, the Colorado Supreme Court limited its analysis to the issue of whether the notice-prejudice rule applies to a claims-made policy’s date-certain requirement.  The court answered the question in the negative.

The court first explained how “occurrence” and “claims-made” policies differ in terms of the coverage they provide.  Whereas occurrence policies (like the policy in Friedman)provide coverage for injuries or damage that occur during the policy term regardless of when the claim is actually made, claims-made policies (like the policy in Craft) only provide coverage if the claim is made during the policy period or any applicable extended reporting period.  The court further explained that this conceptual difference is critical to the risks that insurers undertake and the premiums that insureds pay.  With a claims-made policy, the risk to the insurer passes when the policy expires.  Thus, the date-certain requirement in a claims-made policy is a fundamental policy term because it defines the temporal boundaries of the policy’s basic coverage terms.  The court found that, to extend the notice-prejudice rule in the context of a claims-made policy’s date-certain notice requirement, “would defeat the fundamental concept on which coverage is premised.”

The court also rejected Craft’s argument that strict enforcement of the date-certain notice requirement would result in a windfall for the carrier based on a technicality.  To apply the notice-prejudice rule so as to excuse an insured’s noncompliance with a date-certain requirement would essentially rewrite the policy and effectively create coverage where none previously existed.  By doing so, the insured — and not the insurer — would reap the windfall.

Court Confirms Insurer Permitted to Choose Counsel in Discharging Duty to Defend

Friday, February 13th, 2015

By Aaron Mandel, Sedgwick New York

An insurer’s duty to defend and how that duty gets discharged may be one of the most frequently litigated coverage issues.  Although typical policies afford insurers the right to control their insureds’ defense, insureds often prefer to appoint their own counsel and have their insurer reimburse them for their defense costs.  That is especially true where the insurer reserves its rights under its policy.  The latest opinion addressing this issue came out of the U.S. District Court for the Northern District of California in Travelers Property Casualty Co. v. Kaufman & Broad Monterey Bay, et al., No. 5:13-cv-04745-EJD (Feb. 11, 2015).

Sometime before February 2012, the developers (“KB”) of a housing project located in Northern California hired Norcraft to perform cabinet work.  Norcraft was insured under commercial general liability insurance policies issued by Travelers, which extended additional insured coverage to KB for liability arising out of Norcraft’s work.  In February 2012, homeowners sued KB for construction defects including defects in Norcraft’s work (the “underlying lawsuit”).  Travelers agreed to defend KB in that lawsuit after receiving a copy of Norcraft’s subcontract with KB – which Travelers did not receive until almost eight months after the underlying plaintiffs filed their lawsuit against KB – and appointed defense counsel to do so.  KB objected to the law firm Travelers appointed to defend them because they claimed it was “ethically conflicted from representing [KB] since it had represented parties adverse to [KB] in other cases pertaining to similar issues as the [underlying lawsuit].”

Facing KB’s objection to the appointed counsel, Travelers sought a declaration that KB’s objection was a “material breach of [Travelers’] policies and of the implied covenant of good faith and fair dealing.”  KB counterclaimed arguing that Travelers “did not intend to provide [KB] with an immediate, full, complete, and conflict-free defense” because Travelers knew about the appointed law firm’s alleged conflicts.  The parties cross-moved for summary judgment.

First addressing KB’s claim that Travelers did not “immediately” defend them in the underlying lawsuit, the court concluded that Travelers’ duty to defend was not triggered until it received all relevant information to determine the existence of coverage.  In that regard, the court noted that Travelers first received that information when it received a copy of Norcraft’s subcontract with KB and agreed to defend approximately one week later.

The court next addressed KB’s argument that Travelers did not provide it with a “complete” defense.  KB claimed that Travelers’ defense was not “complete” because it extensively reserved its rights to, among other things, withdrawing its defense if it later determined there was no coverage available under its policy.  The court concluded that this argument failed because KB did not explain why Travelers’ reservation of rights violated its duty to defend.

KB also argued that Travelers improperly “entered into a secretly negotiated settlement agreement” with the underlying plaintiffs that resolved their claims arising out of Norcraft’s work.  Rejecting KB’s argument that this violated Travelers’ duty to defend, the court wrote:

Since it is undisputed that [Travelers] had the duty to defend, [Travelers] had the right to control settlement negotiations of the covered claims without [KB’s] participation.  That [Travelers] settled only the claims arising out of the work of Norcraft does not make the settlement improper, nor does it indicate that [Travelers] further its own interests, and [KB] have not shown that it experienced increased defense fees and costs – outside of what it would have otherwise incurred – due to [Travelers’] withdrawal from the [underlying lawsuit].

Ultimately, the court concluded that, because Travelers “fulfilled its contractual duty to defend [KB] against all claims arising out of the work of Norcraft, . . . [Travelers] did provide a complete defense.”  And because it found that Travelers satisfied its duty to provide KB with an “immediate” and “complete” defense, the court found that Travelers was entitled to appoint counsel to defend KB in the underlying lawsuit.

Eastern District of Pennsylvania Finds No “Link” to Bad Faith in Excess Carrier’s Conduct Towards Sausage Company Insured

Thursday, September 25th, 2014

by Alice Ye, Sedgwick Chicago

This month, the Eastern District of Pennsylvania held that excess carrier American Guarantee and Liability Insurance Company (“American Guarantee”) did not engage in bad faith conduct towards insured Maglio Fresh Foods (“Maglio”), a sausage company. Charter Oak Ins. Co. v. Maglio Fresh Foods, Case Civil No. 12-3967, 2012 WL 4434715 (E.D. Pa. Sept. 9, 2014).

Maglio filed cross-claims against American Guarantee for statutory bad faith under 42 P.S.A. § 8371 and breach of the implied covenant of good faith and fair dealing. The claims were based on American Guarantee’s refusal to post a supersedeas bond for Maglio so that Maglio could appeal an adverse judgment entered in the underlying action. Maglio argued that, as the primary carrier had already tendered its policy limits to the court, the primary limits were exhausted and American Guarantee’s duty to defend, including the duty to post the appellate bond, was triggered. In contrast, American Guarantee argued that, under the terms of its “follow form” policy, it had no duty to defend until the primary carrier exhausted its limits through payment for a covered claim. American Guarantee argued that only one out of the two claims in the underlying action was covered (the “Forte brand claim”). American Guarantee previously disclaimed coverage for the other claim (the “Maglio brand claim”). As the value of the covered Forte brand claim was less than the primary policy limit, the primary carrier’s payment of that claim did not exhaust the policy. American Guarantee further contended that the primary carrier’s payment of an additional $440,000 into the court was a “voluntary payment” that did not exhaust the primary policy.

The court found in favor of American Guarantee, holding that “Maglio has failed to prove, by the applicable standard of proof, clear and convincing evidence, that American Guarantee is liable for statutory bad faith, because the evidence does not show any conduct that meets the Pennsylvania legal standard for statutory bad faith, and certainly no conduct that would warrant punitive damages, under Pennsylvania law.” The court further held that its “analysis of the common law bad faith claim, arising out of the contractual relationship … leads to the same conclusion.”

With respect to its disclaimer of coverage, the court held that “Maglio has not brought forth evidence that American Guarantee’s conduct lacked a reasonable basis.” Rather, American Guarantee’s “vigilance” (including (1) conducting a reasonable investigation, (2) justifiably relying on the primary carrier’s denial of coverage of the Maglio brand claim and the primary carrier’s commitment to continue to defend the claim, and (3) hiring coverage counsel to monitor the underlying action), coupled with the primary carrier’s continued defense of Maglio, relieved American Guarantee of having to take any action in the defense. Moreover, the court held that, even if American Guarantee incorrectly evaluated coverage for the Maglio brand claim, “the evidence fails to show that American Guarantee did so out of self-interest or ill will.” The court found that, “[a]bsent such a showing, Maglio’s bad faith claim falls short.”

The court also determined that, as the verdict for the covered Forte brand claim was only $660,000, it did not exhaust the primary policy limits, and thus concluded that the primary insurer’s payment “did not trigger American Guarantee’s duty to defend, and therefore, its duty to post an appellate bond.” As a result, “American Guarantee did not act in bad faith by refusing to post such bond.”

New Jersey Court Turns the Screws on the Insured, Holding That “Your Product” Exclusion Bars Coverage For Defective Product Claim

Thursday, September 11th, 2014

By Julie Kim, Sedgwick New York

In Titanium Industries, Inc. v. Federal Ins. Co., No. A-1922-12T1, 2014 WL 4428324 (N.J. Super. Ct. App. Div. Sept. 10, 2014), the court held that the commercial general liability policy issued by defendant Federal Insurance Company (“Federal”) to Titanium Industries, Inc. (“TII”) did not provide coverage for TII’s claim based on the policy’s “Your Product” exclusion.

TII manufactured and supplied titanium products, and sold titanium bars to Biomet Manufacturing Corp. (“Biomet”), pursuant to the parties’ long-term supply agreement. Biomet, a manufacturer of orthopedic implants and devices, used TII’s product to manufacture screws that were incorporated into its products. Biomet’s screws were composed entirely of TII’s titanium. After Biomet alerted TII to defects in its titanium bars which undermined the strength of the products manufactured using the screws, Biomed recalled certain affected products. TII and Biomed settled Biomed’s claim, and TII sought defense and indemnification from Federal.

On motions for summary judgment, the trial court ruled in favor of Federal on its motion, and against TII on its motion. The Appellate Division affirmed that ruling, relying on prior decisions by New Jersey state courts. The court noted that an insured bears the risk of its own faulty work, which is a matter of warranty and not insurance coverage. The court determined that the policy would not provide coverage for the claimed loss, which was based solely upon the defective titanium supplied by the insured in contravention of the express warranties made in the parties’ long-term supply agreement. The insured’s titanium was fashioned into screws, as contemplated by the parties’ long-term supply agreement, and the titanium was otherwise unaltered and not appended to other property that was damaged. Thus, the court concluded that Biomet’s claims were for TII’s breach of its warranties regarding the intended use of its product, and the risk of replacement or repair of its faulty goods was the cost of doing business, and was not a risk passed on to Federal. The court further noted that even if the claim fell within the policy’s insuring agreement, coverage was precluded by the policy’s “your product” exclusion, which excluded coverage for “property damage to your product arising out of it or any part of it,” where “your product” was defined to include “goods or products . . . manufactured, sold, handled, distributed or disposed by” the insured, and included “representations or warranties made at any time with respect to the durability, fitness, performance, quality or use of” the insured’s titanium.

 

First Circuit Confirms No Fiduciary Breach in Use of a Retained Asset Account

Wednesday, September 10th, 2014

By Erin Cornell, Sedgwick San Francisco

For the second time this summer, the First Circuit Court of Appeals addressed whether an ERISA fiduciary’s use of a retained asset account (“RAA”) to pay death benefits is a breach of fiduciary duty.  In Merrimon v. Unum Life Ins. Co., 758 F.3d 46 (1st Cir. 2014), the First Circuit held that an insurer acting as a plan administrator properly discharges its duties under ERISA when it pays a death benefit through a RAA, provided that the method of payment is set forth in the plan document.  Eight weeks later, in Vander Luitgaren v. Sun Life Assur. Co. of Canada, Case No. 13-2090, 2014 WL 4197947 (1st Cir. Aug. 26, 2014), the First Circuit again addressed an administrator’s use of a RAA to pay death benefits pursuant to the terms of an ERISA plan.  The court found that Vander Luitgaren could be decided on the basis of its opinion in Merrimon, but it wrote separately to address additional issues not present in Merrimon. 

In Vander Luitgaren, the appellant was a beneficiary of an ERISA-governed life insurance plan.  The insurer, Sun Life, paid the beneficiary the full amount of benefits owed, and placed the entirety of the funds ($151,000) into a RAA, which earned interest for the beneficiary at 2% per year.  The beneficiary had the right to withdraw all or any part of the funds at any time, provided that no withdrawal could be for less than $250.  Sun Life would close the RAA if the balance fell below $250, in which event the beneficiary would receive the balance.  Within a matter of days, the beneficiary withdrew the entire $151,000.  Sun Life then closed the account and mailed him a check for $74.48 in interest. 

The beneficiary then sued Sun Life, contending that its use of the RAA breached its fiduciary duties.  The district court granted Sun Life’s motion for summary judgment, and the beneficiary appealed.  Sun Life challenged his statutory standing, an issue not raised in Merrimon, arguing that because he received the full amount of the death benefit when the sum was credited to the RAA, he was no longer entitled to a benefit under the plan and therefore lacked standing to sue under ERISA.  The court declined to decide this issue and instead resolved the dispute on the merits.  Unlike Merrimon, the plan applicable in Vander Luitgaren did not expressly provide that benefits would be paid via a RAA.  Rather, the plan provided, “[t]he Death Benefit may be payable by a method other than a lump sum.  The available methods of payment will be based on the benefit options offered by Sun Life at the time of election.”  Nevertheless, the court found that this was a distinction without a difference – Sun Life did not breach its fiduciary duties because establishment of a RAA was among the payment options offered by Sun Life, the beneficiary had immediate and unrestricted access to the entire death benefit, and ERISA gives plan sponsors considerable latitude to set the terms of a plan.  The First Circuit thus affirmed the district court’s judgment in favor of Sun Life.

 

In California, Looks Really Do Matter: Visual Appearance and Internal Consistency of Policy Language Supports Application of Exclusion

Friday, September 5th, 2014

By Kimberly K. Jackanich, Sedgwick San Francisco

In Yu v. Landmark American Ins. Co., 2014 WL 4162365 (Cal. Ct. App. Aug. 22, 2014)*, the California Court of Appeals relied on the visual appearance and internal consistency of an endorsement entitled “EXCLUSION – YOUR PRIOR WORK” to find that the endorsement precluded coverage for construction defect claims asserted against a subcontractor for work performed over a year before the policy’s inception.

Yu, a developer, entered into a contract with a general contractor for the construction of a hotel.  The general contractor then entered into a subcontract with C&A Framing Company (“C&A”), but fired C&A before it had completed all of the work required by the subcontract. After May 2003, C&A never returned to the construction site.

Landmark American Insurance Company (“Landmark”) issued C&A a commercial general liability policy for the period of September 18, 2004 to September 18, 2005.  The policy contained an endorsement entitled “EXCLUSION – YOUR PRIOR WORK,” which provided that the insurance did not apply to bodily injury, property damage, or personal and advertising injury arising out of C&A’s work prior to 9/18/04.

In 2004, the developer sued C&A for alleged construction defects, and C&A tendered its defense to Landmark.  The insurer declined the tender on the basis of the Your Prior Work Exclusion and the Policy requirement that the outset of damage occur during the policy period.  Although C&A did not dispute the declination, the developer brought suit against Landmark and other insurers, alleging that C&A had assigned to her all rights against any insurer.  The developer argued that Landmark could not rely on the prior work exclusion because it was ambiguous and should be construed in favor of coverage.  The developer also argued that Landmark had failed to consider certain facts when denying coverage.  Specifically, the developer argued that the language of the prior work exclusion could be construed to modify the term “property damage,” such that property damage rather than prior work was excluded.

Rejecting the developer’s arguments, the court found that the heading of the endorsement, set out in all caps and boldface type, was prominent, clear, explicit and did not require any technical interpretations.  Finding that the developer’s interpretation was not objectively reasonable, the court also relied on the exclusion for pre-existing damage or injury to conclude that the plaintiff’s interpretation would be “wholly redundant and constitute surplusage” if the prior work exclusion was interpreted to preclude prior property damage.  Based on the clear application of the prior work exclusion, the court also rejected all of the developer’s arguments regarding Landmark’s failure to properly investigate or defend the matter.

The court’s holding in Yu is an important reminder for insurers regarding the visual appearance and internal consistency of their policies.  The court’s reliance on the caps and boldface type as well as the title of the “YOUR PRIOR WORK” exclusion illustrates the significance of carefully crafted and visually clear policy headings.  Further, the court’s secondary support in the policy’s pre-existing damage exclusion reinforces that courts will interpret the policy as a whole.  Thus, when limiting and exclusionary language is internally consistent, insureds will face an uphill battle in their efforts to broadly construe policy language for purposes unintended by the insurers.

 

*The opinion is unpublished

District Courts Reviewing ERISA Cases Under the Arbitrary and Capricious Review Standard Serve Only in an Appellate Role

Wednesday, August 27th, 2014

By Matthew P. Mazzola, Sedgwick New York

In McCorkle v. Metro. Life Ins. Co., 13-30745, 2014 WL 2983360 (5th Cir. 2014), the Fifth Circuit reversed the district court’s holding that MetLife’s adverse determination regarding the plaintiff’s claim for benefits due to the death of her husband (the “decedent”) under his employer’s Accidental Death and Dismemberment Plan (the “Plan”) was arbitrary and capricious. MetLife funded benefits and administered claims under the Plan pursuant to a full grant of discretionary authority. In her motion for summary judgment, the plaintiff challenged MetLife’s finding that the decedent’s death was both not “accidental” and subject to the Plan’s exclusions for self-inflicted injuries and suicide. The district court granted plaintiff summary judgment finding that her explanation of the decedent’s death was “more reasonable” than MetLife’s final determination that his death was the result of suicide.

The Fifth Circuit criticized the district court’s application of the arbitrary and capricious review standard, holding that in reviewing denied claims for benefits under this deferential standard, district courts:

are not sitting, as they usually are, as courts of first impression. Rather, they are serving in an appellate role.  And, their latitude in that capacity is very narrowly restricted by ERISA and its regulations, as interpreted by the courts of appeals and the Supreme Court, including the oft-repeated admonition to affirm the determination of the plan administrator unless it is “arbitrary” or is not supported by at least “substantial evidence”—even if that determination is not supported by a preponderance.

The Fifth Circuit also held that MetLife was only required to base its determination on substantial evidence, which means “more than a scintilla, less than preponderance, and such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Based on its review of the plaintiff’s claim under the appropriate standard of review, the Fifth Circuit reversed the district court’s decision finding that MetLife’s determination was, in fact, based on substantial evidence. In addition, the Fifth Circuit held that the district court erred in holding that plaintiff’s explanation of the decedent’s death  was “more reasonable” because this type of analysis improperly “constitutes finding the “‘preponderance,’ which has no place in this ERISA review.” Lastly, the Fifth Circuit held that the district court erred in disregarding MetLife’s deference by improperly substituting its own narrow interpretation of the term “suicide” for MetLife’s reasonable interpretation of that term.

 

You May Have Stolen the Advertising Database, But You Still Have No Advertising Idea

Thursday, August 21st, 2014

By Daniel Pickett, Sedgwick New York

In Liberty Corporate Capital Ltd. v. Security Safe Outlet, 2014 WL 3973726 (6th Cir. August 15, 2014), the Sixth Circuit Court of Appeals held that where a stolen customer database is used as the basis of an advertising campaign, a claim arising from the misappropriation of that database does not constitute an advertising injury.

The case arose from an action brought by BudsGunShop.com, LLC (“BGS”) against a competitor, Security Safe Outlet, Inc. (“SSO”), and its former employee Matthew Denninghoff. While still a BGS employee, Denninghoff conspired with his sister, who was SSO’s Vice President, to open an internet firearms sales operation for SSO, in competition with BGS.  When Denninghoff left BGS, he secretly took a number of backup copies of BGS’s customer database with him. These were used by SSO to send mass promotional emails to BGS’s Kentucky customers. Although BGS directed SSO to desist in its use of the customer information, SSO refused to do so. BGS then sued SSO.

SSO sought a defense from its insurer, Liberty Corporate Capital Limited (“Liberty”), under a series of commercial general liability policies. SSO argued that coverage for BGS’s misappropriation of trade secrets claim fell within the policies’ adverting injury coverage, because the mass promotional emails were “advertisements,” and BGS’s claim constituted an allegation that SSO improperly used BGS’s “advertising idea” in its advertisements.  Liberty denied coverage arguing that, although the emails may have been “advertisements,” BGS’s misappropriation claim was not covered because BGS did not allege that SSO or Denninghoff used any of its “advertising ideas” in the emails, and the customer database itself was not an “advertising idea.”

The Sixth Circuit agreed with Liberty.  BGS’s allegations regarding misappropriation and use of the customer database did not involve the use of an “advertising idea,”  which was “reasonably understood to encompass a company’s plan, scheme, or design for calling its products or services to the attention of the public.”   BGS had not alleged that SSO used any of its advertising plans, schemes, or designs in the emails, only that customer information was used as a basis for the advertising campaign.

The Sixth Circuit affirmed the district’s court’s holding that Liberty had no duty to defend or indemnify SSO.

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