Amica Mutual Ins. Co. v. Levine ( 2019 )

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APPENDIX
AMICA MUTUAL INSURANCE COMPANY
v. MICHELLE LEVINE*
Superior Court, Judicial District of Hartford
File No. CV-XX-XXXXXXX-S
Memorandum filed July 31, 2017
Proceedings
Memorandum of decision on plaintiff’s motion for
summary judgment. Motion granted.
Ondi A. Smith, for the plaintiff.
Jennifer B. Levine, for the defendant.
Opinion
SHAPIRO, J. This matter is before the court concern-
ing the plaintiff Amica Mutual Insurance Company’s
motion for summary judgment (#104) (motion). The
court heard oral argument concerning the motion on
May 30, 2017. For the reasons stated below, the motion
is granted.
I
BACKGROUND
The defendant, Michelle Levine, was a covered per-
son under an automobile liability insurance policy
issued by the plaintiff, Amica Mutual Insurance Com-
pany, for the period December 1, 2010 to December 1,
2011 (policy). The defendant sought medical payments
for treatment she claimed resulted from a December
6, 2010 motor vehicle accident (accident).
In the plaintiff’s complaint, it seeks a declaratory
judgment, finding that it has no duty to provide medical
payment benefits to the defendant because she refused
to undergo requested independent medical examina-
tions (IMEs) with a physician selected by the plaintiff,
which prejudiced the plaintiff’s ability to properly evalu-
ate the defendant’s claim for such benefits.
The correspondence submitted concerning the
motion shows that, in 2012 and 2013, the plaintiff made
several requests for the defendant to submit to a medi-
cal examination, but the defendant never did so. See
plaintiff’s exhibit C; defendant’s exhibits A, B, C, 23, 25
and 27. Additional references to the factual background
are set forth below.
II
STANDARD OF REVIEW
‘‘In seeking summary judgment, it is the movant who
has the burden of showing the nonexistence of any
issue of fact. The courts are in entire agreement that
the moving party for summary judgment has the burden
of showing the absence of any genuine issue as to all
the material facts, which, under applicable principles
of substantive law, entitle him to a judgment as a matter
of law. The courts hold the movant to a strict standard.
To satisfy his burden the movant must make a showing
that it is quite clear what the truth is, and that excludes
any real doubt as to the existence of any genuine issue
of material fact. . . . As the burden of proof is on the
movant, the evidence must be viewed in the light most
favorable to the opponent. . . . When documents sub-
mitted in support of a motion for summary judgment
fail to establish that there is no genuine issue of material
fact, the nonmoving party has no obligation to submit
documents establishing the existence of such an issue.
. . . Once the moving party has met its burden, how-
ever, the opposing party must present evidence that
demonstrates the existence of some disputed factual
issue.’’ (Internal quotation marks omitted.) Romprey v.
Safeco Ins. Co. of America, 310 Conn. 304, 319–20, 77
A.3d 726 (2013). ‘‘A material fact . . . [is] a fact which
will make a difference in the result of the case.’’ (Inter-
nal quotation marks omitted.) Id., 312–13.
III
DISCUSSION1
‘‘[C]onstruction of a contract of insurance presents
a question of law for the court . . . . It is the function
of the court to construe the provisions of the contract
of insurance. . . . The [i]nterpretation of an insurance
policy . . . involves a determination of the intent of
the parties as expressed by the language of the policy
. . . [including] what coverage the . . . [insured]
expected to receive and what the [insurer] was to pro-
vide, as disclosed by the provisions of the policy. . . .
[A] contract of insurance must be viewed in its entirety,
and the intent of the parties for entering it derived from
the four corners of the policy . . . [giving the] words
. . . [of the policy] their natural and ordinary meaning
. . . [and construing] any ambiguity in the terms . . .
in favor of the insured . . . .’’ (Internal quotation marks
omitted.) Chicago Title Ins. Co. v. Bristol Heights Asso-
ciates, LLC, 142 Conn. App. 390, 405–406, 70 A.3d 74,
cert. denied, 309 Conn. 909, 68 A.3d 662 (2013).
As discussed below, the policy contains provisions
which require persons seeking coverage to cooperate
with the insurer in its investigation of the claim and
to submit to physical examinations by physicians it
selected. ‘‘The purpose of the cooperation provision is
to protect the interests of the insurer. . . . If insurers
could not contract for fair treatment and helpful cooper-
ation from the insured, they would at the very least, be
severely handicapped in determining how and whether
to contest the claim . . . .’’ (Citation omitted; internal
quotation marks omitted.) Arton v. Liberty Mutual Ins.
Co., 163 Conn. 127, 134, 302 A.2d 284 (1972).
‘‘A cooperation clause in a liability insurance policy
requires that there shall be a fair, frank, and substan-
tially full disclosure of information reasonably
demanded by the insurer to enable it to prepare for, or
to determine whether there is, a genuine defense. . . .
[I]t has been held that an insured’s failure to disclose
information breached a cooperation clause [when] . . .
[t]he insured . . . [failed] to provide information
requested by the insurer.’’ (Internal quotation marks
omitted.) Double G.G. Leasing, LLC v. Underwriters
at Lloyd’s, London, 116 Conn. App. 417, 433, 978 A.2d
83, cert. denied, 294 Conn. 908, 982 A.2d 1082 (2009);
see Chicago Title Ins. Co. v. Bristol Heights Associates,
supra, 142 Conn. App. 409 (insured’s failure to disclose
information breached cooperation clause when insured
failed to provide information requested by insurer).
‘‘Generally, in the absence of a reasonable excuse,
when an insured fails to comply with the insurance
policy provisions . . . the breach generally results in
the forfeiture of coverage, thereby relieving the insurer
of its liability to pay, and provides the insurer an abso-
lute defense to an action on the policy.’’ (Internal quota-
tion marks omitted.) Double G.G. Leasing, LLC v.
Underwriters at Lloyd’s, London, supra, 116 Conn.
App. 432.
‘‘The lack of cooperation, however, must be substan-
tial or material. . . . [T]he condition of cooperation
with an insurer is not broken by a failure of the insured
in an immaterial or unsubstantial matter. . . . [L]ack
of prejudice to the insurer from such failure is a test
which usually determines that a failure is of that
nature.’’ (Internal quotation marks omitted.) Chicago
Title Ins. Co. v. Bristol Heights Associates, LLC, supra,
142 Conn. App. 408.
Here, the policy, page 11 of 14, provides, in relevant
part: ‘‘Part E—Duties After an Accident or Loss: We
have no duty to provide coverage under this policy
if the failure to comply with the following duties is
prejudicial to us . . . B. A person seeking any coverage
must: 1. Cooperate with us in the investigation, settle-
ment or defense of any claim or suit. . . . 3. Submit,
as often as we reasonably require: a. To physical exams
by physicians we select. We will pay for these exams.’’
See plaintiff’s exhibit A.
The plaintiff asserts that it reasonably requested that
the defendant submit to an IME after review of the
medical bills and reports forwarded by the defendant
in late June, 2011, in connection with her claim made
it was clear that the defendant had been treating for her
medical condition prior to the accident. In September,
2011, the plaintiff requested a records review of the
defendant’s treatment by Dr. Mark Silk, a urologist, who
concluded that, other than a temporal basis, it was
difficult, if not impossible, to establish a relationship
between the accident and defendant’s subsequent medi-
cal course. See defendant’s exhibit 24.
When the defendant was still treating a year and a
half after the accident, and was still seeking medical
payment benefits, the plaintiff requested that the defen-
dant attend an IME by Dr. Silk, to ascertain whether
the defendant’s treatment was related to the accident.
As an integral part of its investigation into the claim,
the plaintiff made several requests that the defendant
submit to such an IME.
In July, 2012, the defendant’s attorney objected to
the plaintiff’s selected medical examiner/urologist on
the basis that he had not been shown to be an expert
who matched the defendant’s out-of-state physician’s
expertise in interstitial cystitis, noting that ‘‘there
appears to be no urologist in Connecticut who
match[es] Dr. [Robert] Moldwin’s knowledge and
expertise regarding this particular disease.’’ See defen-
dant’s exhibit A, page 2 (letter dated July 18, 2012).
The plaintiff contends that the defendant did not have
a reasonable excuse for failing to attend the IME and
outlined a number of conditions which she demanded
be satisfied before she would submit to the IME, none
of which are afforded to her in the policy, such as (1)
furnishing a copy of the doctor’s resume; (2) that she
either not fill out written questionnaires or be provided
with the forms ten days in advance so that counsel may
object to certain questions; (3) that she not be required
to fill out any authorizations unless provided prior to
the exam with an explanation of the reasons for the
request; and (4) that counsel be permitted to attend
and tape record the IME.
The defendant advances several arguments in opposi-
tion to the motion, which the court addresses below:
(1) the policy provision the plaintiff seeks to enforce
is void as against public policy; (2) the provision is
void as against the informed consent doctrine; (3) the
provision is void because Dr. Silk is not a ‘‘physician’’
as defined by the policy; (4) the IME request was not
reasonable; (5) the preconditions proposed by the
defendant were not unreasonable; (6) a fact issue exists
as to whether the plaintiff engaged in bad faith/unclean
hands; and (7) a factual dispute exists as to whether
the plaintiff waived its right to claim a breach of the
cooperation clause by arbitrarily paying out Med-Pay
benefits.
First, the defendant presents two arguments to sup-
port her assertion that the policy provision requiring
an insured to submit to a medical examination is void
as against public policy. She has presented no evidence
to show that, prior to this litigation, she ever advised
the plaintiff that she declined to submit to an IME
because the provision was void as against public policy.
The defendant argues that the provision violates Gen-
eral Statutes § 52-178a2 and Practice Book § 13-11.3 By
their terms, these provisions pertain to requests for
physical examinations in civil actions to recover dam-
ages for personal injuries, not to insurance policies.
They are plainly inapplicable to the parties’ contractual
agreement as set forth in the policy. The decisional
law concerning § 52-178a and Practice Book § 13-11 is
inapplicable as well.
Second, the defendant also contends that the policy
provision violates the public policy behind the informed
consent doctrine. In Connecticut, lack of informed con-
sent is a cause of action based on medical negligence,
as distinguished from medical malpractice. ‘‘In order
to prevail on a cause of action for lack of informed
consent, a plaintiff must prove both that there was a
failure to disclose a known material risk of a proposed
procedure and that such failure was a proximate cause
of his injury.’’ Shortell v. Cavanagh, 300 Conn. 383, 388,
15 A.3d 1042 (2011).
The defendant’s citation to decisions from other
states which reference statutory authority in those
states is inapt in the absence of a similar statute in Con-
necticut.
Having failed to attend the requested examination,
the defendant has no evidence of what information
would have been provided to her at that time. She has
not shown that the doctrine of informed consent is
applicable to the policy provision.
Third, the defendant argues that the plaintiff has
failed to prove that it requested an examination by a
physician. In support of this assertion, the defendant
argues that the plaintiff produced copies of Dr. Silk’s
medical licenses which had expired. See defendant’s
exhibit C (letter dated October 19, 2012, enclosing Dr.
Silk’s curriculum vitae).
The policy provision did not require the plaintiff to
provide to the defendant proof of Dr. Silk’s qualifica-
tions. It provided the information in the October 19,
2012 letter as a courtesy.
The defendant never objected to the IME on this
ground prior to the commencement of suit. In addition,
the policy provision does not afford an insured the right
to belatedly object to a physician’s examination on this
ground. As noted above, the defendant’s only previously
stated concern about Dr. Silk’s credentials was that he
did not have the knowledge and expertise concerning
interstitial cystitis that her own physician possessed.
‘‘A ‘physician’ is defined as ‘a person skilled in the
art of healing: one duly authorized to treat disease: a
doctor of medicine . . . .’ Webster’s Third New Inter-
national Dictionary; see also Black’s Law Dictionary
(5th Ed.).’’ Kilduff v. Adams, Inc., 219 Conn. 314, 337,
593 A.2d 478 (1991).
According to his curriculum vitae, Dr. Silk received
his medical degree from New York Medical School,
and was then an assistant professor of urology at the
University of Connecticut and an attending physician
at Saint Francis Hospital and Medical Center in Hart-
ford. The provision of an expired license to practice
medicine in Connecticut appears to have been inadver-
tent. The record establishes that he was a physician.
Fourth, the defendant argues that the plaintiff failed
to show that she refused to submit to a reasonable IME.
By its terms, the policy provision required the defendant
to submit to the requested IME. The record reflects
that the defendant’s objection to the selected medical
examiner and the proposed examination also was
unreasonable in light of the policy language. See Van-
Haaren v. State Farm Mutual Automobile Ins. Co., 989
F.2d 1, 6–7 (1st Cir. 1993).
Fifth, the defendant contends that the preconditions
she proposed were not unreasonable. The defendant’s
list of conditions regarding the IME constituted an
improper insistence on preconditions to performance
not stated in the contract. See id. The defendant’s
refusal to submit to an IME based upon the identity
and qualifications of the physician performing the
examination, and her insistence on certain conditions
to performance not stated in the contract constituted
an unreasonable refusal to submit to the policy condi-
tions and breach of the IME clause.
Sixth, the defendant asserts that there is a genuine
issue of material fact as to her defense of unclean hands
and that the plaintiff engaged in bad faith. ‘‘Bad faith
in general implies both actual or constructive fraud, or
a design to mislead or deceive another, or a neglect or
refusal to fulfill some duty or some contractual obliga-
tion, not prompted by an honest mistake as to one’s
rights or duties, but by some interested or sinister
motive. . . . Bad faith means more than mere negli-
gence; it involves a dishonest purpose.’’ (Internal quota-
tion marks omitted.) De La Concha of Hartford, Inc.
v. Aetna Life Ins. Co., 269 Conn. 424, 433, 849 A.2d
382 (2004).
In support, the defendant again relies on § 52-178a
and Practice Book § 13-11, which, as discussed above,
are inapplicable to the contract at issue. She also reiter-
ates her informed consent argument, which, as dis-
cussed above, is inapplicable. She also repeats her
arguments concerning Dr. Silk, which the court dis-
cussed above.
In addition, she asserts that the plaintiff acted in bad
faith by arbitrarily refusing to pay for the majority of
Dr. Moldwin’s bills. No evidentiary support was cited
for this conclusory argument, which the court is not
required to consider. The defendant has not shown that
the plaintiff has unclean hands or engaged in bad faith.
Seventh, the defendant argues that a genuine issue
of fact exists as to whether the plaintiff waived its
right to assert a violation of the policy provision. She
contends that the plaintiff made selective medical pay-
ments benefits to her after its request for an August,
2012 examination by Dr. Silk and never again requested
that she submit to a physical examination.
This contention is plainly wrong and unsupported by
the record. In defendant’s exhibit 27, a letter to the
defendant’s counsel dated May 10, 2013, the plaintiff’s
counsel again requested that the defendant submit
to such an examination, citing the policy provision’s
requirement and explicitly reserving the plaintiff’s
rights, including stating: ‘‘please be advised that any
action taken by Amica to date should not be construed
as a waiver of any of its rights.’’ Further, the letter
stated that ‘‘Amica reserves the right to file a declaratory
judgment action to seek a judicial determination of
coverage for this claim.’’ Thus, the defendant was
explicitly put on notice more than four years ago that
the plaintiff did not intend to waive its rights under
the policy.
Next, the court must determine whether the plaintiff
was prejudiced. An insured’s ‘‘failure to comply with
the cooperation clause is presumed to have been detri-
mental to the [insurance company’s interests] . . . .’’
Taricani v. Nationwide Mutual Ins. Co., 77 Conn. App.
139, 151, 822 A.2d 341 (2003). The Appellate Court has
determined that an insured’s refusal to produce various
records and documentation, which reasonably per-
tained to the insured’s loss or damage, materially preju-
dices the insurer by hindering its ‘‘ability to determine
whether the coverage applied and to prevent loss or
damage . . . [and] to investigate and defend the defen-
dant’s claim . . . .’’ Chicago Title Ins. Co. v. Bristol
Heights Associates, LLC, supra, 142 Conn. App. 409–10.
Here, the IME was necessary for the plaintiff to prop-
erly evaluate the plaintiff’s claims for benefits. Without
the IME, the plaintiff could not do so. The plaintiff has
shown that it was prejudiced by the defendant’s failure
to submit to an IME, in that it prevented the plaintiff
from being able to properly evaluate the claim and to
determine whether, and to what extent, the defendant’s
treatment and the expenses incurred for medical care
were causally related to the accident.
Summary judgment is warranted because there is
no genuine issue of material fact as to whether the
defendant breached the policy’s provision and that the
plaintiff was prejudiced as a result.
CONCLUSION
For the reasons stated above, the plaintiff has shown
that it is entitled to judgment as a matter of law. Accord-
ingly, the motion for summary judgment is granted. The
plaintiff is not required to provide Med-Pay benefits to
the defendant under the policy. It is so ordered.
* Affirmed. Amica Mutual Ins. Co. v. Levine, 192 Conn. App. 620,
A.3d (2019).
1
In considering the parties’ arguments, this court has considered the
parties’ oral and written arguments, including those presented in the plain-
tiff’s reply memorandum (#124). By order dated June 15, 2017, the court
(Wahla, J.) granted the defendant’s motion to strike the reply. See #125.86.
This court is not bound by that ruling. See Breen v. Phelps, 186 Conn. 86,
99, 439 A.2d 1066 (1982) (The law of the case doctrine ‘‘expresses the
practice of judges generally to refuse to reopen what has been decided and
is not a limitation on their power. . . . Where a matter has previously been
ruled upon interlocutorily, the court in a subsequent proceeding in the case
may treat that decision as the law of the case, if it is of the opinion that
the issue was correctly decided . . . .’’ [Citations omitted; emphasis added;
internal quotation marks omitted.]).
2
General Statutes § 52-178a provides: ‘‘In any action to recover damages
for personal injuries, the court or judge may order the plaintiff to submit
to a physical examination by one or more physicians or surgeons. No party
may be compelled to undergo a physical examination by any physician to
whom he objects in writing submitted to the court or judge.’’
3
Practice Book § 13-11 (b) provides in pertinent part: ‘‘In the case of an
action to recover damages for personal injuries, any party adverse to the
plaintiff may file and serve . . . a request that the plaintiff submit to a
physical or mental examination at the expense of the requesting party. That
request shall specify the time, place, manner, conditions and scope of the
examination and the person or persons by whom it is to be made. Any such
request shall be complied with by the plaintiff unless, within ten days from
the filing of the request, the plaintiff files in writing an objection thereto
specifying to which portions of said request objection is made and the
reasons for said objection. The objection shall be placed on the short calen-
dar list upon the filing thereof. The judicial authority may make such order
as is just in connection with the request. No plaintiff shall be compelled to
undergo a physical or mental examination by any physician to whom he or
she objects in writing.’’