27 February 2017
Category: Actus Curiae
27 February 2017,
 Off

Issues:

  1. Whether the Insured’s substantial compliance with post-loss obligations under the policy is an issue of fact that is the purview of the jury and, thus, cannot be resolved via summary judgment.
  2. Whether evidence of the Insured’s health is probative on the issues of substantial compliance with the policy obligations and/or prejudice to insurer due to untimely compliance.

Result:

Regarding the first issue, the court determined that an insured’s substantial compliance with her post-loss obligations under the policy involved issues of fact properly resolved by the jury. Regarding the second issue, the court determined that evidence of the Insured’s health should never have been introduced, thus State Farm was entitled to a new trial.

Facts:

Dina Figueroa (“Insured”) filed a claim on October 30, 2005 after her property sustained a loss due to Hurricane Wilma on October 24, 2005. After inspecting the property, State Farm’s adjuster believed that 29 roof tiles had been damaged by the hurricane. Because the cost to repair those roof tiles did not exceed the Insured’s policy deductible, State Farm did not provide payment. State Farm advised the Insured that she was free to obtain her own estimate for the cost of repairs and submit it to State Farm for consideration.

The Insured contacted a few roofers, but none were interested in the job. In January 2006, the Insured began dealing with a serious medical condition, which distracted her from following up with her claim. In late 2008, the Insured obtained a contractor’s estimate that included a new roof because more than 25% of her roof tiles had been loosened by wind damage. The Insured submitted her estimate to State Farm in early 2009 and requested that the claim be reopened. State Farm sent another adjuster to the Insured’s home in April 2009, who concluded that the original estimate was correct. After that inspection, State Farm sent the Insured a reservation of rights letter that outlined her obligations under the policy following a loss, specifically her obligation to make reasonable and necessary temporary repairs and to submit to State Farm a signed sworn proof of loss within 60 days of the loss.

The Insured submitted a sworn proof of loss along with the contractor’s estimate on June 8, 2009. Counsel for State Farm responded in late September 2009, informing the Insured that the proof of loss did not comply with policy provisions. Subsequently, upon State Farm providing a proof of loss form to the insured in March 2010, the Insured completed and submitted the proof of loss form on June 10, 2010. On June 22, 2010, State Farm notified the Insured that it was relieved of its obligations under the policy because of the Insured’s material breach, specifically, her failure to timely submit a valid sworn proof of loss. The Insured filed suit the following month.

During litigation, State Farm moved for summary judgment, arguing that the Insured failed to comply with her post-loss obligations under the policy. It argued that the insured failed to submit a sworn proof of loss within 60 days of the loss and failed to protect her property from further damage by making reasonable and necessary repairs. The Insured responded that she substantially complied with her post-loss obligations and that State Farm was not prejudiced by her untimely compliance. The insured also explained that she was unable to immediately dispute State Farm’s estimate in 2005 because she began experiencing health issues. The trial court denied the motion.

At trial, State Farm moved to limit the Insured’s ability to introduce evidence regarding her health issues because such evidence would be irrelevant and highly prejudicial. The Insured argued that the information regarding her health was necessary to explain the three-year delay between her initial and supplemental claim. The trial court denied State Farm’s motion. At the conclusion of the trial, the jury found in the Insured’s favor. State Farm appealed.

Reasoning:

The court stated that an insured’s substantial compliance with policy obligations and/or prejudice to an insurer due to untimely compliance are questions of fact. An insured’s total failure to comply with a policy provision amounts to a breach of the policy precluding recovery.  However, where an insured cooperates to some extent, a fact question remains as to whether the condition is breached to the extent of denying an insured any recovery under the policy. Further, although an insured’s untimely compliance with policy conditions is presumed to prejudice an insurer, this presumption can be rebutted by a showing that the insurer was not prejudiced.

Here, the Insured did not submit a sworn proof of loss within 60 days of the loss, but she did so before filing suit. In 2005, State Farm responded to the Insured’s claim and evaluated it without requesting a sworn proof of loss. The Insured first submitted a proof of loss shortly after notifying State Farm that she wished to reopen her claim in 2009. When State Farm advised the Insured that the proof of loss did not comply with the policy and provided her with its own form, the Insured completed and returned that proof of loss form. The Insured complied “to some extent,” creating a question for the factfinder. Although the Insured’s compliance with the policy provision was untimely, because she complied prior to suit, whether that compliance was substantial was a fact question that should be reserved for the jury.

As to State Farm’s Motion in Limine, the Court stated that the Insured’s health was not relevant to any issue in the case. The court explained that relevant evidence is evidence tending to prove or disprove a material fact. Because no provision in the policy allowed illness to excuse noncompliance or untimely compliance with the Insured’s obligations, evidence of the Insured’s health did not tend to prove or disprove that she substantially complied with the policy obligations or that State Farm was not prejudiced by her untimely compliance. Not only did the Insured’s health not assist the jury in determining a material fact at issue, it may have led the jury to unfairly infer that her health was a factor to be considered in determining whether she substantially complied. Because the Insured’s health had no probative value, it could only have suggested that the jury decide on an improper basis.

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