Comisionado De Seguros De Puerto Rico v. Mapfre Praico Insurance Company
KLRA202400466
Tribunal De Apelaciones De Pue...Oct 25, 2024Background
- Mr. Clyde Fasick Juliá submitted a travel insurance claim to MAPFRE Praico Insurance Company ("MAPFRE"), seeking reimbursement for trip cancellation due to his emergency hospitalization.
- MAPFRE denied the claim, citing untimely notification and referring to policy terms requiring claim notice no later than 75 days before cancellation.
- Fasick Juliá appealed to the Office of the Commissioner of Insurance of Puerto Rico ("OCS"), arguing MAPFRE failed to act in good faith given the exceptional circumstances.
- OCS found MAPFRE had not reasonably investigated or attempted a fair adjustment, violating Article 27.161(3), (4), and (6) of the Puerto Rico Insurance Code, and imposed a $10,000 administrative fine despite MAPFRE’s subsequent payment of the claim before the order issued.
- MAPFRE sought judicial review, arguing the matter was moot due to payment, that due process had not been afforded, and that OCS had no authority to intervene in what it considered a contractual dispute.
- The Puerto Rico Court of Appeals affirmed OCS’s resolution and fine, holding the violations occurred prior to payment and investigation.
Issues
| Issue | Plaintiff's Argument (MAPFRE) | Defendant's Argument (OCS) | Held |
|---|---|---|---|
| Mootness (Academicidad) | Payment pre-OCS order made case moot | Violation occurred prior to payment | Claim not moot; violations pre-payment |
| Due process in administrative fine | Facts/violations not specifically notified or proven | Order and process gave notice and opportunity to respond | Due process satisfied; agency’s finding upheld |
| OCS authority over contract dispute | OCS cannot adjudicate contract disputes or order insurer action | OCS has statutory authority over insurance practices | OCS has investigative and remedial authority |
| Sufficiency of evidence for violation | No evidence of bad faith or violation | Evidence supported OCS findings | Evidence sufficient to support fine |
Key Cases Cited
- Asoc. Fcias. v. Caribe Specialty et al., 179 DPR 923 (presumption of regularity in administrative decisions; grounds for overturning are limited)
- Torres Rivera v. Policía de Puerto Rico, 196 DPR 606 (standard for judicial review of administrative decisions)
- OCS v. Universal, 187 DPR 164 (summary resolution in administrative adjudications)
- Rivera Candela v. Universal Ins. Co., 2024 TSPR 99 (public interest and regulation of insurance in Puerto Rico)
- Consejo Titulares v. MAPFRE, 208 DPR 716 (role of OCS and insurance regulation)
- PVH Motors v. ASG, 209 DPR 122 (administrative due process requirements)