89 Wash. App. 712 | Wash. Ct. App. | 1997
This case concerns the cooperation clause in an insurance contract and the legislature’s recent efforts to diminish fraud in the making of insurance claims. Here, the Pilgrims, who were in the process of selling their home, reported a theft of approximately $15,000 in personal property from their home to the police; the investigating officer
I.
FACTS
In fall 1993, Keith and Renae Pilgrim wanted to sell their King County house and move to eastern Washington. During the time the house was on the market, the Pilgrims returned home after dinner with friends one October evening to find that their home had been burglarized.
The police officer called Keith a month later. Because the theft did not involve forced entry, the Pilgrims were selling their house, and the officer believed that they were having financial difficulties and had submitted a high claim, he told Keith that it “made him wonder.”
Keith Pilgrim sent State Farm two signed inventory forms describing the stolen property, its replacement cost, and its actual cash value. The replacement cost on those December 1993 and January 1994 forms totaled $70,372.94 and $78,083.18 respectively.
The following April, without being under oath, accompanied by their attorney, Keith and Renae answered the claim specialist’s questions. State Farm requested authorization to obtain credit reports; the record contains no response.
Later, in fall 1994, the Pilgrims informed State Farm that many types of documents that it sought were not “known to exist.” For example, the Pilgrims were not involved in any litigation that had settled during the year preceding the loss.
The Pilgrims filed this action against State Farm in early October 1994, seeking a coverage declaration, attorney fees, and damages pursuant to the Consumer Protection Act. Before they served the complaint, State Farm denied the Pilgrims’ theft claim. After receiving the complaint, State Farm counterclaimed for restitution of the $15,000.
State Farm moved for summary judgment, contending
• An investigating police officer told Keith that the circumstances “made him wonder” and asked Keith if he had filed a false report.
• The Pilgrims refused to authorize third parties to give State Farm documents. On the other hand, because the record contains only a credit bureau authorization, we do not know whether State Farm sought other records.
• The discrepancy between the initial valuation of stolen items to police ($14,760) and the itemized claim to State Farm ($148,000).
• The Pilgrims refused to produce personal income tax returns (1990-93), documents relating to their personal financial condition in the twelve months preceding the loss, documents relating to the financial condition of businesses in which they had an ownership interest at the time of the loss, and financial statements (2/15/89 - 05/94), and produced only their W-2’s for 1990-93. The W-2’s demonstrated that the Pilgrims had a joint annual gross income ranging from $57,500 to $61,500 in 1991-93.[21 ]
In response, Keith Pilgrim detailed his dealings with State Farm, accused it of rude, adversarial behavior, and denied that he and his wife had any financial problems.
In reply, the State Farm claim specialist who had performed the majority of work on the Pilgrims’ claim alleged that (1) when the Pilgrims moved, they refused to give him their new eastern Washington address, (2) having analyzed the claim, nearly $30,000 of the items allegedly stolen were purchased in the 12 months preceding the claim, and (3) State Farm had paid Keith Pilgrim $17,549 for a theft loss in 1988. That loss shared a similarity with the Pilgrims’ fall 1993 loss: in both cases, Keith reported that the thieves had stacked a TV and some stereo equipment near the door.
Keith Pilgrim denied many of the claim specialist’s allegations. He had given the specialist his eastern Washington work address. He labeled the alleged attempt to prevent disclosure of the police report as “false.” He explained that the items left by the door were old and in poor working condition.
The trial court granted State Farm’s motion for summary judgment. To bifurcate the cooperation and concealment clause issues from the restitution counterclaim, it also certified its judgment under CR 54(b).
II.
DISCUSSION
A.
Insured’s Obligation Under Cooperation Clause
The Pilgrims’ homeowner’s insurance policy requires that they cooperate with State Farm by providing it with requested records and documents as often as it reasonably requires.
B.
Reasonableness and Relevance of State Farm’s Requests
During the process of compiling and evaluating the Pilgrims’ claim, State Farm became aware of facts justifying a detailed investigation. These facts included the enormous discrepancy between the amount of the claim given to police and the subsequent claim filed with State Farm, the absence of forced entry, and the existence of a prior claim with one identical fact. Furthermore, based on the record, the Pilgrims were alleging that they had purchased over $18,500 in personal property between October 1992 and October 1993, a year during which their combined net income approximated $56,000 and during which their annual mortgage and car payments totaled $24,000.
1. Income tax returns, documents relating to their personal financial condition in the twelve months preceding the loss, and financial statements
An insured’s income and financial condition are undoubtedly relevant to an investigation of whether they filed a fraudulent claim.
2. Documents relating to the financial condition of businesses in which they had an ownership interest at the time of the loss
The relevant inquiry is whether the Pilgrims had financial obligations that they were unable to meet. At a minimum, the Pilgrims should have produced documentation establishing their obligations to the entrepreneurial enterprises in which they were participating, as well as financial information showing business assets and liabilities.
3. Effect of the Proposed Confidentiality Agreement
The Pilgrims argue that they would have produced
C.
Absence of Cooperation as a Matter of Law
The Pilgrims promised to cooperate with State Farm’s investigation by producing “records and documents” as often as State Farm “reasonably require[s].” The issue is whether, as a matter of law, they breached their promise. No evidence is disputed. That evidence demonstrates that the Pilgrims at least partially complied with the cooperation duty. For example, during Keith’s and Renae’s interviews, both answered questions about financial accounts they maintained, to whom and how much money they owed, the status of their taxes, the absence of judgments, liens, and outstanding credit card balances.
D.
Prejudice
Among the fifty states, “[a] wide divergence of opinion exists as to whether prejudice is necessary in order to enable an insurer to avoid liability where there is some failure to co-operate by the insured.”
State Farm contends-» that the prejudice requirement should apply only to claims in which innocent third parties could be damaged. But Washington courts have not limited the application of the doctrine to such cases. It may be a peculiarity of insurance law, or a variant of general contract law, but not every breach discharges performance by the other party.
To establish prejudice, the insurer must show “concrete
State Farm argues that it was prejudiced by its inability to complete its investigation of the facts underlying the Pilgrims’ claim and the risk of litigation if it denied the claim. We agree. Without access to financial documents, State Farm could not evaluate the validity of the Pilgrims’ claim. It could not decide whether the claim was covered, much less prepare a defense to the inevitable suit by the Pilgrims if it denied coverage. It could not satisfy its statutory duty to ferret out fraud. The Pilgrims’ refusal to disclose relevant financial information prejudiced State Farm as a matter of law.
Given our disposition, we need not address the policy’s concealment clause.
We affirm the judgment.
Appendix
SECTION I, CONDITIONS
2. Your Duties After Loss. After a loss to which this insurance may apply, you shall see that the following duties are performed:
c. prepare an inventory of damages or stolen personal property. Show in detail the quantity, description, actual cash value and amount of loss. Attach to the inventory all bills, receipts and related documents that substantiate the figures in the inventory;
d. as often as we reasonably require:
(1) exhibit the damages [sic] property;
(2) provide us with records and documents we request and permit us to make copies;
(3) submit to and subscribe, while not in the presence of any other insured:
(a) statements; and
(b) examinations under oath; and
SECTION I AND SECTION II — CONDITIONS
2. Concealment or Fraud. This policy is void as to you and any other insured, if you or any other insured under this policy has intentionally concealed or misrepresented any material fact and circumstance relating to this insurance whether before or after a loss.
CP 618.
CP 289.
CP 291.
CP 290.
CP 623.
CP 619.
CP 293.
CP 293.
CP 296-304, 306-16.
CP 8, 318-19.
UCP 343.
CP 348.
CP 370.
CP 361.
CP 362.
CP 377.
CP 377.
CP 432.
CP 614.
The appendix contains policy provisions.
CP 461-65.
CP 623.
CP 594.
RP 541.
CP 556.
CP 542.
CP 592-94.
CP 296-316.
Section I(2)(d)(2). See appendix.
Burr v. Lane, 10 Wn. App. 661, 669, 517 P.2d 988 (1974); 14 George J. Couch et. al., Couch Cyclopedia of Insurance Law § 51:106 (2d ed. 1982); Georgian House of Interiors v. Glens Falls Ins. Co., 21 Wn.2d 470, 494, 151 P.2d 598 (1944).
Georgian House, 21 Wn.2d 470, 494.
RCW 48.30A.045-.050; Gabor v. State Farm Mut. Auto. Ins. Co., 66 Ohio App. 3d 141, 583 N.E.2d 1041, 1043 (1990).
Fine v. Bellefonte Underwriters Ins. Co., 725 F.2d 179, 183 (2d Cir. 1984).
5A John Alan Appleman & Jean Appleman, Insurance Law and Practice § 3552 (rev. 1970).
Shaw v. Standard Fire Ins. Co., 129 Wash. 576, 578-79, 225 P. 651 (1924); Georgian House, 21 Wn.2d 470, 483.
Oregon Auto Ins. Co. v. Salzberg, 85 Wn.2d 372, 376, 535 P.2d 816 (1975).
Salzberg, 85 Wn.2d 372, 377.
CP 296-316, 1247, 1205.
CP 348.
Wood v. Allstate Ins. Co., 21 F.3d 741, 747 (7th Cir. 1994); DiFrancisco v. Chubb Ins. Co., 283 N.J. Super. 601, 662 A.2d 1027, 1031 (Super. Ct., App. Div. 1995).
RCW 48.30A.050(3), .065.
CP 1206-07.
Compare Gabor v. State Farm Mut. Auto. Ins., 583 N.E.2d 1041, 1044 (failure to produce income tax records was substantial breach of cooperation clause as a matter of law) and Powell v. United States Fidelity & Guar. Co., 855 F. Supp. 858, 861 (E.D. Va. 1994) (refusal to provide a substantial amount of requested information related to financial condition breached cooperation clause as a matter of law) with Templin v. Grange Mut. Cas. Co., 81 Ohio App. 3d 572, 611 N.E.2d 944, 947-48 (1992) (partial cooperation and inability to produce some information destroyed by fire raised issue of material fact as to breach of cooperation clause), and Wood, 21 F.3d 741, 747 (because insured signed general authorization allowing insurer access to financial records, summary judgment inappropriate on insurer’s defense that insured breached cooperation clause).
14 George J. Couch et al., Couch Cyclopedia of Insurance Law § 51:107 (2d ed. 1982).
Salzberg, 85 Wn.2d 372, 377; Tibbs v. Johnson, 30 Wn. App. 107, 110, 632 P.2d 904 (1981) (stating applicability of prejudice rule, but disposing of case by applying financial responsibility law); Washington Ins. Guar. Ass’n v. Hill, 19 Wn. App. 195, 196, 574 P.2d 405 (1978) (plaintiff failed to file statement under oath within thirty days) (this case could be characterized as a notice case).
Pederson’s Fryer Farms, Inc. v. Transamerica Ins. Co., 83 Wn. App. 432, 439, 922 P.2d 126 (1996) (no prejudice as a matter of law in case where insured failed to notify insurer in accordance with the policy); Canron, Inc. v. Federal Ins. Co., 82 Wn. App. 480, 485, 918 P.2d 937 (1996) (“Noncompliance with a policy provision does not deprive the insured of the benefits of the policy unless the insurer demonstrates actual prejudice resulting from the insured’s noncompliance.”); Felice v. St. Paul Fire & Marine Ins. Co., 42 Wn. App. 352, 358, 711 P.2d 1066 (1985) (insurer prejudiced as a matter of law); Pulse v. Northwest Farm Bureau Ins. Co., 18 Wn. App. 59, 61, 566 P.2d 577 (1977); Spangler v. Insurance Co. of N. Am., 17 Wn. App. 121, 128, 562 P.2d 635 (1977). See also Olds
Public Util. Dist. No. 1 v. International Ins. Co., 124 Wn.2d 789, 803, 881 P.2d 1020 (1994).
PUD No. 1, 124 Wn.2d at 803.
PUD No. 1, 124 Wn.2d at 803.
Safeco Title Ins. Co. v. Gannon, 54 Wn. App. 330, 774 P.2d 30 (1989) (refusing to apply prejudice analysis to a termination of coverage clause in a “claims-made” policy); and Simms v. Allstate Ins. Co., 27 Wn. App. 872, 876-77, 621 P.2d 155 (1980) (finding of prejudice not required when insured relies on statute of limitations clause because it is “simply a contractual modification of the statute of limitations.”); Mutual of Enumclaw Ins. Co. v. Cox, 110 Wn.2d 643, 757 P.2d 499 (1988) (“This entire policy is void if. . . there has been fraud or false swearing”).
6 Arthur Linton Corbin, Corbin on Contracts § 1253 (1962).
PUD No. 1, 124 Wn.2d at 803.
Canron, Inc. v. Federal Ins. Co., 82 Wn. App. 480, 487, 918 P.2d 937 (1996).
Pulse v. Northwest Farm Bureau Ins. Co., 18 Wn. App. 59, 62, 566 P.2d 577 (1977). Accord PUD No. 1, 124 Wn.2d at 805; Twin City Fire Ins. Co. v. King County, 749 F. Supp. 230, 233 (W.D. Wash. 1990) (applying Washington law).
PUD No. 1, 124 Wn.2d at 805; see also Canron, 82 Wn. App. at 491-92.
42 Wn. App. 352, 711 P.2d 1066 (1985).
Felice, 42 Wn. App. at 360.