Never Lie or Conceal Potential Claims From Insurer
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Post 4823
Plaintiff CMGK, LLC, doing business as Massage Envy, appealed from an order granting summary-judgment to defendant Certain Underwriters at Lloyd’s, London Subscribing to Policy Number ME10XXXX, and dismissing with prejudice plaintiff’s claims. Plaintiff sought coverage under a Sexual Acts Liability Endorsement of a claims-made-and-reported policy issued by Lloyd’s to plaintiff. The court found plaintiff was not entitled to coverage and granted the motion.
In CMGK, LLC d/b/a Massage Envy v. Certain Underwriters At Lloyd’s, London Subscribing To Policy Number ME10XXXX, No. A-1836-22, Superior Court of New Jersey, Appellate Division (June 13, 2024) the appeal was considered based on the facts established by the motions.
FACTS
CMGK operated a Massage Envy Spa franchise located in Mays Landing. Emad Gus Khalifa was the sole member of plaintiff and was familiar with its operations. In 2013, plaintiff hired April Pippin as a general manager to assist Khalifa with the day-to-day management of the facility. Pippin and Khalifa performed management functions for plaintiff.
The Application for Insurance
Khalifa executed on behalf of plaintiff an application for the policy at issue. “This Claims Made policy applies only to those claims arising from covered incidents which occur on or after the stated retroactive date. In addition, the claim must first be made and reported to the company during the policy period or applicable extended reporting period.” (Emphasis in the policy).
The Policy
Defendant issued its Specified Medical Professions Professional Liability Insurance Policy to plaintiff for the policy period March 9, 2018, to March 9, 2019, and subject to a Retroactive Date of March 9, 2014. The policy included a Sexual Acts Liability Endorsement.
The Sexual Acts Liability Endorsement. Prior to the effective date of the policy, the Insured represented that it had no knowledge of a Sexual Act or any fact, circumstance, situation or incident involving a Sexual Act which may result in a Claim under this policy.
In 2016, plaintiff hired Steffon Davis as a massage therapist. According to plaintiff’s client M.N., Davis sexually assaulted her during a massage he performed on her on September 23, 2017. Two days later, M.N. reported the alleged assault to Pippin. On September 26, 2017, M.N. went to the Township of Hamilton police station and told a police officer about the incident. According to the officer, M.N. told her “[Davis had] placed his finger between her vagina lips and cupped her breast during a massage.”
M.N. eventually sued. On September 5, 2018, plaintiff tendered the suit to defendant for coverage who refused to defend or indemnify the Plaintiff who sued Lloyd’s claiming Lloyd’s had breached the policy and seeking a judgment declaring M.N.’s claims fell within the coverage provided by Lloyd’s.
Finding the language of the prior-knowledge clause to be “clear and unambiguous,” the trial court rejected plaintiff’s attempt to interpret it in a manner where an honest belief in the futility of a claim negates actual knowledge of allegations of wrongdoing. The court found the police decision not to file criminal charges does not support a reasonable belief that M.N. would not file a civil lawsuit.
Khalifa’s assumption or hope, purportedly based on the officer’s decision not to file a criminal complaint or M.N.’s decision not to file a civil complaint sooner, that M.N. wouldn’t file a claim is not enough to defeat summary judgment. Adopting plaintiff’s interpretation of the policy language would have the effect of rendering meaningless the prior-knowledge clause. To avoid the application of the clause, an insured could simply assert it did not believe – in the face of all evidence to the contrary – a claim might be filed.
The reasonableness of excluding claims based on prior conduct that the insured could reasonably have foreseen might serve as the basis for a future claim was apparent to the appellate court as it would be to anyone involved in the business of insurance. The Appellate Division, therefore, affirmed the order granting defendant’s summary-judgment motion.
ZALMA OPINION
An application for insurance is a request to an insurer to make an offer of insurance. The insurer relies on the good faith of the proposed insured to accurately respond to all the inquires including any information available to the insured at the time the application is presented, of any acts that could result in a claim. Such an act, sexual abuse of a customer by a massage therapist, known to the insured but not yet grown into an actual suit must be disclosed to allow the insurer to make a well reasoned decision to offer to insure the proposed insured.
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Foolish to Repeatedly Disobey Court Orders
All That Remains For Trial Is Plaintiff’s Damages On Each Of These Claims And Establishing Proximate Causation Of Those Damages.
Post number 5348
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In Linh Wang v. Esurance Insurance Company, No. C24-0447-JCC, United States District Court, W.D. Washington, Seattle (May 1, 2026) John C. Coughenour, United States District Judge, found that throughout this case, culminating with its briefing on Plaintiff’s renewed motion and that Defendant has subjected Plaintiff to unnecessary motion practice for clearly discoverable information and made dubious representations (including to the Court).
FACTUAL BACKGROUND
This case involves an underinsured/uninsured motorist insurance bad faith claim arising from a 2017 motor vehicle collision. The plaintiff, Linh Wang, alleges that Esurance Insurance ...
The Right to Negotiate with Insurer is Not an Assignment of Claims
Post number 5347
Read the full article at https://www.linkedin.com/pulse/ambiguous-contract-repair-assignment-barry-zalma-esq-cfe-2xppc, see the full video at https://rumble.com/v79is1s-ambiguous-contract-to-repair-not-an-assignment.html and at and at https://zalma.com/blog plus more than 5300 posts.
Nebraska Requires an Actual Assignment to Allow Contractor to Sue Insurer
In Millard Gutter Company, a corporation doing business as Millard Roofing and Gutter v. Farmers Mutual Insurance Company of Nebraska, also known as Farmers Mutual Insurance, also known as Farmers Mutual, No. A-24-818, Court of Appeals of Nebraska (May 5, 2026) Millard sued Farmers as an assignee of Jane Anzalone who had hired Millard Gutter to repair the roof of her home and agreed to allow Millard Gutter to coordinate with her insurer, Farmers Mutual, concerning reimbursement for repairs authorized under her insurance policy.
FACTUAL BACKGROUND
In ...
Attempt to Withdraw Plea After Sentencing Fails
Post number 5346
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Stealing from Insurers and Employer Gets Defendant Five Years in Prison
In State of Wisconsin v. Jacquelyn R. Harris, No. 2025AP489-CR, Court of Appeals of Wisconsin (April 22, 2026) Harris pled no contest and was found guilty. She was sentenced to five years of initial confinement and three years of extended supervision, with restitution ordered in the amounts of $31,086 to Kaliber and $25,000 to Erie Insurance Company.
FACTUAL BACKGROUND
In late 2022, Jacquelyn R. Harris was charged with theft in a business setting under WIS. STAT. § 943.20(1)(b) (2023-24). Harris, while employed as the office manager for Kaliber Collision Repair in Port ...
Plaintiff May Try Again to get a Judgment
Posted on May 22, 2026 by Barry Zalma
Just Because a Defendant Defaults Evidence is Needed to get a Judgment
Even on a Default Motion the Plaintiff Must Do More Than Rely on Conclusory Allegations.
Post number 5356
The Commissioners Of The State Insurance Fund v. Capcon Construction Industries Corp., Capcon Construction Supply Corp., Jab Masonry Corp., Agra Masonry Inc., Agra Industries Usa Corp, A & A Masonry Corp., Alexander Shvartsberg, Darren Caputo, Maryann Furman, Index No. 452680/2024, MOTION SEQ. No. 003, 2026 NY Slip Op 31767(U), Supreme Court, New York County (April 20, 2026)
FACTS
The Commissioners of the State Insurance Fund (SIF) had already obtained two judgments for unpaid workers’ compensation insurance premiums: one against A\&A Masonry Corp. and another, much larger one, against Agra Masonry Inc. SIF then brought this action against several related corporations and individuals, alleging that they all operated as a single de facto enterprise and that assets had ...
Defaulting Fraud Perpetrator Lets Insurer Defeat Fraud
Post number 5355
Posted on May 21, 2026 by Barry Zalma
In Transamerica Life Insurance Company v. John Joseph Egan, et al., No. 25-cv-06167-JD, United States District Court, N.D. California (May 12, 2026) Transamerica Life Insurance Company issued John Egan a life insurance policy with a long-term care rider that covered in-home skilled nursing or other professional care if he qualified as chronically ill.
FACTUAL BACKGROUND
In 2023, Egan submitted a claim alleging severe pain, major loss of daily functioning, and limited mobility following an auto accident. Transamerica approved coverage and paid benefits based on those representations and repeated proofs of loss describing in-home care services. After later surveillance in 2024 and 2025 showed Egan working, driving, shopping, and otherwise functioning without visible impairment — and showed no evidence of in-home care — Transamerica concluded that the claim was fraudulent and filed suit.
Transamerica surveilled ...
Defaulting Fraud Perpetrator Lets Insurer Defeat Fraud
Post number 5355
Posted on May 21, 2026 by Barry Zalma
In Transamerica Life Insurance Company v. John Joseph Egan, et al., No. 25-cv-06167-JD, United States District Court, N.D. California (May 12, 2026) Transamerica Life Insurance Company issued John Egan a life insurance policy with a long-term care rider that covered in-home skilled nursing or other professional care if he qualified as chronically ill.
FACTUAL BACKGROUND
In 2023, Egan submitted a claim alleging severe pain, major loss of daily functioning, and limited mobility following an auto accident. Transamerica approved coverage and paid benefits based on those representations and repeated proofs of loss describing in-home care services. After later surveillance in 2024 and 2025 showed Egan working, driving, shopping, and otherwise functioning without visible impairment — and showed no evidence of in-home care — Transamerica concluded that the claim was fraudulent and filed suit.
Transamerica surveilled ...
