Never Lie or Conceal Potential Claims From Insurer
Read the full article at https://lnkd.in/gJkzeXBc, shttps://lnkd.in/gJkzeXBc and at https://zalma.com/blog plus more than 4800 posts.
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.
(c) 2024 Barry Zalma & ClaimSchool, Inc.
Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos.
Subscribe to my substack at https://barryzalma.substack.com/subscribe, & Subscribe to my substack at https://lnkd.in/gmmzUVBy.
Go to X @bzalma; Go to Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg.
Go to X @bzalma; Go to the Insurance Claims Library – https://lnkd.in/gwEYk
Coverage for Fraud Encourages Crime
Post 5166
Posted on August 12, 2025 by Barry Zalma
See the full video at and at
Tandem Fund II, L.P. (“Tandem”) a venture capital firm, provided loans to Cuff, Inc. (“Cuff”), a startup company. Cuff failed as a business, and Tandem was never repaid on the loans. Tandem assigned the loans to Bijoux Corp. (“Bijoux”), which then initiated arbitration against Cuff and its CEO, Deepa Sood, for intentional misrepresentation and fraudulent concealment. The arbitration panel ruled in favor of Bijoux, awarding damages against Cuff and Sood.
In Tandem Fund II, L.P. v. Scottsdale Insurance Company, No. 23-16187, United States Court of Appeals, Ninth Circuit (August 4, 2025) Scottsdale argued that the award was uninsurable under California law, which prohibits insurance coverage for restitution of wrongfully acquired funds. The district court agreed with ...
Interrelated Acts Constitute a Single Claim
Post 5165
See the full video at https://lnkd.in/geriBpJT and at https://lnkd.in/gJxi77kg and at https://zalma.com/blog plus more than 5150 posts.
In Yonah Rothman v. Complete Packaging & Shipping Supplies, Inc. and Mitchell Mankosa, Complete Packaging & Shipping Supplies, Inc. v. Arch Insurance Company, No. 22-CV-2821-SJB-ST, United States District Court, E.D. New York (August 4, 2025) dealt with the issue of parties seeking a partial judgment to be resolved on appeal.
Complete Packaging & Shipping Supplies, Inc. (“Complete”) and Arch Insurance Company (“Arch”) litigated disputes about coverage in relation to the Rothman employment discrimination action.
THE KEY ISSUES
Background:
Yonah Rothman filed a lawsuit against Complete and Mitchell Mankosa, alleging employment discrimination, underpayment, and wrongful termination. Rothman claims he was retaliated against for participating in a separate lawsuit brought by another employee.
Insurance Coverage Dispute:
Complete ...
Interrelated Acts Constitute a Single Claim
Post 5165
See the full video at https://lnkd.in/geriBpJT and at https://lnkd.in/gJxi77kg and at https://zalma.com/blog plus more than 5150 posts.
In Yonah Rothman v. Complete Packaging & Shipping Supplies, Inc. and Mitchell Mankosa, Complete Packaging & Shipping Supplies, Inc. v. Arch Insurance Company, No. 22-CV-2821-SJB-ST, United States District Court, E.D. New York (August 4, 2025) dealt with the issue of parties seeking a partial judgment to be resolved on appeal.
Complete Packaging & Shipping Supplies, Inc. (“Complete”) and Arch Insurance Company (“Arch”) litigated disputes about coverage in relation to the Rothman employment discrimination action.
THE KEY ISSUES
Background:
Yonah Rothman filed a lawsuit against Complete and Mitchell Mankosa, alleging employment discrimination, underpayment, and wrongful termination. Rothman claims he was retaliated against for participating in a separate lawsuit brought by another employee.
Insurance Coverage Dispute:
Complete ...
Rulings on Motions Reduced the Issues to be Presented at Trial
Read the full article at https://lnkd.in/gwJKZnCP and at https://zalma/blog plus more than 5100 posts.
CASE OVERVIEW
In Richard Bernier v. State Farm Mutual Automobile Insurance Company, No. 4:24-cv-00002-GMS, USDC, D. Alaska (May 28, 2025) Richard Bernier made claim under the underinsured motorist (UIM) coverage provided in his State Farm policy, was not satisfied with State Farm's offer and sued. Both parties tried to win by filing motions for summary judgment.
FACTS
Bernier was involved in an auto accident on November 18, 2020, and sought the maximum available UIM coverage under his policy, which was $50,000. State Farm initially offered him $31,342.36, which did not include prejudgment interest or attorney fees.
Prior to trial Bernier had three remaining claims against State Farm:
1. negligent and reckless claims handling;
2. violation of covenant of good faith and fair dealing; and
3. award of punitive damages.
Both Bernier and State Farm dispositive motions before ...
ZIFL Volume 29, Issue 10
The Source for the Insurance Fraud Professional
See the full video at https://lnkd.in/gK_P4-BK and at https://lnkd.in/g2Q7BHBu, and at https://zalma.com/blog and at https://lnkd.in/gjyMWHff.
Zalma’s Insurance Fraud Letter (ZIFL) continues its 29th year of publication dedicated to those involved in reducing the effect of insurance fraud. ZIFL is published 24 times a year by ClaimSchool and is written by Barry Zalma. It is provided FREE to anyone who visits the site at http://zalma.com/zalmas-insurance-fraud-letter-2/ You can read the full issue of the May 15, 2025 issue at http://zalma.com/blog/wp-content/uploads/2025/05/ZIFL-05-15-2025.pdf
This issue contains the following articles about insurance fraud:
Health Care Fraud Trial Results in Murder for Hire of Witness
To Avoid Conviction for Insurance Fraud Defendants Murder Witness
In United States of America v. Louis Age, Jr.; Stanton Guillory; Louis Age, III; Ronald Wilson, Jr., No. 22-30656, United States Court of Appeals, Fifth Circuit (April 25, 2025) the Fifth Circuit dealt with the ...
Professional Health Care Services Exclusion Effective
Post 5073
See the full video at https://lnkd.in/g-f6Tjm5 and at https://lnkd.in/gx3agRzi, and at https://zalma.com/blog plus more than 5050 posts.
This opinion is the recommendation of a Magistrate Judge to the District Court Judge and involves Travelers Casualty Insurance Company and its duty to defend the New Mexico Bone and Joint Institute (NMBJI) and its physicians in a medical negligence lawsuit brought by Tervon Dorsey.
In Travelers Casualty Insurance Company Of America v. New Mexico Bone And Joint Institute, P.C.; American Foundation Of Lower Extremity Surgery And Research, Inc., a New Mexico Corporation; Riley Rampton, DPM; Loren K. Spencer, DPM; Tervon Dorsey, individually; Kimberly Dorsey, individually; and Kate Ferlic as Guardian Ad Litem for K.D. and J.D., minors, No. 2:24-cv-0027 MV/DLM, United States District Court, D. New Mexico (May 8, 2025) the Magistrate Judge Recommended:
Insurance Coverage Dispute:
Travelers issued a Commercial General Liability ...
