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.
(c) 2024 Barry Zalma & ClaimSchool, Inc.
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Insurer Must Pay Damages Caused by its Insureds Negligence
Post number 5273
Read the full article at https://www.linkedin.com/pulse/defendant-started-fire-bed-liable-ensuing-damage-zalma-esq-cfe-ngjcc, see the video at and at and at https://zalma.com/blog plus more than 5250 posts.
Smoking in Bed Can be Very Expensive
In Spires Of Sherwood Owner, LLC v. Jackie Baker, Joseph Baker And First American Property & Casualty Insurance Company, No. 2025 CA 0541, Court of Appeals of Louisiana, First Circuit (January 24, 2026) Spires of Sherwood Owner, LLC owned the Spires of Sherwood Apartments and sued Jackie Baker, Joseph Baker, and First American Property & Casualty Insurance Company following a fire that occurred on June 19, 2019, in the Bakers’ apartment.
The fire caused damage to multiple units. Investigations by both parties concluded that the fire originated in Joseph Baker’s bedroom and ...
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Insurance Policy Exclusions Must be Enforced as Written
Post number 5272
Pollution With a State Permit is Still Excluded
In Griffith Foods International, Inc., et al. v. National Union Fire Insurance Company Of Pittsburgh, Pa, No. 131710, Supreme Court of Illinois, 2026 IL 131710 (January 23, 2026) Griffith Foods International, Inc., and its successor Sterigenics U.S., LLC, operated a medical-equipment sterilization facility in Willowbrook, Illinois. Local residents alleged that for over 35 years, the facility emitted ethylene oxide (EtO), which they claimed caused cancer and other serious illnesses.
The policyholders sought a declaration that National Union Fire Insurance Company of Pittsburgh, PA, was obligated to defend them in the underlying mass tort litigation, based on two CGL policies issued for the facility between September 1983 and September 1985.
The two policies required the ...
Coverage is Available for Bicycle Rentals not Excluded
Post number 5271
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The Insurance Contract Never Indicated that Coverage was Limited to Activities Specifically Described
In Mollie R. Lerner v. Bela LLC d/b/a The Perch Hotel, et al., CIVIL No. 25-1546 (FAB), United States District Court, D. Puerto Rico (January 21, 2026) Plaintiff Mollie R. Lerner, a North Carolina resident visiting Puerto Rico, rented a bicycle from The Perch Hotel while staying at a nearby Airbnb. While riding the bicycle back, she encountered a steep hill and, upon attempting to brake, was unable to slow down. She lost control, fell over the handlebars, and was subsequently struck by a truck, resulting in serious injuries.
ALLEGATIONS
Lerner alleged that her injuries were caused by the Hotel’s negligence in maintaining...
Declaratory Relief Available to an Insurer from USDC
Post number 5274
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Insurer Seeks Limitation of Liability of Child Killed by Foster Dogs
In the Cincinnati Specialty Underwriters Insurance Company, an Ohio corporation v. Dennis Murphy, as Personal Representative of the Wrongful Death Estate of Avery Colin Jackson-Dunphy, Deceased; Patrick Admiral Dunphy, an Individual; Danika Thompson, an Individual; and Animal Services Center Of The Messila Valley, a New Mexico limited Liability Company, No. CIV 24-1039 JB/JFR, United States District Court, D. New Mexico (January 23, 2026) resolved the issues raised about the court's jurisdiction.
Cincinnati Specialty Underwriters Insurance Company ...
Posted on January 26, 2026 by Barry Zalma
Insurance Fraud Should Not be a Retirement Plan
More from Excellence in Claims Handling Substack for Subscribers Only
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Health Insurance Providers Are Attempting Insurance Fraud to Fund Retirement
Every insurer is required by its shareholders, members, state statutes and state regulations to do everything possible to deter and defeat attempts at insurance fraud. Most insurers, therefore, have a staff of fraud investigators working under their Special Investigative Unit (SIU) and the SIU works to train the claims handlers to recognize the indicators or red flags of fraud.
Much to the surprise of...
Posted on January 26, 2026 by Barry Zalma
Insurance Fraud Should Not be a Retirement Plan
More from Excellence in Claims Handling Substack for Subscribers Only
You’re reading, until you reach the paywall, from the free part of Excellence in Claims Handling until you reach the paywall. You should consider joining as a paid member to get full access to articles for members only, to our news, analysis, insurance coverage, claims, insurance fraud and insurance webinars, by clicking at the “subscribe” button below.
Health Insurance Providers Are Attempting Insurance Fraud to Fund Retirement
Every insurer is required by its shareholders, members, state statutes and state regulations to do everything possible to deter and defeat attempts at insurance fraud. Most insurers, therefore, have a staff of fraud investigators working under their Special Investigative Unit (SIU) and the SIU works to train the claims handlers to recognize the indicators or red flags of fraud.
Much to the surprise ...
