Professional Health Care Services Exclusion Effective
Post 5073
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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 (CGL) Policy to NMBJI, which includes a Professional Health Care Services exclusion that limits coverage for claims related to medical treatment.
Allegations Against NMBJI:
Dorsey alleges he suffered injuries due to medical negligence by NMBJI providers, leading to a lawsuit that includes multiple claims such as medical negligence and intentional infliction of emotional distress.
Exclusionary Clauses:
Travelers argues that the claims made by Dorsey fall under exclusions in the CGL Policy, thus asserting there is no duty to defend NMBJI.
Court’s Legal Standard:
New Mexico law states that an insurer must defend its insured if the allegations in the complaint could potentially be covered by the policy.
Ruling on Claims:
The court found that the claims related to medical negligence and other allegations arise from professional health care services, which are excluded from coverage under the policy.
No Duty to Indemnify:
Since Travelers had no duty to defend the claims, it also had no obligation to indemnify NMBJI for any potential damages arising from the state lawsuit.
LEGAL STANDARD
New Mexico substantive law governs the issue of whether Travelers has a duty to defend the CGL Policy insureds. To determine whether an insurance company must defend an insured client against a lawsuit, courts compare the factual allegations in the complaint with the insurance policy.
If the claimant’s complaint alleges facts potentially within the coverage of the policy, then the insurer has an obligation to defend its insured. This is true even though the complaint fails to state facts with sufficient clarity so that it may be determined from its face whether or not the action is within the coverage of the policy, provided the alleged facts tend to show an occurrence within the coverage.
Exclusionary clauses in insurance contracts must be narrowly construed.
Travelers Has No Duty To Indemnify.
If the allegations of the complaint clearly fall outside the provisions of the policy, neither defense nor indemnity is required. Because the Magistrate recommend finding that Travelers does not owe “the broader duty to defend in the underlying” state lawsuit, he further recommended finding that Travelers had no duty to indemnify the CGL Policy Insureds for the state claims either.
ZALMA OPINION
I am often confused by people and their lawyers try to turn an exclusion into an insuring agreement. Their arguments are creative and often brilliant, as were the arguments in this case. However, the Magistrate Judge simply read the clear and unambiguous exclusion and applied it to the facts and found that the CGL simply provided no coverage for defense or indemnity to the podiatrists for their medical malpractice and the bodily injuries caused to the plaintiffs because of the Professional Health Care Services exclusion in the Travelers policy.
(c) 2025 Barry Zalma & ClaimSchool, Inc.
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False Report of Theft of Vehicle Established
Post 5090
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Creating a Fake Theft of Vehicle and Insurance Claim is a Crime
Shonda Brown faced multiple charges, including felonies related to false reporting and insurance fraud changed to class A misdemeanors such as tampering with public records and making false statements.
The case arose from allegations that Brown paid an informant to move her inoperable vehicle and then reported it stolen to the NYPD, despite evidence suggesting the vehicle had been tampered with and was found in a damaged state.
In The People of the State of New York v. Shonda Brown, Index No. CR-024423-24KN, 2025 NY Slip Op 25122, Criminal Court of the City of New York, Kings County (May 23, 2025) the Criminal Court concluded that the charges were appropriately filed and rejected Brown’s motion to dismiss.
Sufficiency of the Accusatory Instrument
The ...
Notice of Claim Later than 60 Days After Expiration is Too Late
Post 5089
Injury at Massage Causes Suit Against Therapist
Read the full article at https://lnkd.in/gziRzFV8, see the full video at https://lnkd.in/gF4aYrQ2 and at https://lnkd.in/gqShuGs9, and at https://zalma.com/blog plus more than 5050 posts.
Hiscox Insurance Company (“Hiscox”) moved the USDC to Dismiss a suit for failure to state a claim because the insured reported its claim more than 60 days after expiration of the policy.
In Mluxe Williamsburg, LLC v. Hiscox Insurance Company, Inc., et al., No. 4:25-cv-00002, United States District Court, E.D. Missouri, Eastern Division (May 22, 2025) the trial court’s judgment was affirmed.
FACTUAL BACKGROUND
Plaintiff, the operator of a massage spa franchise, entered into a commercial insurance agreement with Hiscox that provided liability insurance coverage from July 25, 2019, to July 25, 2020. On or about June 03, 2019, a customer alleged that one of Plaintiff’s employees engaged in tortious ...
ZIFL – Volume 29, Issue 11
The Source for the Insurance Fraud Professional
Posted on June 2, 2025 by Barry Zalma
Post 5087
See the full video at and at
Read the full article and the full issue of ZIFL June 1, 2025 at https://zalma.com/blog/wp-content/uploads/2025/05/ZIFL-06-01-2025.pdf
Zalma’s Insurance Fraud Letter – June 1, 2025
See the full video at https://lnkd.in/gw-Hgww9 and at https://lnkd.in/gF8QAq4d, and at https://zalma.com/blog plus more than 5050 posts.
ZIFL – Volume 29, Issue 11
The Source for the Insurance Fraud Professional
Read the full article and the full issue of ZIFL June 1, 2025 at https://lnkd.in/gTWZUnnF
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 ...
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 ...
A Heads I Win, Tails You Lose Story
Post 5062
Posted on April 30, 2025 by Barry Zalma
"This is a Fictionalized True Crime Story of Insurance Fraud that explains why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is designed to help everyone to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the Perpetrators than any Other Crime."
Immigrant Criminals Attempt to Profit From Insurance Fraud
People who commit insurance fraud as a profession do so because it is easy. It requires no capital investment. The risk is low and the profits are high. The ease with which large amounts of money can be made from insurance fraud removes whatever moral hesitation might stop the perpetrator from committing the crime.
The temptation to do everything outside the law was the downfall of the brothers Karamazov. The brothers had escaped prison in the old Soviet Union by immigrating to the United...
Punitive Damages Must Be Added to Gross Income for Tax Purposes
See the full article at https://www.linkedin.com/pulse/punitive-damages-must-added-gross-income-tax-purposes-barry-n08yc and at https://zalma.com/blog plus subscribe at https://barryzalma.substack.com/subscribe.
This blog post is just a taste of the full article that is only available to subscribers to Excellence in Claims Handling. Anyone can subscribe to “Excellence in Claims Handling” at https://barryzalma.substack.com/subscribe for only $5 a month or $50 a year.
A TASTE OF EXCELLENCE IN CLAIMS HANDLING
The stated purpose of punitive damages is to punish a wrongdoer civilly to deter the wrongdoer and others from acting wrongfully. Insurance Bad Faith litigants dream of large punitive damage awards as a bonus and revenge upon the insurer that did not treat them fairly.
Punitive damages may be awarded where there is substantial harm and where there is none. [Restatement (First) of Torts § 908 cmt. c (Am. L. Inst. 1939); see also ...
