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Progressive Not Liable for Medical Bills if Insured Refused to Cooperate

Auto insurer Progressive Insurance is not responsible for a hospital bill incurred by a Massachusetts insured who refused to cooperate with its efforts to investigate the accident claim that led to the medical expenses.

Mount Auburn Hospital claimed that Progressive was liable for $1,758.71 of expenses under the personal injury protection (PIP) coverage in the Massachusetts auto insurance policy it issued to Natalia Zapata. The hospital sued Progressive after its bill went unpaid for over three months. It alleged that Progressive’s handling of the claim violated the state’s insurance and consumer protection laws

 

Progressive defended as reasonable its efforts by mail, email and phone to contact its insured, Zapata, and Leonardo O’Campo, the other driver in the accident, to discuss the accident and potential coverage but neither cooperated. Its early efforts were unsuccessful but Progressive was eventually able to reach a lawyer to schedule an examination under oath only to be told neither driver would show up and neither did.

A District Court judge allowed Progressive’s motion for summary judgment, and a panel of the Appellate Division of the District Court affirmed. Now a Massachusetts Court of Appeals has again affirmed the view that an insurer has no obligation to settle a claim where liability is not reasonably clear.

The appeals court cited a Massachusetts law that clearly states “noncooperation of an injured party” shall be a defense to the insurer in any suit for benefits.

It also cited case law that an insured’s refusal to submit to a reasonable request for an examination under oath amounts to a material breach of the policy that releases the insurer from its obligation.

The hospital argued that Progressive’s actions were flawed and contributed to the insured not agreeing to an examination. The court acknowledged that Progressive’s initial efforts were far from perfect. The first correspondences to Zapata were mistakenly sent to a wrong address.

However, the court ultimately found that the hospital simply did not demonstrate that Progressive’s handling of a claim for which no coverage has been shown constituted a violation of state law.

 

According to an affidavit, between March 28, 2018, and May 17, 2018, Progressive tried to contact O’Campo twice by email, three times by letter, and eight times by phone. During the last phone attempt, O’Campo hung up.

The judges concluded that Progressive’s early contact efforts were still “extensive and prompt” even though they were unsuccessful. Also, Progressive’s second round of contacts reached O’Campo, and his failure to respond to Progressive indicated his own intent not to cooperate, which the court said provided Progressive an independent basis for disclaiming coverage.

The hospital also contended that Progressive waited too long to schedule an examination under oath — it was nine months after the accident and seven months after the insurer first saw the hospital bill. However, the court found that that was within the timeframes allowed in case law.

While the court did not decide the matter, it noted there was evidence suggesting that the two parties in the accident were members of the same household. The judges noted that “existence of such ready and available evidence underscores the legitimacy of Progressive’s desire to investigate before paying the PIP claim.”

 

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