VanHaaren v. State Farm Mut. Auto. Ins. Co.

• Decision Date: 05 March 1993
• Docket Number: No. 92-1667,92-1667
• Citation: 989 F.2d 1
• Parties: Dennis VANHAAREN, Plaintiff, Appellant, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant, Appellee.
• Court: U.S. Court of Appeals — First Circuit

Page 1

989 F.2d 1

Dennis VANHAAREN, Plaintiff, Appellant, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant, Appellee.

No. 92-1667.

United States Court of Appeals First Circuit.

March 5, 1993.

Francis M. Jackson, Portland, ME, for plaintiff, appellant.

Michael S. Wilson with whom Louise K. Thomas and Pierce, Atwood, Scribner, Allen, Smith & Lancaster, Portland, ME, were on brief, for defendant, appellee.

Before SELYA, Circuit Judge, HIGGINBOTHAM, ^* Senior Circuit Judge, and CYR, Circuit Judge.

CYR, Circuit Judge.

The district court determined that plaintiff Dennis VanHaaren had forfeited coverage under the uninsured motorist policy issued by defendant State Farm Mutual Automobile Insurance Company ("State Farm") by not complying with State Farm's requests that he submit to an independent medical examination ("IME"). The district court granted summary judgment in favor of State Farm, and VanHaaren appealed. We affirm.

I BACKGROUND

VanHaaren was involved in an automobile collision with an uninsured motorist on July 1, 1989. Alleging permanent back injury, VanHaaren soon exhausted the $5,000 medical payments coverage provided under his State Farm automobile insurance policy, and in March 1991 he submitted a $100,000 claim representing the full amount of the uninsured motorist coverage under the State Farm policy. The State Farm policy contained a provision ("IME clause") which required VanHaaren to submit to an "examin[ation] by physicians chosen and paid by [State Farm] as often as [State Farm] reasonably may require."

On April 8, and again on May 2, 1991, State Farm wrote VanHaaren's counsel requesting confirmation that VanHaaren was residing in Florida, so that an IME could be conducted in Florida. On May 17, VanHaaren's counsel advised State Farm that VanHaaren had relocated to North Carolina to take a job at a summer resort, and suggested that "a realistic approach to the case would be to allow [State Farm] to obtain an [IME] in the Ashville, North Carolina area and then to set up an arbitration or mediation." The State Farm representative responded, noting that the policy included On September 13, VanHaaren brought an action in Maine Superior Court, which State Farm promptly removed to federal district court. Counsel to State Farm wrote VanHaaren's counsel on December 16, requesting confirmation that VanHaaren would attend an IME scheduled for January 14, 1992, in Portland, Maine. One week later, VanHaaren's counsel declined to confirm VanHaaren's attendance at the IME, noting that he considered the usual diagnoses of the orthopedist chosen by State Farm too "conservative," inviting State Farm to propose other orthopedists, and inquiring why the IME could not be conducted in Florida where VanHaaren was again residing. Otherwise, VanHaaren's counsel suggested, State Farm "may bring a motion for an examination in the [district court]." On January 10, 1992, over VanHaaren's opposition, the presiding magistrate judge granted State Farm's motion to compel VanHaaren to attend the IME scheduled for January 14 in Portland. VanHaaren complied.

                an arbitration provision.   He requested that VanHaaren's counsel advise State Farm "where [VanHaaren] will be for a reasonable period of time so I may refer [sic] to the proper State Farm office to make [IME] arrangements."   It is conceded that VanHaaren's counsel did not respond to the latter request
                

In May 1992 the district court granted State Farm's motion for summary judgment on the ground that VanHaaren's conduct before and after filing suit constituted a breach of the IME clause, barring recovery under the uninsured motorist provision in the State Farm policy.

II DISCUSSION

A. Applicable State Law

We review a grant of summary judgment de novo, employing the same criteria incumbent upon the district court. Pedraza v. Shell Oil Co., 942 F.2d 48, 50 (1st Cir.1991), cert. denied, --- U.S. ----, 112 S.Ct. 993, 117 L.Ed.2d 154 (1992). Summary judgment is appropriate where the record, including the pleadings, depositions, answers to interrogatories, admissions on file, and affidavits, viewed in the light most favorable to the nonmoving party, reveals no genuine dispute as to any material fact and the moving party is entitled to judgment as a matter of law. See Fed.R.Civ.P. 56(c); Canal Ins. Co. v. Benner, 980 F.2d 23, 25 (1st Cir.1992).

Although the parties agree that Maine law informs the present determination as to the materiality of any fact in genuine dispute, see Blanchard v. Peerless Ins. Co., 958 F.2d 483, 485 (1st Cir.1992), the Maine Supreme Judicial Court has yet to address the pivotal issue presented by this appeal: what material facts must an insurer establish beyond genuine dispute to warrant summary judgment against a policy holder who breaches an IME clause? Absent controlling state court precedent, a federal court sitting in diversity may certify a state law issue to the state's highest court, or undertake its prediction "when the course [the] state courts would take is reasonably clear." Porter v. Nutter, 913 F.2d 37, 41 n. 4 (1st Cir.1990) (quoting Bi-Rite Enters., Inc. v. Bruce Miner Co., 757 F.2d 440, 443 n. 3 (1st Cir.1985)). See also American Waste & Pollution Control Co. v. Browning-Ferris, Inc., 949 F.2d 1384, 1386 (5th Cir.1991); S & R Metals, Inc. v. C. Itoh & Co., 859 F.2d 814, 816 (9th Cir.1988). The prognostic chore is reasonably straightforward in the instant case.

State Farm argues that Maine law would follow established contract law principles, permitting the insurer to avoid all liability under its insurance contract where the policy holder commits an anticipatory breach of a condition precedent to coverage by "refusing" to submit to an IME, irrespective of any prejudice to the insurer. In our view, its assessment is less than prescient.

In Ouellette v. Maine Bonding & Cas. Co., 495 A.2d 1232 (Me.1985), the Maine Supreme Judicial Court, sitting as the Law Court, explicitly "abandon[ed] the analysis of a negotiated contract," under which an insurer's performance would be State Farm endeavors to forfend against the portent of the Ouellette decision on the ground that the "prejudice" issue was not preserved in the district court. State Farm correctly points out that VanHaaren neither cited to the Ouellette decision nor argued to the district court that Maine law would require proof of prejudice. Although the district court acknowledged the significance of Ouellette, it expressly bypassed the issue since VanHaaren had neither contended that State Farm was required to show "prejudice" under Maine law, nor argued that prejudice had not been established. Although loathe to conclude that VanHaaren waived the "prejudice" issue, we do so in light of the district court's pellucid determination that VanHaaren had made no claim that State Farm was either required to demonstrate

                excused on the bare showing that the insured breached a condition precedent to coverage by inexcusably delaying notification of the policy claim for four years.  Id. at 1235.   Rather, the Law Court held that the insurer must prove "that the notice provision was in fact breached, and ... that the insurer was prejudiced by the insured's delay."  Id. (emphasis added).  Ouellette brought Maine law in line with the growing majority of jurisdictions which acknowledge that a post-occurrence forfeiture of insurance coverage is rarely to be invoked, absent actual prejudice to the insurer, because (1) insurance policies are contracts of adhesion, (2) the insured has prepaid the premiums for coverage, and (3) insurance coverage furthers broader public policy aims.   See, e.g., St. Paul Fire & Marine Ins. Co. v. Petzold, 418 F.2d 303, 305 (1st Cir.1969) (applying New Hampshire law to "notice of claim" provision);  Johnson Controls, Inc. v. Bowes, 381 Mass. 278, 282-83, 409 N.E.2d 185, 188 (1980) ("notice of claim" provision);  cf. Piro v. Pekin Ins. Co., 162 Ill.App.3d 225, 113 Ill.Dec. 220, 223, 514 N.E.2d 1231, 1234 (1987) ("Declaring forfeiture of the benefits of [fire] insurance bought and paid for based solely on events occurring subsequent to the event of the insured-against loss should be avoided.").   As Maine law plainly requires a showing of prejudice for "notice of claim" violations, we can discern no sound reason to anticipate a less stringent requirement for breach of an IME clause in an uninsured motorist policy.   Cf. Bankers Ins. Co. v. Macias, 475 So.2d 1216, 1217-18 (Fla.1985) (breach of "notice of claim" provision raises rebuttable presumption of prejudice to insurer, whereas breach of "cooperation clause" in policy raises no presumption but requires showing by insurer that breach was material and caused substantial prejudice). 1
                prejudice or failed to do so. 2  In these circumstances, VanHaaren's failure to move for reconsideration of the district court order should not be excused.   See Boston Celtics Ltd. Partnership v. Shaw, 908 F.2d 1041, 1045 (1st Cir.1990);  Brown v. Trustees of Boston Univ., 891 F.2d 337, 357 (1st Cir.1989), cert. denied, 496 U.S. 937, 110 S.Ct. 3217, 110 L.Ed.2d 664 (1990)
                

B. Breach of IME Clause

VanHaaren nevertheless contends that State Farm failed to establish beyond reasonable disputation the other essential element of its defense--that he breached the IME clause by "refusing" to comply with State Farm's reasonable IME requests.

As a general rule, whether there was substantial compliance with a condition precedent in an insurance contract is a question of fact ill-suited to disposition on summary judgment. See, e.g., Piro, 514 N.E.2d at 1234 (noting that whether the insured provided necessary information "too late" normally is a question for the factfinder). Under Maine law, even if the insurer suffers appreciable prejudice from the breach, the insured may still quell the insurer's affirmative defense by proffering a valid excuse or justification for the failure or refusal to comply. See Ouellette, 495...