United States District Court, W.D. Pennsylvania
MEMORANDUM OPINION AND ORDER
PATRICIA L. DODGE UNITED STATES MAGISTRATE JUDGE.
Plaintiff
Kirsti Loughery brings this action against Defendant
Mid-Century Insurance Co. ("Mid-Century"), arising
out of Mid-Century's handling of her claim for first
party income loss benefits following a motor vehicle accident
which occurred on October 24, 2016.
The
Complaint, which was originally filed in the Court of Common
Pleas of Beaver County and then removed to this Court,
alleges four causes of action against Mid-Century. In Count
I, Plaintiff alleges that Mid-Century breached the terms of
the insurance policy. Count II asserts that Mid-Century
breached the duty of good faith and fair dealing and in Count
III, Plaintiff claims that Mid-Century engaged in bad faith
in violation of 42 Pa.C.SA § 8371. Finally, Count IV
asserts a claim for violation of the Unfair Trade Practices
and Consumer Protection Law, 73 P.S. §§ 201-1 to
201-9.3 ("UTPCPL").
On
April 19, 2019, Mid-Century filed a partial motion to dismiss
(ECF No. 4), in which it contends that Counts II, III and IV
of the Complaint should be dismissed. Its motion has been
fully briefed and is ripe for adjudication. For the reasons
that follow, Mid-Century's motion will be granted with
respect to Count IV of the Complaint and denied with respect
to Counts II and III.
I.
Relevant Factual Background
Plaintiff
purchased an automobile policy from Mid-Century[1] which has
first-party income loss benefits of $2, 500.00 per month and
$50, 000.00 aggregate. According to Plaintiff, she paid an
additional premium for the income loss benefits. (Compl.
¶¶ 5-8.)[2] On October 24, 2016, Plaintiffs vehicle
was struck from behind in a violent collision with a third
party and she suffered serious and permanent injuries.
(Compl. ¶¶ 9, 10.) The third party accepted
liability for the accident and paid its policy limits.
(Compl. ¶ 11.) At the time of the accident, Plaintiff
owned and operated a home cleaning/maid service known as Maid
in the USA, which cleaned both residential and commercial
properties. She was the sole employee and her duties were
very physical, requiring lifting, movements overhead,
carrying objects and activities associated with heavy
cleaning. (Compl. ¶¶ 9-14.)
Because
of the injuries she sustained in the accident, Plaintiff was
required to undergo extensive medical treatment, including
surgery. As a result, she missed several weeks of work and
submitted lost benefit claims which were paid by Mid-Century.
(Compl. ¶¶ 15-19.) In addition to medical
authorizations, wage loss information, disability slips and
other documents, Plaintiff submitted medical narrative
reports from Dr. DeChellis and Dr. Myers, who rendered
opinions that her continued work at Maid in the USA would
aggravate the injuries sustained in the automobile accident.
(Compl. ¶¶ 21, 22.) Plaintiff also provided
Mid-Century with a disability slip from Dr. DeChellis.
(Compl. ¶ 23.)
According
to the Complaint, however, when Plaintiff filed a timely
claim with Mid-Century's claim handler, Jeffrey Silfies,
for income loss benefits after she closed her business on
September 1, 2018, Mid-Century did not pay her claim. Rather,
it informed her that it was scheduling a physical examination
with Dr. James C. Craig, Jr. and directed her to bring all
x-rays, MRIs and medical records and to fill out a medical
history and social history questionnaire. (Compl.
¶¶ 20-28 & Exs. 1-3.)
After
being asked by Plaintiffs counsel the purpose of the exam,
Mr. Silfies responded in a letter dated November 20, 2018
that the purpose was to determine her disability for income
loss benefits, stating "The policy states: a person
claiming any coverage under this policy must also as required
by Pennsylvania law, submit to physical examination at our
expense by doctors we select as often as we may reasonably
require." (Compl. ¶¶ 29-30 & Exs. 4-5.)
Plaintiffs counsel responded by again furnishing the reports
of Drs. DeChellis and Myers in support of her inability to
return to her previous job with Maid in the USA. In a
subsequent letter, counsel explained to Mr. Silfies that,
under Pennsylvania law, an insured is only required to submit
to a physical examination after "good cause is
shown" and because Mid-Century had not provided good
cause or obtained a court order, Plaintiff would not be
submitting to a physical exam. (Compl. ¶¶ 31-32
& Exs. 6-7.) On November 30, 2018, counsel also sent to
Mr. Silfies Plaintiffs tax information for the years 2016 and
2017, information that had previously been requested and sent
on several occasions. (Compl. ¶ 33 & Ex. 8.)
On
December 5, 2018, Mr. Silfies indicated that he had received
counsel's letters but was awaiting some undefined
additional information regarding Plaintiffs income loss
claim. (Compl. ¶ 34 & Ex. 9.) When subsequently
asked what additional information was required, Mr. Silfies
replied that Mid-Century was requesting an examination under
oath. Plaintiff was again asked to provide her tax returns as
well as a number of other documents, which she did, and the
examination under oath eventually took place at the office of
Defendant's counsel on February 5, 2019. (Compl.
¶¶ 35-44 & Exs. 10-16.)
Plaintiff
alleges that Mid-Century intentionally and without legal
justification attempted to schedule a medical examination
when it knew or should have known that she was not required
to submit to such an examination without a court order based
on good cause shown. She also claims that Mid-Century has a
well-established business relationship with Dr. Craig and
that the sole purpose of scheduling the exam was to
"fashion[] a reason to delay or deny Plaintiffs claim
for income loss benefits." (Compl. ¶¶ 50-51.)
As of
the date of the filing of the Complaint in February of 2019,
Mid-Century had not provided Plaintiff with a decision
regarding the payment of her income loss benefits. (Compl.
¶ 45.) Plaintiff contends that Mid-Century's failure
to provide her with a decision as to her claim for income
loss benefits constitutes a bad faith denial of the claim
without a reasonable basis. (Compl. ¶¶ 46-49.)
According
to the Complaint, Plaintiff has been without income loss
benefits since her last day of work on January 1, 2018, has
sustained a loss of needed income and has incurred past and
ongoing legal costs, fees and expenses associated with the
attempt to obtain the benefits. (Compl. ¶¶ 55-57.)
II.
Standard of Review
"Under
Rule 12(b)(6), a motion to dismiss may be granted only if,
accepting all well-pleaded allegations in the complaint as
true and viewing them in the light most favorable to the
plaintiff, a court finds that plaintiffs claims lack facial
plausibility." Warren Gen. Hosp. v. Amgen Inc.,
643 F.3d 77, 84 (3d Cir. 2011) (citing Bell Atl. Corp. v.
Twombly, 550 U.S. 544, 555-56 (2007)). "This
requires a plaintiff to plead "sufficient factual matter
to show that the claim is facially plausible," thus
enabling "the court to draw the reasonable inference
that the defendant is liable for misconduct alleged."
Id. (quoting Fowler v. UPMC Shadyside, 578
F.3d 203, 210 (3d Cir. 2009)). While the complaint "does
not need detailed factual allegations ... a formulaic
recitation of the elements of a cause of action will not
do." Twombly, 550 U.S. at 555. See also
Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (citing
Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570
(2007)).
The
Court of Appeals has summarized the inquiry as follows:
To determine the sufficiency of a complaint, a court must
take three steps. First, the court must "tak[e] note of
the elements a plaintiff must plead to state a claim."
Ashcroft v. Iqbal, 556 U.S. 662, 129 S.Ct. 1937,
1947, 173 L.Ed.2d 868 (2009). Second, the court should
identify allegations that, "because they are no more
than conclusions, are not entitled to the assumption of
truth." Id. at 1950. Third, "whe[n] there
are well-pleaded factual allegations, a court should assume
their veracity and then determine whether they plausibly give
rise to an entitlement for relief." Id. This
means that our inquiry is normally broken into three parts:
(1) identifying the elements of the claim, (2) reviewing the
complaint to strike conclusory allegations, and then (3)
looking at the well-pleaded components of the complaint and
evaluating whether all of the elements identified in part one
of the inquiry are sufficiently alleged.
Malleus v. George, 641 F.3d 560, 563 (3d Cir. 2011).
The
Court of Appeals has explained that: "In deciding a Rule
12(b)(6) motion, a court must consider only the complaint,
exhibits attached to the complaint, matters of public record,
as well as undisputedly authentic documents if the
complainant's claims are based upon these
documents." Mayer v. Belichick,605 F.3d 223,
230 (3d Cir. 2010) (citation omitted). Therefore, the Court
can consider the Complaint and the exhibits ...