Omni Health Solutions, LLC v. Zurich American Insurance Company

CourtCourt of Appeals for the Eleventh Circuit
DecidedMay 21, 2021
Docket19-12406
StatusUnpublished

This text of Omni Health Solutions, LLC v. Zurich American Insurance Company (Omni Health Solutions, LLC v. Zurich American Insurance Company) is published on Counsel Stack Legal Research, covering Court of Appeals for the Eleventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Omni Health Solutions, LLC v. Zurich American Insurance Company, (11th Cir. 2021).

Opinion

USCA11 Case: 19-12406 Date Filed: 05/21/2021 Page: 1 of 41

[DO NOT PUBLISH]

IN THE UNITED STATES COURT OF APPEALS

FOR THE ELEVENTH CIRCUIT ________________________

No. 19-12406 ________________________

D.C. Docket No. 5:17-cv-00168-TES

OMNI HEALTH SOLUTIONS, LLC,

Plaintiff - Appellant,

versus

ZURICH AMERICAN INSURANCE COMPANY,

Defendant - Appellee.

________________________

Appeal from the United States District Court for the Middle District of Georgia ________________________

(May 21, 2021)

Before GRANT, MARCUS, and JULIE CARNES, Circuit Judges.

JULIE CARNES, Circuit Judge:

Plaintiff Omni Health Solutions, LLC, obtained a commercial property

insurance policy from Defendant Zurich American Insurance Company covering USCA11 Case: 19-12406 Date Filed: 05/21/2021 Page: 2 of 41

its medical building in Macon, Georgia (the “Policy”). In 2011, Plaintiff filed an

insurance claim with Defendant seeking coverage for a damaged and leaky roof.

Eventually, Defendant agreed that covered damage existed, but the parties were

unable to agree on a loss amount. Despite a multi-year appraisal process that

produced a binding award for structural damage and a binding award for business

income loss, the parties continue to dispute the amount of loss Defendant owes

Plaintiff.

Plaintiff filed this suit alleging that Defendant breached the Policy and acted

in bad faith by failing to make a timely coverage decision, underpaying the amount

awarded for structural damage, and refusing to compensate Plaintiff for the

diminished value of its property. The district court granted Defendant summary

judgment on all of Plaintiff’s claims. After careful review, and with the benefit of

oral argument, we affirm the district court’s grant of summary judgment on

Plaintiff’s claims seeking additional payments for structural damage and

diminished value, but reverse the grant of summary judgment on Plaintiff’s claims

that Defendant failed to make a timely coverage decision and acted in bad faith.

2 USCA11 Case: 19-12406 Date Filed: 05/21/2021 Page: 3 of 41

I. BACKGROUND 1

On February 15, 2011, Plaintiff filed a property insurance claim with

Defendant, reporting hail damage to the roof of its medical facility in Macon,

Georgia, and water intrusion. The Policy requires Defendant to give notice of its

intentions with respect to a claim within 30 days of receiving a sworn proof of loss.

1. Defendant’s Alleged Delay in Making a Coverage Decision

Shortly after Plaintiff reported its claim, Defendant sent one of its

representatives, Michael Ferunden, to inspect the roof. Plaintiff asserts that the

inspection did not occur because Ferunden was unable to access portions of the

roof. In any event, during the next few weeks, engineers hired by Plaintiff and

Defendant did inspect the roof. Defendant’s independent engineer, Raymond

Ramos, inspected the roof on March 10, 2011. Ramos prepared and delivered a

report to Defendant, concluding that the water intrusion on the facility occurred

because of wear and tear on an improperly installed and poorly maintained roof,

not because of hail. Plaintiff asserts that Defendant did not provide Plaintiff the

Ramos report, or any other document denying coverage, during the 30-day period

following the filing of Plaintiff’s claim. Rather, Plaintiff contends that Defendant

did not make a coverage decision until September 2011.2

1 Because this appeal arises from a grant of summary judgment to Defendant, we construe all facts in the light most favorable to Plaintiff. 2 Although Plaintiff continues to assert on appeal that Defendant did not make a coverage decision until September 2011, the district court, relying on Plaintiff’s response to Defendant’s 3 USCA11 Case: 19-12406 Date Filed: 05/21/2021 Page: 4 of 41

Plaintiff’s property suffered additional water damage in the summer of 2011,

which Plaintiff reported to Defendant. After re-inspecting the property in

September 2011, Ferunden determined that the condition of the roof had changed

since his initial inspection months earlier, and he concluded that the roof damage

was covered by the Policy.

2. An Appraisal Process Produces Two Binding Awards

Following Defendant’s acknowledgment of covered damage in September

2011, the parties entered protracted negotiations regarding the amount of Plaintiff’s

loss. Unable to reach agreement, on January 12, 2012, Plaintiff invoked Section

IV.B of the Policy and demanded an appraisal conducted by a three-member panel

consisting of two appraisers (one selected by each party) and an umpire (selected

by agreement of the two appraisers). Section IV.B of the Policy provides that

“[t]he appraisers will state separately the value of the property and amount of loss”

statement of undisputed fact, found that “it is undisputed that Defendant informed Plaintiff of its position on March 28, 2011.” Defendant stated in paragraph 8 of its undisputed facts that certain information from the Ramos report was communicated to Dr. Green, Plaintiff’s managing member, and that Defendant “reiterated its position that there was no covered damage to the roof on or about March 28, 2011.” Plaintiff disputed this statement but specifically controverted only the information contained in the Ramos report, stating “Ramos also referred to the lack of insulation.” In accordance with Local Rule 56, the district court deemed that Plaintiff admitted facts not specifically denied—meaning that Plaintiff admitted that Defendant had communicated to Dr. Green its position that there was no covered damage to the roof on or about March 28, 2011. Nevertheless, the alleged March 28 communication occurred more than 30 days after Plaintiff reported damage to Defendant. Thus, by itself, Plaintiff’s admission would not preclude a claim for breach of the Policy based on Defendant’s failure to make a timely coverage decision. 4 USCA11 Case: 19-12406 Date Filed: 05/21/2021 Page: 5 of 41

and, if they fail to agree, their differences will be submitted to the umpire and the

decision of any two of the three panel members will be binding.

The parties’ appraisers first worked to establish an award for structural

damage but were unable to agree on a loss amount. Plaintiff’s appraiser, Chris

Cole, valued the loss at approximately 1.1 million dollars and Defendant’s

appraiser, Robert Corley, valued the loss in the six-hundred-thousand dollar range.

Failing to reach an agreement, the two appraisers selected Michael Wasden as an

umpire. Wasden prepared his own estimate of Plaintiff’s loss amount for structural

damage.

Despite the contentious appraisal process, both parties’ appraisers joined

umpire Wasden in signing a structural damage award. The award issued on

October 8, 2012 and was based on the estimate prepared by umpire Wasden. The

structural damage award stated the “AMOUNT OF LOSS” as $886,795.57 in

replacement cost value (sometimes referred to as “RCV”) and $804,295.98 in

actual cash value (“ACV”).3 Without explanation, and in a separate location after

the signature block, the award also listed the specific figures for code

improvements ($115,116.43) and mold remediation ($222,307.92).

3 The difference between replacement cost value and actual cost value is the depreciation in the property attributable to the loss.

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