Omni Health Solutions, LLC v. Zurich American Insurance Company

Court of Appeals for the Eleventh Circuit·Decided May 21, 2021·No. 19-12406·Unpublished

Opinion

[DO NOT PUBLISH]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

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.

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

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.

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. The Policy obligated Defendant to pay Plaintiff the replacement cost value if Plaintiff chose to make repairs to the property or the actual cost value if Plaintiff chose not to repair the property.

Two months later, on December 14, 2012, the panel issued a business interruption award, fixing the amount of loss for business interruption at $322,455.61. This time, however, Plaintiff’s appraiser refused to sign the award. The award nonetheless appeared to be valid at the time because the Policy required only two signatures and both Defendant’s appraiser (Corley) and the umpire (Wasden) had signed the award, thereby meeting this requirement.

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

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