Universal American Corp. v. National Union Fire Insurance

38 Misc. 3d 859
CourtNew York Supreme Court
DecidedJanuary 7, 2013
StatusPublished
Cited by3 cases

This text of 38 Misc. 3d 859 (Universal American Corp. v. National Union Fire Insurance) is published on Counsel Stack Legal Research, covering New York Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Universal American Corp. v. National Union Fire Insurance, 38 Misc. 3d 859 (N.Y. Super. Ct. 2013).

Opinion

OPINION OF THE COURT

O. Peter Sherwood, J.

This is an insurance coverage action by plaintiff Universal American Corp. (Universal) in connection with a “Computer [860]*860Systems Fraud” insurance policy issued to plaintiff by defendant National Union Fire Insurance Company of Pittsburgh, PA (National Union). Universal moves, pursuant to CPLR 3212, for an order granting partial summary judgment and declaring that certain losses that Universal suffered from the entry of electronic data into its computer system are covered by the policy. National Union cross-moves for an order granting summary judgment dismissing the complaint. For the reasons stated below, the motion is denied, the cross motion is granted and the complaint is dismissed.

Factual Background

According to the complaint, Universal is a health insurance company which provides Medicare managed-care plans, Medicare prescription drug benefits and other insurance products. Universal’s offerings include “Medicare Advantage Private Fee-For-Service” plans (MA-PFFS), which are government-regulated alternatives to Medicare. Essentially, members enroll in health care plans offered by private insurers, which plans receive reimbursement payments from the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The plans also receive payments from plan members themselves. Under such plans, health care providers submit claims for services provided to plan members, similar to traditional health insurance policies. In Universal’s case, many of the claims are “auto-adjudicated” through Universal’s computer system, with payments rendered without any manual review.

Rider No. 3 to a financial institution bond issued to Universal by National Union on July 29, 2008, provided insurance coverage to Universal against a variety of losses. The rider is titled “Computer Systems Fraud” and provides indemnification for:

“Loss resulting directly from a fraudulent “(1) entry of Electronic Data or Computer Program into, or
“(2) change of Electronic Data or Computer Program within the Insured’s proprietary Computer System . . . provided that the entry or change causes
“(a) Property to be transferred, paid or delivered,
“(b) an account of the Insured, or of its customer, to be added, deleted, debited or credited, or “(c) an unauthorized account or a fictitious account to be debited or credited.”

[861]*861The term “Computer Program” was defined as “related electronic instructions which direct the operations and functions of a computer . . . which enable the computer ... to receive, process, store or send Electronic Data.” The term “Electronic Data” was defined as “facts or information converted to a form usable in a Computer System by Computer Programs, and which is stored on magnetic tapes or disks, or optical storage disks or other bulk media.”

The rider has a policy limit of $10 million with a $250,000 deductible for each “single loss.” The rider provided that a series of losses arising from the fraudulent acts of one individual, or of several unidentified individuals using the same method of operation, would constitute a single loss under the policy.

Universal states that, in late 2008, it suffered approximately $18,321,296 in losses from fraudulent claims made against its MA-PFFS plans. Most of these claims were submitted, by providers, directly into Universal’s computer system and processed through the system. In some cases, the perpetrators enrolled new members in the MA-PFFS plan with the person’s cooperation, in return for which the member received a kickback from the provider. In some cases, the provider used the member’s personal information without that person’s knowledge. In either event, the provider itself did not enroll in the plan. Instead, they were able to submit claims after obtaining a National Provider Identifier (NPI) from CMS. In some cases, the NPI was obtained for a fictitious provider, in other cases it was fraudulently taken from a legitimate provider.

Universal states that approximately 80% of the losses at issue resulted from claims submitted to its computer system. In February of 2009, it submitted a proof of loss to National Union. That claim was eventually denied. In June of 2010, Universal commenced this action, asserting claims for breach of contract and for a declaratory judgment stating that its losses are covered by the policy and are not subject to any exclusions. Plaintiff alleges losses of $7,764,211, after the application of the deductible.

Discussion

A party moving for summary judgment is required to make a prima facie showing that it is entitled to judgment as a matter of law, by providing sufficient evidence to eliminate any material issues of fact from the case (see Winegrad v New York Univ. [862]*862Med. Ctr., 64 NY2d 851 [1985]; Grob v Kings Realty Assoc., 4 AD3d 394 [2d Dept 2004]). The party opposing must then demonstrate the existence of a factual issue requiring a trial of the action (see Zuckerman v City of New York, 49 NY2d 557, 562 [1980]).

The central issue here is the meaning of the clause which states that Universal shall be indemnified for “[l]oss resulting directly from a fraudulent . . . entry of Electronic Data . . . into [Universal’s] proprietary Computer System.” Universal contends that this clause covers the entry of fraudulent information, e.g. fraudulent claims, even by an authorized user such as a provider with a valid NPI. National Union argues that this clause in rider No. 3 does not cover such data. Instead, it argues that the policy provides coverage against computer hackers, i.e., situations in which an unauthorized user accessed the system and caused money to be paid out. In reply, Universal argues that, if the clause is ambiguous, then the court must construe it against National Union as the drafter, and determine that there is coverage (see Gould Invs., L.P. v Travelers Cas. & Sur. Co. of Am., 83 AD3d 660, 661 [2d Dept 2011]).

Interpretation of the provisions of contracts, including insurance policies, is a matter of law for the court, including interpreting whether a given term is ambiguous (see Ashwood Capital, Inc. v OTG Mgt., Inc., 99 AD3d 1, 7-8 [1st Dept 2012]; Seaport Park Condominium v Greater N.Y. Mut. Ins. Co., 39 AD3d 51, 54 [1st Dept 2007]). “[T]he terms of an insurance contract are not ambiguous merely because the parties interpret them differently” (Board of Mgrs. of Yardarm Condominium II v Federal Ins. Co., 247 AD2d 499, 500 [2d Dept 1998], citing Mount Vernon Fire Ins. Co. v Creative Hous., 88 NY2d 347, 352 [1996]). “In determining whether a policy provision is ambiguous, the focus is on the reasonable expectations of the average insured upon reading the policy” (Villanueva v Preferred Mut. Ins. Co., 48 AD3d 1015, 1016 [3d Dept 2008] [citations and internal quotation marks omitted]).

The parties have not cited to any New York cases interpreting the clause at issue here, i.e., “loss resulting directly from a fraudulent . . . entry of electronic data” into Universal’s computer system. In support of its motion, plaintiff relies on the decision in Owens, Schine & Nicola, P.C. v Travelers Cas. and Sur. Co. of Am. (2010 WL 4226958, 2010 Conn Super LEXIS 2386 [2010]).

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Related

Universal American Corp. v. National Union Fire Insurance
37 N.E.3d 78 (New York Court of Appeals, 2015)
Universal American Corp. v. National Union Fire Insurance
110 A.D.3d 434 (Appellate Division of the Supreme Court of New York, 2013)

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Bluebook (online)
38 Misc. 3d 859, Counsel Stack Legal Research, https://law.counselstack.com/opinion/universal-american-corp-v-national-union-fire-insurance-nysupct-2013.