Case Study America Insured

In the event that Amica elects to deny coverage on the ground that the insured failed to make an election with regard to her PIP coverage, it is conceivable that the insured would argue that Amica waived or is estopped from asserting the failure to make an election as a policy defense. Based on the facts available at this juncture, it seems unlikely that the insured would be successful in proving that the doctrines of waiver or estoppel applied in order to preclude Amica from relying on its policy defense. In the event that this case proceeded to litigation, it is possible that the Insured could allege a set of facts sufficient to survive a motion to dismiss that it was induced to refrain from an activity that prejudiced it in its litigation
v. Max Wolman Co., 388 F. Supp. 729, 731 (D.D.C. 1975), an insured purchased a policy of insurance from an agent to insure its twenty-three restaurants. Id. at 731. One of the restaurants opened in January of 1972. About half a month after the restaurant opened, it was destroyed in a fire. Id. The insurer immediately paid the property claim. Id. Thereafter, the insured presented a business income claim. Id. Upon receiving the business income claim, the insurer denied coverage on the basis that the destroyed restaurant was not a covered property when the policy was last negotiated in November of the year prior. Id. Likewise, the insured never submitted a proof of loss in support of its
It is likely that if PIP coverage is denied, the insured will contend that Amica either waived its defense to coverage or that Amica is estopped from asserting a defense to coverage on those grounds. As to the estoppel argument, the insured was provided notice on October 7, 2016, of her obligation to elect PIP coverage within sixty (60) days. Those sixty days expired in December of 2016. Up to that point, the insured had failed to elect to receive PIP coverage. Therefore, on December 7, 2016, D.C. Code § 31-2405(g) was triggered and the tortfeasor’s mandatory third-party liability insurance was the only insurance available to the insured. Notwithstanding the fact that Amica would pay the insured $6,102.85 months later, that payment did not induce the insured the insured to act in any way to her detriment because the deadline to pursue PIP coverage had already long expired. Moreover, the issue of payment to the insured did not impair her ability to pursue a third-party liability claim. Finally, the issue of payment alone in a first-party claim—especially when the insured possesses coverage for medical payments—is insufficient to constitute a