Another Material misrepresentation

Understanding Material Misrepresentation Defenses in No-Fault Insurance Cases

In a significant ruling that affects how insurance companies can defend against no-fault insurance claims on Long Island, the Appellate Term addressed the material misrepresentation defense in JFL Med. Care, P.C. v Wesco Ins. Co., 2022 NY Slip Op 51376(U)(App. Term 2d Dept. 2022). This case provides important guidance for both healthcare providers and patients dealing with insurance coverage disputes.

What is Material Misrepresentation in Insurance Law?

Material misrepresentation occurs when an applicant provides false or incomplete information during the insurance application process, and that information would have influenced the insurance company’s decision to issue coverage or determine premiums. In the context of no-fault insurance, this defense is commonly raised when carriers want to avoid paying claims by arguing that the policy was obtained through deception.

However, not every incorrect statement constitutes material misrepresentation. The information must be:

• False or misleading – The statement must be factually incorrect
• Made knowingly – The applicant must have known the information was false
• Material to the risk – The insurer must prove it wouldn’t have issued the policy if it knew the truth
• Relied upon – The insurance company must have actually relied on the false information

The JFL Med. Care Case: A Failed Defense Strategy

In this case, Wesco Insurance Company attempted to use the material misrepresentation defense to avoid paying no-fault benefits. The company alleged that the insured failed to disclose that the vehicle was used as a “for hire” livery vehicle, which they claimed was an excluded operation under their underwriting guidelines.

Why the Defense Failed

The court rejected Wesco’s material misrepresentation defense for several critical reasons that insurance companies and attorneys should carefully note. Most importantly, the insurance company failed to provide proper documentary evidence to support their claim.

As the court explained: “However, a misrepresentation is only material ‘if the insurer would not have issued the policy had it known the facts misrepresented’” (citing Interboro Ins. Co. v Fatmir, 89 AD3d 993, 994 ). The key failure was that “defendant failed to ‘present documentation concerning its underwriting practices, such as underwriting manuals, bulletins, or rules pertaining to similar risks, that show that it would not have issued the same policy if the correct information had been disclosed in the application.’”

The Preclusion Problem

Attorney Jason Tenenbaum notes a critical procedural issue that arose in this case: “The defense is subject to preclusion, which always makes me question the DJ’s that do not plead or prove timely disclaimers per claim.” This observation highlights a fundamental problem in how some insurance companies and their attorneys handle material misrepresentation defenses.

The court specifically stated: “The defense that an insured made a material misrepresentation when obtaining the insurance policy is subject to preclusion.” This means that if the insurance company doesn’t properly raise and prove this defense in a timely manner, they lose the right to use it altogether.

What This Means for Insurance Companies

Insurance companies must be extremely thorough when raising material misrepresentation defenses. Simply having an employee testify that they “don’t insure livery vehicles” is not enough. Companies must provide:

• Detailed underwriting manuals
• Internal bulletins and guidelines
• Documentation of consistent practices
• Evidence of how similar risks were handled
• Proof that disclosure would have changed their decision

What This Means for You

If You’re an Injured Party

When you’re injured in a motor vehicle accident on Long Island, it’s crucial to understand that insurance companies may try to avoid paying your rightful benefits by claiming you or your vehicle owner made material misrepresentations on the insurance application. However, as the JFL Med. Care case demonstrates, these defenses often fail when properly challenged.

Key protections for injured parties include:

• The burden is on the insurance company to prove materiality with documentary evidence
• Conclusory statements by insurance employees aren’t enough
• The defense can be precluded if not properly raised
• You have the right to challenge inadequate proof

If You’re a Healthcare Provider

Medical providers pursuing no-fault reimbursement should be aware that insurance companies may attempt to use material misrepresentation defenses to avoid paying legitimate claims. The JFL Med. Care decision provides strong precedent for challenging these defenses when they’re not properly supported by documentation.

When facing material misrepresentation defenses, providers should:

• Demand detailed underwriting documentation
• Challenge conclusory statements from insurance personnel
• Point out procedural failures in raising the defense
• Seek summary judgment when evidence is insufficient

The Burden of Proof: What Insurance Companies Must Show

The JFL Med. Care case reinforces that insurance companies cannot simply make vague claims about their underwriting practices. The court was clear that “conclusory statements by insurance company employees, unsupported by documentary evidence, are insufficient to establish materiality as a matter of law.”

Required Documentation

To successfully prove material misrepresentation, insurance companies must provide comprehensive evidence including:

Underwriting Guidelines: Detailed manuals showing specific exclusions and how applications are evaluated.

Consistent Practices: Evidence that the company consistently excludes the type of risk in question.

Decision-Making Process: Documentation showing how the specific misrepresentation would have affected the underwriting decision.

Comparative Analysis: Examples of similar applications that were denied due to the same type of disclosure.

Common Scenarios Where Material Misrepresentation is Claimed

Insurance companies frequently attempt to use material misrepresentation defenses in various scenarios:

Commercial Use of Vehicles

As in the JFL Med. Care case, insurers often claim that failure to disclose commercial use (delivery, rideshare, livery) constitutes material misrepresentation.

Driving History

Claims that applicants failed to disclose previous accidents, violations, or license suspensions.

Household Members

Allegations that policyholders failed to disclose all household members who might drive the vehicle.

Vehicle Modifications

Claims that undisclosed modifications to vehicles affect coverage.

Strategic Implications for Legal Professionals

The JFL Med. Care decision provides important strategic guidance for attorneys handling no-fault insurance disputes. The case demonstrates that aggressive discovery and motion practice can effectively challenge inadequate material misrepresentation defenses.

Discovery Strategies

When facing material misrepresentation defenses, attorneys should pursue comprehensive discovery including:

• All underwriting manuals and guidelines
• Internal communications about the specific application
• Training materials for underwriters
• Examples of similar applications and their outcomes
• Testimony from underwriting personnel with actual knowledge

Frequently Asked Questions About Material Misrepresentation

Can my insurance company cancel my policy for material misrepresentation?

Yes, but only if they can prove with proper documentation that the misrepresentation was material—meaning they wouldn’t have issued the policy if they knew the truth. Vague claims without supporting evidence are insufficient.

What happens if my no-fault benefits are denied due to alleged material misrepresentation?

You have the right to challenge this denial. The insurance company must provide detailed documentation of their underwriting practices and prove that your alleged misrepresentation actually affected their decision to issue coverage.

How long does an insurance company have to raise a material misrepresentation defense?

Material misrepresentation defenses are subject to preclusion rules, meaning they must be raised in a timely manner following proper legal procedures. Delays in asserting this defense can result in the insurance company losing the right to use it.

What constitutes adequate proof of materiality?

Insurance companies must provide documentary evidence such as underwriting manuals, bulletins, and consistent practices showing they would not have issued the same policy if the correct information had been disclosed. Employee testimony alone is insufficient.

Can I recover attorney fees if I successfully defend against a material misrepresentation claim?

In many cases, yes. New York’s no-fault law often allows for the recovery of attorney fees when insurance companies unsuccessfully assert defenses, particularly when those defenses are not supported by adequate evidence.

The Importance of Experienced Legal Representation

Material misrepresentation cases involve complex legal and factual issues that require experienced representation. As the JFL Med. Care case demonstrates, success often depends on thorough discovery, understanding of underwriting practices, and aggressive advocacy.

At the Law Office of Jason Tenenbaum, we have extensive experience challenging inadequate material misrepresentation defenses. We understand how insurance companies operate and what evidence is required to support their claims. Our approach includes:

• Comprehensive discovery to expose gaps in the insurer’s evidence
• Expert analysis of underwriting practices and industry standards
• Strategic motion practice to secure favorable rulings
• Aggressive advocacy for our clients’ rights

Don’t let insurance companies deny your rightful benefits based on unsupported claims of material misrepresentation. These cases require sophisticated legal analysis and aggressive advocacy to protect your interests.

If your no-fault insurance benefits have been denied due to alleged material misrepresentation on Long Island, you need experienced legal representation to fight for your rights. Call 516-750-0595 for a free consultation with an attorney who understands how to challenge these defenses and protect your interests.