The Plastic Surgery Center, P.A. v. the Hanover Insurance Group, Inc. ( 2024 )

NOT FOR PUBLICATION WITHOUT THE
APPROVAL OF THE APPELLATE DIVISION
This opinion shall not "constitute precedent or be binding upon any court ." Although it is posted on the
internet, this opinion is binding only on the parties in the case and its use in other cases is limited. R. 1:36-3.
SUPERIOR COURT OF NEW JERSEY
APPELLATE DIVISION
DOCKET NO. A-3711-20
THE PLASTIC SURGERY
CENTER, P.A., JOT
MANAGEMENT, LLC, d/b/a
SYCAMORE MEDICAL
MANAGEMENT, and
THE WOODS O.R., INC.,
d/b/a THE SURGERY CENTER
FOR OUTPATIENT SURGERY,
Plaintiffs-Appellants,
v.
THE HANOVER INSURANCE
GROUP, INC., and
MASSACHUSETTS BAY
INSURANCE COMPANY,
MARSCHIL INSURANCE
AGENCY, INC., d/b/a
NORTHEAST INSURANCE
SERVICES,
Defendants-Respondents.
______________________________
Submitted January 19, 2023 – Decided January 12, 2024
Before Judges Accurso, Vernoia and Firko.
On appeal from the Superior Court of New Jersey, Law
Division, Monmouth County, Docket No. L-1874-20.
Maggs, McDermott & DiCicco, LLC, attorneys for
appellants (Michael M. DiCicco, of counsel and on the
briefs; Stephanie L. DeLuca, on the briefs).
Finazzo Cossolini O'Leary Meola & Hager, LLC,
attorneys for respondents The Hanover Insurance
Group, Inc., and Massachusetts Bay Insurance
Company (Jeremiah Lynn O'Leary, on the brief).
The opinion of the court was delivered by
VERNOIA, J.A.D.
Plaintiffs The Plastic Surgery Center, P.A. (TPSC), JOT Management
LLC d/b/a Sycamore Medical Management (Sycamore), and The Woods O.R.,
Inc. d/b/a The Center for Outpatient Surgery (TCOPS) (collectively,
"plaintiffs"), appeal from a Law Division order granting defendants', The
Hanover Insurance Group, Inc. (Hanover) and Massachusetts Bay Insurance
Company (Mass Bay) (collectively, "defendants"), motion for summary
judgment and dismissing plaintiffs' amended complaint with prejudice. 1 Based
on our de novo review of the record on appeal, we affirm.
I.
1
The amended complaint also included causes of action against Marschil
Insurance Agency, Inc., doing business as Northeast Insurance Services. Those
causes of action were dismissed by stipulation of the parties.
A-3711-20
2
We discern the following undisputed facts from the summary judgment
record and consider them in a light most favorable to plaintiffs because they are
the parties against whom summary judgment was entered. Brill v. Guardian Life
Ins. Co. of Am., 142 N.J. 520, 540 (1995).
TPSC is a medical practice specializing in plastic, reconstructive, and
cosmetic surgery. TCOPS is an ambulatory surgery center owned and operated
by TPSC. Sycamore is a management services organization that provides its
services to TPSC and TCOPS.
Hanover is a holding company and Mass Bay is an insurance company
licensed to do business in New Jersey. Mass Bay issued two successive annual
policies to plaintiffs (collectively, "the policy") in exchange for premium
payments. The policy covered the period March 8, 2019, to March 8, 2021.
Under the policy, Mass Bay agreed to indemnify plaintiffs for certain losses at
plaintiffs' thirty-seven insured properties in New Jersey and Pennsylvania under
separate Business Income, Extra Expense, and Civil Authority coverage
provisions.2
2
Although the policy insures plaintiffs' New Jersey and Pennsylvania
properties, the parties do not dispute that New Jersey law governs the
interpretation of the policy.
A-3711-20
3
The Business Income provision provides coverage for "the actual loss of
Business Income[,]" the insured sustained during a period of suspension of its
operations caused "by direct physical loss of or damage to a described premises
shown in the Declarations," where the "loss or damage" is "caused by or
resulting from any Covered Cause of Loss." The Extra Expense provision
provides coverage for "necessary Extra Expense[s]" plaintiffs incurred during a
period of restoration of their operations "due to direct physical loss of or
damage" to an insured premises "caused by or resulting from a Covered Cause
of Loss."
A "Covered Cause of Loss" under the policy includes "risks of direct
physical loss[,]" unless the claimed loss is otherwise excluded or limited by a
separate provision in the policy. For example, the policy explicitly excludes
coverage for loss or damage "caused directly or indirectly" by "[a]ny virus,
bacterium or other microorganism that induces or is capable of inducing
physical distress, illness or disease."
The Civil Authority coverage provision provides coverage for business
income loss and extra expense as follows:
(1) When a Covered Cause of Loss causes damage to
property other than property at the described premises,
[defendants] will pay for the actual loss of Business
Income [the insured] sustain[ed] and necessary Extra
A-3711-20
4
Expense caused by action of civil authority that
prohibits access to the described premises due to direct
physical loss of or damage to property within one mile
of the described premises, provided that both of the
following apply:
(a) Access to the area immediately surrounding
the damaged property is prohibited by civil authority as
a result of the damage, and the described premises are
within that area but are not more than one mile from the
damaged property;
(b) The action of civil authority is taken in
response to dangerous physical conditions resulting
from the damage or continuation of the Covered Cause
of Loss that caused the damage, or the action is taken
to enable a civil authority to have unimpeded access to
the damaged property.
Pertinent to this appeal, on March 9, 2020, Governor Phillip Murphy
issued Executive Order 103, declaring a public health emergency and state of
emergency in New Jersey in response to the COVID-19 pandemic.3 On March
21, 2020, Governor Murphy issued Executive Order 107, which required closure
of facilities where personal care services are performed including medical spas
at which solely elective and cosmetic procedures are performed. 4 On March 23,
2020, Governor Murphy issued Executive Order 109, which suspended all
3
Exec. Order No. 103 (Mar. 9, 2020), 52 N.J.R. 549(a) (Apr. 6, 2020).
4
Exec. Order No. 107 (Mar. 21, 2020), 52 N.J.R. 554(a) (Apr. 6, 2020).
A-3711-20
5
elective surgeries and invasive procedures performed on adults and cancelled or
postponed indefinitely all elective or invasive procedures already scheduled. 5
Similarly, Pennsylvania Governor Tom Wolf issued March 19 and March 23,
2020 executive orders requiring the closure of all non-life sustaining businesses
and effectively prohibiting Pennsylvania hospitals and surgical centers from
performing elective medical and surgical procedures.
In response to the executive orders, plaintiffs temporarily suspended
certain business operations—elective medical and surgical procedures—at their
various locations in New Jersey and Pennsylvania. More particularly, their
office and surgical encounters dropped from 2,870 and 941, respectively, in
January 2020, to 1,280 and 345, respectively, in April 2020. On March 24, 2021,
plaintiffs furloughed 116 employees due to a "slowdown in business" that they
attribute to the executive orders and COVID-19. By June 14, 2020, plaintiffs
had rehired the furloughed staff.
Plaintiffs filed suit against defendants, seeking a declaratory judgment
that they were entitled to coverage under the policy's Business Income, Extra
Expense, and Civil Authority provisions for losses allegedly sustained as a result
5
Exec. Order No. 109 (Mar. 23, 2020), 52 N.J.R. 827(a) (Apr. 20, 2020).
A-3711-20
6
of the presence of COVID-19 at their insured premises in New Jersey and
Pennsylvania and the restrictions on the operations at those premises under the
executive orders.
Defendants filed an answer denying plaintiffs' claimed entitlement to
coverage under the policy. Defendants' answer asserted affirmative defenses,
including: plaintiffs are not entitled to coverage under the Business Income and
Extra Expense provisions because plaintiffs did not suffer a direct physical loss
of or damage to covered property; the executive orders did not trigger coverage
under the Civil Authority provision; and any claimed coverage under the policy
is otherwise excluded under the virus exclusion.
Defendants later moved for summary judgment, arguing plaintiffs are not
entitled to relief as a matter of law because the policy does not provide coverage
for plaintiffs' alleged causes of loss. Defendants argued: plaintiffs had not
suffered a direct physical loss of or damage to their property such that they are
entitled to coverage under any of the policy's provisions; neither COVID-19 nor
the executive orders resulted in any direct physical loss of or damage to
plaintiffs' properties within the plain language of the policy; and plaintiffs'
alleged losses do not fall within the policy's provisions or are otherwise excluded
from coverage under the policy.
A-3711-20
7
Plaintiffs opposed the motion, arguing they established facts supporting
their entitlement to coverage under the Business Income, Extra Expense, and
Civil Authority provisions that is not barred by the virus exclusion. Plaintiffs
argued they had suffered a "physical loss" of the insured premises by virtue of
the presence of COVID-19 and as a result of the executive orders. Plaintiffs
also alleged they are otherwise entitled to coverage under the Civil Authority
provision because discovery would establish the presence of COVID-19 at the
properties, or within one mile of them, that resulted in direct physical loss of or
damage to the properties and required the closure or curtailment of plaintiffs'
operations. Plaintiffs also argued the virus exclusion in the policy is
unenforceable on the grounds of regulatory estoppel.
Following argument, the motion court found that under the policy's plain
language, there is coverage only for direct physical loss of or damage to the
insured premises under the policy's Business Income and Extra Expense
provisions, and plaintiffs had not sustained such damage or loss because
plaintiffs' business operations continued at their properties, with the limited
exception of elective surgical and medical procedures. The court further found
that even if plaintiffs could prove a direct physical loss of or damage to their
properties due to the presence of COVID-19 on their premises, the policy's plain
A-3711-20
8
language states there is no coverage under the virus exclusion. The court did
not expressly address plaintiffs' regulatory estoppel argument. The court
granted defendants' motion for summary judgment and dismissed plaintiffs'
complaint with prejudice. This appeal followed.
II.
Our review of an order granting a summary judgment motion is de novo.
Gilbert v. Stewart, 247 N.J. 421, 442 (2021) (citing Branch v. Cream-O-Land
Dairy, 244 N.J. 567, 582 (2021)). We apply the same standard as the trial court
and determine whether the record shows "no genuine issue as to any material
fact challenged and that the moving party is entitled to a judgment . . . as a
matter of law." Burnett v. Gloucester Cnty. Bd. of Chosen Freeholders, 409 N.J.
Super. 219, 228 (App. Div. 2009) (quoting R. 4:46-2(c)).
"An issue of material fact is 'genuine only if, considering the burden of
persuasion at trial, the evidence submitted by the parties on the motion, together
with all legitimate inferences therefrom favoring the non-moving party, would
require submission of the issue to the trier of fact.'" Grande v. St. Clare's Health
Sys., 230 N.J. 1, 24 (2017) (quoting R. 4:46-2(c)). To determine whether there
are genuine issues of material fact, we consider "whether the competent
evidential materials presented, when viewed in the light most favorable to the
A-3711-20
9
non-moving party, are sufficient to permit a rational factfinder to resolve the
alleged disputed issue in favor of the non-moving party." Davis v. Brickman
Landscaping, Ltd., 219 N.J. 395, 406 (2014) (quoting Brill, 142 N.J. at 540).
When "interpreting insurance contracts, we first examine the plain
language of the policy and, if the terms are clear, they 'are to be given their plain,
ordinary meaning.'" Pizzullo v. N.J. Mfrs. Ins. Co., 196 N.J. 251, 270 (2008)
(quoting Zacarias v. Allstate Ins. Co., 168 N.J. 590, 595 (2001)). The policy
must "be enforced as written when its terms are clear" so the "expectations of
the parties will be fulfilled." Flomerfelt v. Cardiello, 202 N.J. 432, 441 (2010)
(citations omitted).
We nevertheless recognize that insurance policies are generally
"contract[s] of adhesion between parties who are not equally situated." Oxford
Realty Grp. Cedar v. Travelers Excess & Surplus Lines Co., 229 N.J. 196, 215
(2017) (quoting Nav-Its, Inc. v. Selective Ins. Co. of Am., 183 N.J. 110, 118
(2005) (alteration in original)). Thus, where an insurance policy is ambiguous,
courts construe the terms in favor of the insured. MAC Prop. Grp. LLC v.
Selective Fire & Cas. Ins. Co., 473 N.J. Super. 1, 18 (App. Div.) (citation
omitted), certif. denied sub nom, MAC Prop. Grp. LLC v. Selective Fire & Cas.
Ins., Co., 252 N.J. 258 (2022).
A-3711-20
10
A genuine ambiguity arises when "'the phrasing of the policy is so
confusing that the average policyholder cannot make out the boundaries of
coverage,'" Birmingham v. Travelers N.J. Ins. Co., 475 N.J. Super. 246, 256
(App. Div. 2023) (quoting Weedo v. Stone-E-Brick, Inc., 81 N.J. 233, 247
(1979)), and "when 'the text appears overly technical or contains hidden pitfalls,
cannot be understood without employing subtle or legalistic distinction, is
obscured by fine print, or requires strenuous study to comprehend ,'" ibid.(quoting Zacarias, 168 N.J. at 601). The reasonable expectations of the parties
are of no moment where the terms of the policy are unambiguous. Oxford Realty
Grp. Cedar, 229 N.J. at 212; see also Cypress Point Condo. Ass'n v. Adria
Towers, L.L.C., 226 N.J. 403, 415 (2016) ("[w]hen the terms of an insurance
contract are clear, it is the function of a court to enforce it as written").
By extension, "[e]xclusions in insurance contracts 'are presumptively
valid and will be given effect if [they are] 'specific, plain, clear, prominent, and
not contrary to public policy.'" MAC Prop. Grp. LLC, 473 N.J. Super. at 35
(quoting Princeton Ins. Co. v. Chunmuang, 151 N.J. 80, 95 (1997)). "'The basic
notion [is] that the premium paid by the insured does not buy coverage for
all . . . damage but only for that type of damage provided for in the policy.'" Id.
at 19 (quoting Weedo, 81 N.J. at 237). Limitations on coverage "designed 'to
A-3711-20
11
restrict and shape the coverage otherwise afforded'" are therefore permissible.
Ibid. (quoting Hardy ex rel. Dowdell v. Abdul-Matin, 198 N.J. 95, 102 (2009)).
III.
We examine the pertinent provisions of the policy in accordance with the
above-mentioned principles. The Business Income provision obligated
defendants to compensate plaintiffs for actual loss of business income sustained
during a suspension of business operations where the suspension was caused by
direct physical loss of or damage to an insured premises resulting from a covered
loss. Under the Extra Expense provision, defendants are obligated to
compensate plaintiffs for necessary expenses incurred during the period of
restoration that resulted from a direct physical loss of or damage to an insured
premises.
Under the Civil Authority provision, defendants are obligated to
compensate plaintiffs for the loss of business income and necessary extra
expense caused by civil authority that prohibited access to an insured premises
as the result of the direct physical loss of or damage of other properties within
one mile of the insured premises resulting from a covered cause of loss at the
other properties. As noted, the policy excluded coverage for loss or damage
"caused directly or indirectly" by "[a]ny virus, bacterium or other
A-3711-20
12
microorganism that induces or is capable of inducing physical distress, illness
or disease."
On appeal, plaintiffs argue the motion court erred by granting summary
judgment because plaintiffs had demonstrated an entitlement to coverage under
the Business Income, Extra Expense, and Civil Authority provisions of the
policy and that they had sustained a Covered Cause of Loss under the policy. In
making their arguments, plaintiffs expressly acknowledge, in accordance with
the policy's plain language, that to establish an entitlement to coverage under
those provisions they are required to establish "a suspension of [their] business
operations . . . caused by direct physical loss of or damage to property at [the]
premises . . . or the issuance of a civil authority order." Plaintiffs claim the
presence of COVID-19, and the executive orders' prohibition against performing
elective procedures, resulted in the direct physical loss of or damage to the
property at their premises such that they are entitled to coverage. Plaintiffs also
argue the virus exclusion cannot be applied to exclude the coverage because the
court granted summary judgment prematurely—that is, before plaintiffs had an
opportunity to develop evidence supporting their claim the virus exclusion is
unenforceable under the doctrine of regulatory estoppel.
A-3711-20
13
In MAC Property Group LLC, we rejected virtually identical arguments—
regarding virtually identical policy provisions—as those asserted by plaintiffs
here. 473 N.J. Super 1. We interpreted an insurance policy that provided
business income loss coverage where the plaintiff had alleged it suffered losses
due to "direct physical loss of or damage to" covered property resulting in a
period of suspension of business operations during the period of restoration of
the property. Id. at 20. We held that business losses suffered as the result of
executive orders barring or curtailing the plaintiff's operations in response to the
COVID-19 pandemic did not constitute "direct physical loss of or damage to"
the insured property such as to permit or require coverage. Id. at 10. We
explained the phrase "direct physical loss of or damage to" property was neither
ambiguous nor "so confusing that the average policyholders . . . could not
understand that coverage extended only to instances where the insured property
has suffered a detrimental physical altercation of some kind, or there was a
physical loss of the insured property." Id. at 21-22.
As noted in MAC Property Group LLC, "scores of federal and state
appellate-level courts . . . have addressed" claims for coverage for losses due to
executive orders limiting or curtailing business operations due to the COVID -
19 pandemic under insurance policies providing coverage for "direct physical
A-3711-20
14
loss of or damage" to insured property, and the "overwhelming majority of them
have" dismissed the complaints "because the losses were not due to physical loss
or damage to their insured premises." Id. at 26-27; see also Verveine Corp. v.
Strathmore Ins. Co, 489 Mass. 534, 542 (2022) (noting that "[e]very appellate
court that has been asked to review COVID-19 insurance claims has agreed" that
"'direct physical loss of or damage to' property requires some 'distinct,
demonstrable, physical alteration of the property'"); see, e.g., Wilson v. USI Ins.
Serv. LLC, 57 F.4th 131, 142-43 (3d Cir. 2023) (applying New Jersey Law, and
finding COVID-19 executive orders limiting or curtailing operation of an
insured's business did not result in a "direct physical loss of or damage" to the
insured's property because the orders were not issued in response to physical
damage to the property and "[t]he propert[y] could certainly be used and
inhabited, just not in the way the business[] would have liked").
Applying what we determined was the plain and ordinary meaning of the
phrase "direct physical loss of or damage to property," we explained that because
New Jersey has "adopted a broad notion of the term 'physical[,]'" when the word
is paired with another word, e.g. "'physical injury,'" "the resulting term means a
'detrimental alteration[],' or 'damage or harm to the physical condition of a
thing,'" MAC Prop. Grp. LLC, 473 N.J. Super. at 20. We concluded the
A-3711-20
15
plaintiffs were not entitled to coverage because they had failed to show COVID-
19 physically damaged their equipment or property on the insured premises, or
that the presence of COVID-19 rendered the insured premises uninhabitable,
and therefore the plaintiffs failed to establish they suffered a direct physical loss
of or damage to their property under the plain and unambiguous language of the
policy. Id. at 23.
Here, plaintiffs' arguments fail for the same reasons we rejected the claims
in MAC Property Group LLC. The uncontroverted material facts establish
plaintiffs have not, and cannot, show they suffered any "direct physical loss or
damage" to their property such that they are entitled to coverage under the
Business Income, Extra Expense, or Civil Authority provisions of the policy. It
is undisputed the executive orders did not require that plaintiffs cease operations
completely, or render the insured premises uninhabitable, and instead they
resulted only in a curtailment of plaintiffs' normal business operations.
Plaintiffs claim they suffered a "physical loss" and damage because the
"physical presence of COVID-19" did not allow use of their businesses for
elective medical procedures for a finite duration. As we have explained, for
plaintiffs to be entitled to coverage under the policy language, "the loss itself
must be a 'direct physical' loss, clearly requiring a direct, physical deprivation
A-3711-20
16
of possession" and a partial curtailment of the of use of the premises "'without
any physical alteration [to the premises] to accompany it'" does not amount to
such. MAC Prop. Grp. LLC, 473 N.J. Super. at 26 (alteration in original)
(quoting Verveine Corp., 489 Mass. at 545); see also Wilson, 57 F.4th at 142-
43. Therefore, as a matter of law, plaintiffs are not entitled to coverage under
the Business Income or Extra Expense provisions of the policy because the
material facts do not reflect that their premises were directly, physically altered
such that they suffered a direct physical loss of or damage to their property
within the policy's plain language.
In MAC Property Group LLC, we also considered a claim for coverage
under a civil authority provision that is essentially identical to the provision at
issue here. 473 N.J. Super. at 27-30. We found no coverage under the provision
because it provided coverage where the civil authority "prohibited [the plaintiff
from] access to the insured premises," and we explained the Governor Murphy's
executive orders did not prohibit access to the insured premises but instead only
restricted business activities at the premises. Id. at 30. Thus, because the
plaintiff alleged that the executive orders only restricted its business activities,
and did not prohibit access to its insured premises, we did not find the civil
authority provision provided coverage. Ibid. So too here.
A-3711-20
17
In pertinent part, the Civil Authority provision in plaintiffs' policy
provides coverage where the exercise of civil authority "prohibits access to the
described premises due to direct physical loss of or damage to property within
one mile of the described premises." The undisputed facts establish the
executive orders did not impose such a prohibition and did not bar access to
plaintiffs' insured premises. Rather, the executive orders permitted access to
plaintiffs' insured premises and limited only the procedures that could be
performed following access. Moreover, there is no evidence the executive
orders were issued "due to direct physical loss of or damage to property within
one mile of the [plaintiffs' insured] premises" as is required for coverage under
the Civil Authority provision. Plaintiffs are therefore not entitled to coverage
under the Civil Authority provision of the policy.
We recognize plaintiffs' claim they were unable to complete their planned
discovery of information from the New Jersey Department of Banking and
Insurance concerning plaintiffs' addition of the virus exclusion to the policy.
Plaintiffs had sought the information under the Open Public Records Act,
N.J.S.A. 47:1A-1 to -13, and argue the requested information may have
supported their contention the virus exclusion is unenforceable under the
doctrine of regulatory estoppel. See MAC Prop. Grp. LLC, 473 N.J. Super. at
A-3711-20
18
33 (rejecting plaintiff's claim the doctrine of regulatory estoppel barred an
insurer carrier from enforcing a virus exclusion barring coverage for business
losses suffered as a result of COVID-19). We find it unnecessary to address
plaintiffs' contention summary judgment was awarded prematurely because it
was not afforded the opportunity to obtain the information, because plaintiffs
otherwise failed to present evidence establishing an entitlement to coverage
under the policy provisions under which they sought coverage. Stated
differently, we need not address the validity of the virus exclusion because
plaintiffs failed to demonstrate an entitlement to coverage in the first instance.
Plaintiffs' remaining arguments, to the extent we have not addressed them,
lack sufficient merit to warrant any further discussion in a written opinion. R.
2:11-3(e)(1)(E).
Affirmed.
A-3711-20
19