337 N.J.Super. 393,
767 A.2d 485 Superior Court of New
Jersey, Appellate Division. STATE FARM
INSURANCE COMPANY, Plaintiff-Respondent, v. Dr. Ulises C.
SABATO, as assignee of Carlos Naula, Hugo Naula and Wilmer Naula,
Defendants-Appellants. Submitted Nov. 28,
2000. Decided Feb. 6, 2001. [**485] [*393] COUNSEL: S. Gregory
Moscaritolo, attorney for appellants. Harwood Lloyd, attorneys for respondent (Curtis J. Turpan, of
counsel and on the brief). JUDGES: Before Judges CONLEY and LESEMANN. [*394] OPINION BY: LESEMANN, J.A.D. Defendant, assignee of Personal Injury Protection (PIP) claims of
three brothers, Carlos, Hugo and Wilmer Naula, who were injured in an
automobile accident, appeals from a Law Division judgment which dismissed the
claims of two of the brothers. The court rejected defendants request
to submit the claims to arbitration under N.J.S.A. 39:6A-5c. Instead, it
enjoined such arbitration and held a plenary hearing on the claims. It then
concluded that one of the brothers, Wilmer, had lied to the plaintiff insurer
respecting his Social Security number, and another, Carlos, had provided
information that was confusing and evasive. The court
therefore denied the claims of Wilmer and Carlos, although it allowed the claim
of the third brother, Hugo, who had not appeared for the examination at which
his two brothers allegedly provided misinformation. [FN1] FN1. The trial court determined the plaintiff
insurer was required to pay PIP benefits on behalf of Hugo (including bills
submitted by defendant Dr. Sabato for treatment of Hugo) and no one appeals
from that determination. Defendant does, however, appeal from the amount of
counsel fees awarded to him and to Hugos personal attorney respecting
Hugos claim, and that issue is discussed below. We agree with defendant that the court should have permitted the
claims to proceed to statutory arbitration, that the arbitrator in such a
proceeding is empowered to determine the issues of coverage and fraud which the
trial court improperly decided itself, and that the judgment on appeal should
therefore be reversed and the matter remanded for arbitration. As the facts appear at this early stage of the case, Wilmer Naula
was operating a vehicle owned by his father, Hector Naula, with Carlos and Hugo
as passengers, when the vehicle was involved in an accident and [**486] the three
brothers were injured. The three maintain that they live with their father,
that none of them owns an automobile of his own, and thus they are additional
insureds under Hectors policy with plaintiff State Farm Insurance
Company (State Farm). They say also that they were [*395] treated by Dr.
Ulises C. Sabato for their injuries, and Dr. Sabato then filed an application
for PIP benefits on behalf of the brothers and as assignee of their claims. When State Farm received those claims, it commenced an
investigation and, as part of that investigation, it scheduled an Examination
Under Oath (EUO) to depose the brothers and obtain information that the insurer
deemed relevant to the matter. Wilmer and Carlos appeared for the examination;
Hugo did not, and plaintiff made no further effort to obtain Hugos
appearance. Wilmer and Carlos speak little if any English, and, although a
translator was present, the transcript of the EUO is confusing and difficult to
follow. Such basic questions as Wilmers address and that of his
father produced what seems to be conflicting information. The same is true
respecting the nature and extent of Wilmers injury and his Social
Security status. Wilmer provided a number which he maintained was his Social
Security number, but that number could not be confirmed. He also said he did
not own a car, that he used the car owned by his father with whom he lived, and
that he did have a drivers license. Similar confusion characterized Carlos' examination. Carlos gave
confusing information as to where he lived. He said he did not own an
automobile, but he seemed to indicate that Wilmer had owned an automobile for
at least some time during the last few years. He also said he lived with his
father and used his fathers car. He had applied for Social Security
enrollment but had not yet received a number. Following the EUO, defendant filed a request for the statutory
arbitration called for by N.J.S.A. 39:6A-5c. State Farm, however, sought a
restraining order against the claimants' proceeding with that arbitration. The
trial court granted a temporary restraint, held a plenary hearing, and then
dismissed the claims of both Wilmer and Carlos. The court concluded that,
although illegal aliens can recover PIP benefits, Wilmer had knowingly lied to
State Farm respecting his Social Security status. It said the purpose of the
EUO was to enable the carrier to acquire knowledge [*396] and investigate
a claim, and therefore Wilmers lying to the carrier had the capacity
to influence State Farms investigation. Accordingly, the court held
that Wilmers claim, and that of Dr. Sabato which was based on Wilmers
claim, were barred. Similarly, the court found that Carlos' testimony was
confusing and his answers were evasive. In addition, since Carlos had
failed to appear at the scheduled plenary hearing, the court dismissed his
claim for lack of prosecution. However, since State Farm
had established no basis for dismissal of Hugos claim, the court
directed that State Farm must compensate Hugo (by payment to his assignee, Dr.
Sabato) pursuant to the normal schedule of PIP benefits. On appeal, defendant argues that the court erred in hearing and
resolving the brothers' claims rather than referring them to arbitration as
mandated by statute. State Farm answers by asserting that the court was
authorized to determine the threshold issue of whether there was PIP coverage
here, or whether the claimants were disqualified for fraud or some other
reason. However, we are satisfied that the defenses asserted by State Farm--be
they fraud or some other basis for alleged non coverage--should have been
resolved by an arbitrator. The statutorily mandated arbitration is not as
narrow and circumscribed as State Farm claims. The arbitration we deal with here is not simply a matter of
contract. Rather, it is [**487] mandated by statute. N.J.S.A. 39:6A-5c provides
that, [a]ll automobile insurers shall provide any claimant with the
option of submitting a dispute under this section to binding arbitration.
Arbitration proceedings shall be administered and subject to procedures
established by the American Arbitration Association. In State Farm
Mutual Auto. Ins. Co. v. Molino, 289 N.J.Super. 406, 410, 674 A.2d 189
(App.Div.1996), this court held that the language of that statute should be
read as broadly as the words themselves indicate, that statutory arbitrators
are authorized to determine both factual and legal issues, and that coverage
issues are to be decided by the arbitrator in the [*397] same manner as
issues dealing with the extent of injury and the amount of recovery.
Carriers should not be empowered to avoid arbitration simply by
characterizing PIP disputes as questions of entitlement or
coverage and then seeking judicial resolution of those
issues. Id. at 411, 674 A.2d 189. State Farm argues that the Law Division decision in Allstate
Ins. Co. v. Lopez, 311 N.J.Super. 660, 710 A.2d 1072 (Law Div.1998) authorizes a
trial court to stay arbitration while the court itself determines coverage
issues arising from allegations of fraud. However, Lopez involved what was
described as a massive insurance fraud ring. The court there concluded that in
order to avoid the unmanageable spectacle of innumerable individual arbitration
proceedings, all susceptible to varying and inconsistent results, judicial
economy as well as the entire controversy doctrine required resolution of all
claims in a single action, and thus arbitration was inappropriate. That
reasoning has no application here. We also note that if there is indeed an
inconsistency between Molino and Lopez, the trial court decision in Lopez must,
of course, give way to the appellate decision in Molino. In addition to the basic question of whether the trial court
should have heard and resolved this case at all, we find the courts
substantive conclusions troubling. We are not clear as to how, if at all, State
Farm claims it was prejudiced by misrepresentations respecting
Wilmers or Carlos Social Security numbers and/or status.
And the same is true concerning their alleged confusing and dissembling answers
to other questions. While an insurer certainly has the right to obtain
information to aid in its investigation of a claim, it is not clear what, if
anything, State Farm claims it was prevented from accomplishing or what a more
detailed investigation might have revealed. In any event, if State Farm alleges
it was prejudiced, or that it should have a right to disclaim coverage even
without a showing of prejudice, State Farm can certainly submit those
contentions to the arbitrator, and the arbitrator will be free to hear and
resolve them. But under the [*398] statutory scheme, it is the arbitrator
and not the court that must resolve those issues. Finally, we note that defendant also appeals from what he claims
is the inadequate size of the counsel fee awards respecting Hugos
successful claim: $3,500 to plaintiffs attorney for services
respecting Hugos claim; and $500 to Hugos personal
attorney. Plaintiff claims the trial court should have held a hearing before
fixing those amounts. However, both the trial court and State Farm note that in
fact the parties had reached an agreement on the amount of fees to be awarded
respecting Hugos claims, and those agreed upon amounts are the sums
embodied in the courts agreement. In view of that agreement there was
obviously no need for a hearing, and plaintiffs argument to the
contrary has no merit. The dismissal of the claims respecting Wilmer and Carlos Naula is
reversed, and the matter is remanded for arbitration pursuant to N.J.S.A.
39:6A-5c. The award of counsel fees respecting the claim of Hugo Naula is
affirmed. |