Court Opinion

ID: 9942812
Source: CourtListenerOpinion
Date Created: 2024-02-21 21:08:39.167529+00
Date Added: 2024-06-11T13:44:43.000828
License: Public Domain

State Farm Mut. Auto. Ins. Co. v Gaspard
               2024 NY Slip Op 30503(U)
                    February 16, 2024
           Supreme Court, New York County
        Docket Number: Index No. 159311-2022
                  Judge: Lynn R. Kotler
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  FILED: NEW YORK COUNTY CLERK 02/16/2024 03:42 PM                                                   INDEX NO. 159311/2022
  NYSCEF DOC. NO. 220                                                                        RECEIVED NYSCEF: 02/16/2024

                      SUPREME COURT OF THE STATE OF NEW YORK
                                  NEW YORK COUNTY
            PRESENT: HON.LYNN R. KOTLER, J.S.C.                                              PART~

            State Farm Mutual Automobile Insurance Company                                   INDEX NO. 159311-2022

                                                                                             MOT.DATE

                                                                                             MOT. SEQ. NO. 002
            Nasia Gaspard, et. al.

            The following papers were read on this motion to/for _summ==ary=.......,-=ju=-dgm;o==e=nt~---------
            Notice ofMotion/Petition/O.S.C. -Affidavits- Exhibits                    NYSCEF DOC No(s). 135-203
            Notice of Cross-Motion/Answering Affidavits - Exhibits                   NYSCEF DOC No(s). 204-218
            Replying Affidavits                                                      NYSCEF DOC No(s). 219

                 In this action, plaintiff-insurer seeks a declaration that it does not have an obligation to pay no-fault
            benefits in connection with a motor vehicle accident. Jhe accident allegedly occurred on March 16,
            2022 in Stamford, Connecticut. There is no police report. Plaintiff State Farm Mutual Automobile Insur-
            ance Company ("State Farm") now moves for summary judgment against the answering provider de-
            fendants 101 RX Pharmacy Inc., All City Family Healthcare Center Inc., Park Avenue Medical Imaging,
            P.C., Tri-Borough NY Medical Practice, P.C., Eden Ortho Supply LTD, Gotham Supply Group Inc., Ad-
            vantage Radiology, P.C., NYC Discount Pharmacy, Inc., RVA Leasing Corp., and Queens Cognitive Be-
            havioral Therapy Psychology, PLLC (together the" motion defendants") pursuant to CPLR § 3212.
            State Farm also seeks a declaration that: 1) it has no duty to pay the no-fault benefits in connection
            with the March 16, 2022 motor vehicle accident; 2) the original motion defendants lack standing to seek
            or receive no-fault reimbursement for any bill submitted; 3) that the alleged motor vehicle accident was
            not the product of a covered event because it was the product of a staged and/or intentional event; 4)
            State Farm does not need to pay out any money associated with the alleged accident since it was
            staged and/or intentional.

                 In a stipulation dated October 24, 2023, State Farm discontinued the matter as to Eden Ortho Sup-
            ply LTD and Gotham Supply Group Inc. Therefore, the motion is denied as moot as to these two de-
            fendants. The motion continues as to the remaining motion defendants. The motion is opposed by de-
            fendants All City Family Healthcare Center Inc., Park Avenue Medical Imaging, P.C., and Tri-Borough
            NY Medical Practice, P.C. (together the "opposing defendants"). Issue has been joined as to the motion
            defendants and note of issue has not yet been filed. Therefore, this motion was timely brought, and
            summary judgment relief is available.

                · On a motion for summary judgment, the proponent bears the initial burden of setting forth eviden-
            tiary facts to prove a prima facie case that would entitle it to judgment in its favor, without the need for a
            trial (CPLR 3212; Winegrad v. NYU Medical Center, 64 NY2d 851 [1985]; Zuckerman v. City of New
            York, 49 NY2d 557, 562 [19801). "Once this showing has been made, the burde[" to the

            Dated:       -z....l t IA l-i,j                                                                       ·
                          ~                                                       HON. LYNN R. KOTLER, J.S.C.

            1. Check one:                        ~ CASE DISPOSED              O NON-FINAL DISPOSITION
            2. Check as appropriate: Motion is   '1,GRANTED □ DENIED □ GRANTED IN PART □ OTHER
                                                                         r
                                                             ,t'\,!)6He.,,
            3. Check if appropriate:             ig§ETTLE--6lffin □ SUBMIT ORDER □ DO NOT POST

                                                 □ FIDUCIARY APPOINTMENT □ REFERENCE

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  FILED: NEW YORK COUNTY CLERK 02/16/2024 03:42 PM                                               INDEX NO. 159311/2022
  NYSCEF DOC. NO. 220                                                                    RECEIVED NYSCEF: 02/16/2024

            nonmoving party to produce evidentiary proof in admissible form sufficient to establish the existence of
            material issues of fact that require a trial for resolution" ( Giuffrida v. Citibank Corp., 100 NY2d 72
            (2003]). If the proponent fails to make out its prima facie case for summary judgment, however, then its
            motion must be denied, regardless of the sufficiency of the opposing papers (Alvarez v.. Prospect Hos-
            pital, 68 NY2d 320 (1986}; Ayotte v. Gervasio, 81 NY2d 1062 [1993]). Granting a motion for summary
            judgment is the functional equivalent of a trial, therefore it is a drastic remedy that should not be
            granted where there is any doubt as to the existence of a triable issue (Rotuba Extruders v. Ceppos, 46
            NY2d 223 [1977]). The court's function on these motions is limited to "issue finding," not "issue determi-
            nation" (Sillman v. Twentieth Century Fox Film, 3 NY2d 395 [19571).

                  The relevant facts are as follows. State Farm issued an automobile insurance policy to defendant
            policy holders, Lemaitre Videau ("Lemaitre") and Nasia Gaspard·("Gaspard"), which insured a 2015
            Land Rover Sport (the "insured vehicle"). The policy included uninsured motorist coverage. On March
            16, 2022, an individual who was allegedly "falsely and fraudulently impersonating Miguel Philippi" ("Phi-
            lippi") was driving the insured vehicle and defendants Patrick Joseph ("Joseph"}, Vena Videau ("Vena"},
            Joseph Pierre ("Pierre") and Shawn Williams ("Williams") were passengers (together the "individual
            claimants"). Gaspard and Lemaitre were not in the vehicle. It is alleged that the insured vehicle was
            involved in an accident with a BMW reportedly owned by Odaya Simpson ("Simpson") and being oper-
            ated by Gail Wheatle ("Wheatle"). There is no police report from the scene of the accident and all alle-
            gations concerning the accident arise from a motorist accident report filed by the individual claimants.
            State Farm has received multiple bills for treatments allegedly provided to the individual claimants due
            to injuries suffered from the accident.

                 In support of its motion, plaintiff submits the sworn affidavit of Lori Madigan, a Claims Specialist
            employed by State Farm, who states the following. Based on her employment with State Farm, Madi-
            gan received training and is personally familiar with the company's standard business practices for New
            York no-fault claims. Madigan states that those business practices were followed for claims associated
            with this action. Madigan also states that she has personal knowledge of the instant action based upon
            her review of the State Farm file. She states after it was made aware of the loss, State Farm began an
            investigation into the alleged collision.

                 Madigan asserts that after investigation, State Farm questioned the legitimacy of the claim be-
            cause: 1) there was no police report filed despite the insured vehicle being declared a total loss; 2) Both
            Phillipi and Wheatle denied being in any kind of motor vehicle accident on March 16, 2022; 3) the sub-
            ject insurance policy was obtained less than two months before the alleged· Ioss. Accordingly, State
            Farm requested EUOs of Gaspard, Lemaitre, Philippi, Joseph, Vena, Pierre and Williams. Madigan
            states that Joseph and Philippi both appeared for their EUOs, but no one else did.

                 Madigan then states that after completion of the full investigation, State Farm determined that the
            alleged accident was staged and/or intentionally caused. Madigan expounds upon the reasons that led
            to this conclusion including, but not limited to: 1) both Wheatle and Philippe, the reported drivers of the
            vehicles, denied involvement in the alleged accident; 2) In his EUO, Joseph testified that he had known
            Philippe for a year, but Philippe testified that he did not know Joseph; 3) Joseph testified that he had
            never met Vena, Williams or Pierre before the accident and that he never saw them since, but both Jo-
            seph and Vena received medical treatment at the same facility; 4) Joseph testified that they were in
            Stamford, Connecticut at the time of the accident because he was going to a club for his birthday, but
            then also testified that he did not know where the loss occurred, did not know the name of the club and
            did not know the city where the club was located; 5) Joseph changed his testimony multiple times and
            there were difference in his story during his EUO versus the paperwork that he filed with State Farm for
            the loss; 6) State Farm hired an individual to inspect the vehicle after the loss and the report suggested
            that the damage to the front of the vehicle was done by contact with a piece of wood or similar instru-
            ment, and damage to the undercarriage was caused by a hammer or steel punch, not by contact with
            another vehicle; 7) The inspection also suggested that the damage was done while the vehicle was sta-
            tionary because there was no spray of any fluids from the engine as would be common in a motor ·
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  FILED: NEW YORK COUNTY CLERK 02/16/2024 03:42 PM                                              INDEX NO. 159311/2022
  NYSCEF DOC. NO. 220                                                                   RECEIVED NYSCEF: 02/16/2024

            vehicle accident; 8) Gaspard advised State Farm that Lemaitre gave Philippi permission to use the
            Range Rover, but Philippi denied knowing either Gaspard or Lemaitre and denied filing an MV-104 or
            otherwise being involved with the alleged incident in any way.

                  Additionally, Madigan's affidavit includes a break down of dates of service and the dates that bills
           were received from all the motion defendants for services provided to Vena. This table states that the
           bi.II received from 101 Rx Pharmacy Inc. for Vena was received on 5/27/22. The bills from Advantage
           Radiology, P.C. for services provided to Vena were received by State Farm on 6/17/22 and 6/27/22. The
           bill from All City Family Healthcare Center, Inc. for services provided to Vena was received on 8/25/22.
           The bills from Eden Ortho Supply Ltd. for services provided to Vena were received on 10/4/22 and
           9/30/22. The bill from Gotham Supply Group for services provided to Vena was received on 9/20/22.
           The bill form NYC Discount Pharmacy Inc. was received on 4/25/22. The bill from Park Avenue Medical
           Imaging, P.C. for services to Vena was received on 5/31/22. The bills from RVA Leasing Corp. were re-
           ceived by State Farm on 5/23/22. Finally, State Farm received bills from Tri-Borough NY Medical Prac-
           tice for services provided to Vena on 5/9/22, 5/11 /22, 6/4/22, 6/10/22, and 7/13/22.

                 State Farm has also submitted the affirmation of Kevin W. O'Leary, a partner with the law firm of
            Siegel & O'Leary LLP ("S&O"), the attorneys for State Farm. O'Leary states that he is fully familiar with
            the facts and circumstances of the lawsuit because of his position at S&O. He states that on May 16,
            2022, Vena was scheduled to appear for an EUO at the S&O office to take place on June 10, 2022.
            O'Leary claims that he was present at the office at the time of the scheduled EUO and Vena did not ap-
            pear. He states that in a letter dated June 13, 2022, Vena's EUO was rescheduled for July 1, 2022, at
            the S&O office .. Again, O'Leary was present at the scheduled time and again Vena did not appear for
            the EUO. O'Leary also states that on May 16, 2022, Lemaitre was scheduled to appear for an EUO on
            June 6, 2022. O'Leary was present at the office on June 6, 2022 to take the EUO, but Lemaitre did not
            appear. In a letter dated May 16, 2022, the EUO was rescheduled to June 28, 2022 at the S&O office.
            O'Leary was again present at the office at the date and time of the EUO, but Lemaitre again did not ap-
            pear. O'Leary states that on May 16, 2022 Gaspard was also scheduled for an EUO to take place on
            Jun 6, 2022 at the S&O office. O'Leary was present at the office on the time and date of the EUO but
            Gaspard did not appear. In a letter dated June 9, 2022, the EUO was rescheduled for June 9, 2022 at
            the S&O office. Again, O'Leary was present at the office at the scheduled time and again Gaspard did
            not appear for the EUO. Next, O'Leary claims that on May 23, 2022, Pierre was noticed that he was
            scheduled for an EUO to take place on June 16, 2022 at the S&O office. On June 16, 2022, O'Leary
            was present at the S&O office at the scheduled time to take Pierre's testimony, but Pierre did not ap'"
            pear. In a letter dated June 20, 2022, the EUO was rescheduled to July 14, 2022 at the S&O office.
            Again, O'Leary was present at the scheduled time and again Pierre did not appear. Finally, on May 23,
            2022, Williams was scheduled to appear for an EEUO on June 16, 2022 at the S&O office. O'Leary was
            present at the office on the scheduled date and time, but Williams did not appear. By letter dated June
            20, 2022, the EUO was rescheduled for July 14, 2022. On that date and time another attorney from
            S&O, Jeffrey S. Siegel, was present to take the EUO, but Williams again did not appear. All notices for
            EUOs were sent to the address obtained from the no-fault application that the individual claimants sub-
            mitted to State Farm

                  O'Leary also states that on July 7, 2022 Philippi appeared for his second scheduled EUO. Follow-
            ing the examination, the EUO transcript was sent to Philippi for him execute and return. To date, Phi-
            lippi has not returned an executed copy of the EUO transcript. Similarly, on June 30, 2022, Joseph ap-
            peared for his EUO. Following the examination, the EUO transcript was sent to Joseph for him execute
            and return. To date, Joseph has not returned an executed copy of the EUO transcript.

                State Farm submitted the affirmation of Jeffrey S. Siegel as well. Seigel states that he is a partner
           with S&O, and that he is familiar with the lawsuit and S&O's handling of the lawsuit from his review of
           S&O file on the matter. He states that he was present at the S&O office on July 14, 2022 to take the
           EUO of Williams and that Williams did not appear for the EUO.                  ·

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                 State Farm has submitted the notices that it sent to each of the individual defendants for each of
            their scheduled EUOs, and the letters to Joseph and Philippi requesting their signatures on their EUO
            transcripts.

            Parties' arguments

                 State Farm claims that it is entitled to summary judgment and a declaration that it has no duty to
            pay any no-fault benefits for claims submitted by the motion defendants because: 1) Vena, Pierre and
            Williams failed to attend EUOs on multiple occasions, thereby breaching a condition precedent to cov-
            erage; 2) State Farm maintains a founded belief that the loss in question was not a covered event be-
            cause it was staged an/or intentional.

                 In opposition to the motion, the opposing defendants assert that summary judgment should not be
            granted because 1) State Farm has failed to establish, by clear and convincing evidence in admissible
            form, that the alleged accident was intentional; 2) State Farm has failed to demonstrate compliance
            with 11 NYCRR § 65-3.8, 3.5 & 3.6 and failed to establish that it "properly mailed" EUO notices; 3)
            State Farm failed to prove the merits of the no-show EUO defense because it did not demonstrate an
            objective good reason to demand the EUOs; 4) the motion is premature because there has not been
            adequate time for discovery.

                 The opposing defendants also assert generally that any EUO/deposition taken before the inception
            of the action are not admissible under CPLR § 3117 and affidavits that plaintiff relies on are not admis-
            sible as they are hearsay. Regarding State Farm's founded belief defense, the motion defendants ar-
            gue that: 1) to establish that it has no duty to pay no-fault benefits to a given defendant, State Farm
            must demonstrate that the defendant was responsible for the intentional collision. None of the individual
            claimants who have been accused of creating a fraudulent collision have "assigned his or her benefits
            to the Provider Defendants" and thus the motion must be denied; and 2) the affidavit of an investigator
            with no personal knowledge of the incident cannot be the basis of a founded belief of fraud.

                 On reply, State Farm argues that: 1) the request for EUOs were timely pursuant to regulations and
            it demonstrated an objective good reason to demand those EUOs; 2) the opposing defendants have
            failed to raise a triable issue of fact; 3) the motion is not premature because the opposing defendants
            have failed to demonstrate that any further discovery would lead to relevant evidence.

            Discussion

                 It is well established that "failure to submit to an EUO and 'subscribe to the same' violates a condi-
            tion precedent to coverage" (Hertz Vehicles, LLC v. Best Touch PT, P.C., 162AD3d 617 [1st Dept
            2018); 11 NYCRR § 65-2.4[c][2]). A violation of a condition precedent to coverage vitiates an insurance
            policy (PV Holding Corp. v. Hank Ross Med., P.C., 188AD3d 429 [1st Dept 2020]; Unitrin Advantage
            Ins. Co. v. Bayshore Physical Therapy, PLLC, 82AD3d 559 [1st Dept 2011)). Through the affidavit of
            Lori Madigan and the affirmations of Kevin E. O'Leary and Jeffrey S. Siegel, State Farm has demon-
            strated that Vena, Pierre and Williams failed to appear for their EUOs. Additionally, the affidavit of Madi-
            gan and the affirmation of O'Leary demonstrate that Joseph failed to subscribe to his EUC> despite
            State Farm's efforts to obtain his signature: Therefore, the burden shifts to the answering defendants to
            demonstrate that a triable issue of fact exists.

                 At the outset, it is well established that an affidavit or affirmation from someone with personal
            knowledge is sufficient to support a summary judgment motion (see eg. Wilson v. Bristol-Myers Co.,
            403 NYS2d 251 [1978)). Here, the affirmations of O'Leary and Siegel and the affidavit of Madigan are
            all provided based on the personal knowledge of the affirmants based upon their review of the State
            Farm and S&O records. Therefore, the affidavit and affirmations can be considered in support of this
            summary judgment motion.

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                 First, the court will consider the motion defendants' argument that State Farm has failed to demon-
            strate sufficient evidence that the service of the EUO notices and notices to subscribe Joseph's EUO
            were compliant with the timeliness requirements of 11 NYCRR §§ 65-3.5, 3.6 & 3.8. 11 NYCRR § 65-3.8
            states that an insurer must pay a claim or issue a denial within 30 days of receipt of proof of the claim.
            However, contrary to the assertion of the answering defendants, the timeliness of State Farm's denial of
            their claims is irrelevant since the violation of a condition precedent to coverage gives plaintiff the right
            "to deny all claims retroactively to the date of the loss, regardless of whether the denials were timely
            issued" (Unitrin Advantage Ins. Co. v. Dowd, 194AD3d 507 [1st Dept 2021]; Unitrin Advantage Ins. Co.
            v. Bayshore Physical Therapy, PLLC, 82 AD3d 559 [1st Dept 2011]; see Kemper Independence Ins. Co.
            v. Cornerstone Chiropractic, PC., 185 AD3d 468 [1st Dept 2020][stating that failure to subscribe to an
            EUO warranted denial of a claim "notwithstanding plaintiff's failure to present proof of proper delivery of
            the denials"]).

                   11 NYCRR § 65-3.5(b) states that an EUO must be requested within fifteen days of receipt of the
             claim or verification form. The motion defendants state that State Farm must demonstrate that it de-
             manded an EUO within fifteen days of receipt of their individual claims. However, an insurer need only
           · demonstrate that it requested an EUO within 15 business days from receipt of a bill (State Farm Fire
             and Gas. Co. v. Blackbum, 79 Misc3d 1229[A] [Sup Ct NY Co 2023]). An insurer seeking judgment
             against a given provider need not show that it timely requested an EUO relative to a bill received from
             that provider; rather, as long as the EUO requests were timely relative to a bill from any provider, the
             claimant's failures to appear at the EUO will support the insurer's coverage defense (Id.). Here, State
             Farm has submitted the affidavit of Madigan in which she states that of the opposing defendants, the
             earliest received bill was the Tri-Borough NY Medical Practice, P.C. and the bill was received on May 9,
             2022. In his affirmation, O'Leary asserts that State Farm mailed a notice to Vena to appear for an EUO
             on May 16, 2022, within the 15-day time frame permitted by the regulation. State Farm also mailed a
             notice to Pierre to appear for an EUO on May 23, 2022 and mailed a notice to Williams to appear for an
             EUO on May 23, 2022. In its affirmation in reply, State Farm claims that "no claims for no-fault benefits
             have yet been submitted by or on behalf of Joseph Pierre and Shawn Williams." Therefore, State Farm
             has met its burden of demonstrating that its requests for EUOs were served within 15 days of receipt of
             bills that served as the bases for those requests. Additionally, the affidavit of Madigan states that the
             no-fault policies of State Farm were followed in this case, and the affirmation of O'Leary states that no-
             tices for EUOs were sent to the homes of the individual claimants as were recorded on their no-fault
             claims submitted to State Farm. Accordingly, State Farm has met its burden of demonstrating that the
             notices were properly mailed.

                  The burden shifts to the opposing defendants to demonstrate a triable issue of fact. The opposing
             defendants have not submitted any evidence that contradicts State Farm's claims concerning the timeli-
             ness and proper mailing of its EUO notices. Assuming arguendo that State Farm's defense fails if it did
             not demand EUOs within 15 days of the receipt of the claims of each of the individual opposing defend-
             ants, the opposing defendants must prove that their claims were filed with State Farm more than 15
             days before State Farm noticed the subject EUOs. Yet the opposing defendants have not submitted any
             of their bills as evidence that the EUO requests were untimely. Therefore, the opposing defendants
             have failed to raise an issue of fact on this point.

                 Next, 11 NYCRR § 65-3.6 states that "if any requested verification has not been supplied to the
            insurer 30 calendar days after the original request, the insurer shall, within 1O business days, follow up
            with the party from whom the verification was requested ... " This means that after a failed EUO, the
            plaintiff-insurer must request a follow up EUO within 10 days (see eg. Mapfre Ins. Co. of N. Y. v. Manoo,
            140 AD3d 46~ [1st Dept 2016]). State Farm has demonstrated through the affirmation of O'Leary that
            Ve~a was marled a follow up EUO request three days after her first missed EUO, that Pierre was
            marled a follow up EUO request four days after his first missed EUO, and that Williams was mailed a
            follow up EUO request four days after his first missed EUO. Therefore, State Farm has met its burden
            of d~monstrating that t~e follow up let~ers for Vena, Pierre and Williams were sent within 1o days as
            required by the regulation. The opposing defendants do not introduce any evidence challenging the

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             assertions made in O'Leary's affirmation. Accordingly, the opposing defendants have failed to raise an
             issue of fact on this point.

                   Next, the opposing defendants argue that State Farm failed to demonstrate that it had an objective
             justification to request the EUOs of the individual claimants. However, in her affidavit, Madigan ex-
             pounds on the facts that raised a strong possibility that the collision did not occur as the claimants al-
             lege. These facts provide a reasonable basis to request an EUO. Therefore, State Farm has demon-
             strated an objective justification for its EUO requests.

                   Finally, the opposing defendants argue that the summary judgment motion is premature because
             there has not been adequate time for discovery. The opposing defendants argue that the information
             that they could use as a defense is in the sole custody, control, and possession of State Farm. How-
             ever, the court does not believe that any further discovery would help the opposing defendants to de-
             feat State Farm's condition precedent to coverage defense for the individual claimants' failure to appear
             for, and subscribe to, EUOs. The opposing defendants have, or ought to have, dated copies of their
             own bills that they sent to plaintiff that they could introduce in opposition. They have failed to introduce
             those bills. State Farm has produced the documents surrounding the EUOs, mainly the EUO notice let-
             ters, and the requests for Joseph to subscribe to his EUO. The opposing defendants have failed to
             show how depositions and further paper discovery would establish a different outcome on this cause of
             action.

                  Based on the foregoing, State Farm has established a prima facie case that a condition precedent
             to coverage was breached thereby relieving plaintiff of the duty to pay no-fault benefits in connection
             with the underlying accident and the motion for summary judgment is granted in its entirety. Accord-
             ingly, motion as to the cause of action for denial of coverage based upon a founded belief that the loss
             did not arise from a covered event is denied as moot. Similarly, the court declines as moot plaintiff's
             request for a declaration that the original motion defendants lack standing to seek or receive no-fault
             reimbursement for any bill submitted, or that the accident was the product of a staged and/or intentional
             event.

                 In accordance herewith, it is hereby

                 ORDERED that motion sequence number 002 is granted in its entirety.

                 Settle judgment.

                 Any requested relief not expressly addressed herein has nonetheless been considered and is
             hereby expressly rejected and this constitutes the decision and order of the court.

             Dated:                                                    SoOrderilL

                                                                       Hon. Lynn R. Kotler, J.S.C.

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