Court Opinion

ID: 9589310
Source: CourtListenerOpinion
Date Created: 2023-08-21 23:43:31.731314+00
Date Added: 2024-06-11T18:01:01.649747
License: Public Domain

RUSSELL, J.,
dissenting.
In my view, the insurance company’s need for prompt notice of a medical expense claim is considerably less acute than its need for notice of a liability claim.
*289In a liability case, the insurer must often reconstruct, before the evidence disappears and the memories of witnesses fade, an evanescent scene on the highway in order to prepare a defense for the insured against tort claims as yet unknown. In these circumstances, prejudice to the insurer is inherent in any delay, and the insurer should not be required to show it where the claimant has been unreasonably dilatory in giving notice.
Although the medical expense provision appears in the same policy as the liability provision, it is a separate and distinct part of the policy. Unlike the liability coverage, which depends upon negligence, the medical expense coverage is based upon a simple contract between the insured and insurer. In Moorman v. Insurance Company, 207 Va. 244, 148 S.E.2d 874 (1966), we distinguished between the general liability provision and the medical payments provision in an automobile insurance policy. There we stated:
Here, the engagement [of the insurer] to pay medical expenses, regardless of negligence on the part of the insured, is somewhat similar to a personal accident policy ... for the benefit of an injured person, rather than for a person insured against liability. The injured person is placed in the position of a third party beneficiary, and as such, has in Virginia a statutory right to maintain an action on the contract in his own name. [Citation omitted.]
Id. at 248, 148 S.E.2d at 877.
Under the medical expense provision, the company’s exposure does not depend upon the negligence of the insured, the issue of proximate cause, or the various defenses that may be asserted against third persons. The company, for an additional premium, has merely bound itself to pay the reasonable and necessary medical expenses of an insured who sustains bodily injury caused by accident while occupying a covered automobile, regardless of fault, causation, or defenses. If the claim is of the kind agreed upon, the company’s exposure is fixed and final. See Nagy v. Lumbermens’ Mutual Casualty Company, 100 R.I. 734, 219 A.2d 396 (1966), and Cockrum v. Travelers Indemnity Company, 420 S.W.2d 230 (Tex. Civ. App. 1967). In these circumstances, the insurer should be required to show that any delay in the receipt of notice was unreasonable before it may avoid payment of the claim solely upon that ground.
*290“The requirement to give notice of an accident ‘as soon as practicable’ means that the notice must be given within a reasonable time after the accident. To determine the reasonableness of a delay in giving the required notice, the facts and circumstances in each particular case must be considered.” [Citations omitted.] State Farm Mutual v. Douglas, 207 Va. 265, 267, 148 S.E.2d 775, 777 (1966).
Although the insurer is entitled, as a condition precedent to coverage, to receive notice of a claim within a reasonable time after the accident, the standard of reasonableness varies with the circumstances. For the reasons given above, the standard applicable to medical payments insurance should be less stringent than that which applies to liability insurance. The General Assembly, in enacting Chapter 21.1 of Title 19.2 of the Code, which provides for the compensation of crime victims who have claims almost identical to the one before us, deemed six months to be a reasonable deadline for the presentation of claims, with a provision for an extension of time up to two years for good cause shown. Code § 19.2-368.5(B).
In this case the insurer received notice of the claim five months and twenty days after the assault on Lord. At that time the assailant, one Calvin Ray Davis, had been identified, along with his three companions, and was facing criminal charges arising out of the assault on Lord. These four individuals, in addition to Lord, were the only witnesses in the case. Davis was later sentenced to the pentientiary for this assault, as well as for another which he had committed a few minutes earlier against another citizen. All of this information was available at the court house. All of Lord’s medical records were available at the University of Virginia Hospital. Thus the insurance company, when it received notice, had available to it all of the information which it would ever need or ever could have had, in order to evaluate the claim. I cannot agree with the majority’s conclusion that “the facts of this case furnish a perfect illustration of the. need for prompt. notification to the insurer of a claim for medical expenses.” They seem to me to demonstrate the contrary.
Where an insurer defends against a claim for medical payments on the ground that the insured failed to give it notice of the claim “as soon as practicable,” the insurer should have the burden of showing by a preponderance of the evidence that the delay was unreasonable under the facts and circumstances of the case. In *291determining the question of reasonableness, the trier of fact should consider, among the other circumstances, whether the delay, even if short, has actually resulted in prejudice to the insurer. Although the insurer is not required to show prejudice, such a showing, when made, should affect the court’s determination as to whether the notice was given within a reasonable time. The stipulated evidence in the case before us shows, in my view, neither an unreasonable delay nor any possibility of prejudice to State Farm resulting from late notice of the claim.
From the record before us, I am of opinion that Lord was “entering” his car, which the policy equates with “occupying” it, see Goodwin v. Lumbermens Mut. Cas. Co., 199 Md. 121, 85 A.2d 759 (1952); and that the casualty meets the definition of “accident” which we adopted in Ocean Accident, etc. Corp. v. Glover, 165 Va. 283, 182 S.E.2d 221 (1935). For these reasons, I would reverse and enter final judgment for Lord in the stipulated amount.
CARRICO, C.J., joins in dissent.