SUPERIOR COURT OF NEW JERSEY
APPELLATE DIVISION
A-0802-99T5
STATE FARM INSURANCE COMPANY,
Plaintiff-Respondent,
v.
DR. ULISES C. SABATO, as
assignee of CARLOS NAULA,
HUGO NAULA and WILMER NAULA,
Defendants-Appellants.
____________________________________________________
Submitted November 28, 2000 - Decided February 6, 2001
Before Judges Conley and Lesemann.
On appeal from Superior Court of
New Jersey, Law Division, Bergen County,
Docket No. BER-L-3524-96.
S. Gregory Moscaritolo, attorney for
appellants.
Harwood Lloyd, attorneys for respondent
(Curtis J. Turpan, of counsel and on
the brief).
The opinion of the court was delivered 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 defendant's 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.See footnote 11
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 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 Hector's policy with plaintiff State Farm Insurance Company
(State Farm). They say also that they were 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 Hugo's 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 Wilmer's address
and that of his father produced what seems to be conflicting
information. The same is true respecting the nature and extent of
Wilmer's 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 driver's 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 father's
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 and
investigate a claim, and therefore Wilmer's lying to the carrier
had the capacity to influence State Farm's investigation.
Accordingly, the court held that Wilmer's claim, and that of Dr.
Sabato which was based on Wilmer's 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 Hugo's 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 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 (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 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.
State Farm argues that the Law Division decision in Allstate
Ins. Co. v. Lopez,
311 N.J. Super. 660 (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
court's substantive conclusions troubling. We are not clear as to
how, if at all, State Farm claims it was prejudiced by
misrepresentations respecting Wilmer's 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 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
Hugo's successful claim: $3,500 to plaintiff's attorney for
services respecting Hugo's claim; and $500 to Hugo's 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 Hugo's
claims, and those agreed upon amounts are the sums embodied in the
court's agreement. In view of that agreement there was obviously
no need for a hearing, and plaintiff's 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.
Footnote: 1 1 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 Hugo's personal attorney respecting Hugo's claim, and that issue is discussed below.