Filed: Aug. 02, 2018
Latest Update: Mar. 03, 2020
Summary: Puerto Rico hospital and several of its employees. According to, Jiménez, Liberty first issued the Hospital a D&O policy with a, coverage period from on or about November 30, 2008 through November, 30, 2009.a result of a Claim first made during the Policy Period .motion for summary judgment.
United States Court of Appeals
For the First Circuit
No. 15-2138
NILDA ESTHER LIND-HERNÁNDEZ; JOEL LIND-HERNÁNDEZ,
Plaintiffs,
v.
HOSPITAL EPISCOPAL SAN LUCAS GUAYAMA, a/k/a Hospital Episcopal
Cristo Redentor; DR. PEDRO RAMOS-CANSECO; DR. ALBERT MATOS; DR.
RUBEN ANTONIO PÉREZ-RAMIREZ; DR. JOSE ALFREDO CEBOLLERO-
MARCUCCI; ADMIRAL INSURANCE COMPANY, as insurer of Hospital
Episcopal San Lucas Guayama; CONJUGAL PARTNERSHIP RAMOS-DOE;
JOHN DOE; CORPORATION X, Y & Z; CONJUGAL PARTNERSHIP MATOS-DOE;
CONJUGAL PARTNERSHIP PEREZ-DOE; CONJUGAL PARTNERSHIP CEBOLLERO-
DOE,
Defendants.
DR. GERSON JIMÉNEZ-CASTANER, as Medical Director of Hospital
Episcopal San Lucas Guayama,
Defendant/Third-Party Plaintiff - Appellant,
v.
LIBERTY MUTUAL INSURANCE COMPANY,
Third-Party Defendant - Appellee.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Jay A. García-Gregory, U.S. District Judge]
Before
Howard, Chief Judge,
Thompson and Barron, Circuit Judges.
Juan M. Martínez Nevárez, with whom González & Martínez, PSC
was on brief, for appellant.
Eric Pérez-Ochoa, with whom Adsuar Muñiz Goyco Seda & Pérez-
Ochoa, P.S.C. was on brief, for appellee.
August 2, 2018
BARRON, Circuit Judge. This appeal concerns the
dismissal of a suit that Dr. Gerson Jiménez-Castaner ("Jiménez")
brought against Liberty Mutual Insurance Company ("Liberty").
Jiménez alleges that Liberty breached his contractual rights by
wrongfully denying his request for coverage under the Directors
and Officers ("D&O") insurance policy that Liberty had issued to
a hospital in Puerto Rico where Jiménez served as the medical
director.1 The District Court granted Liberty's summary judgment
motion on the ground that, under the policy, the "Claim" that would
give rise to the "Loss" for which Jiménez sought coverage should
be deemed to have been "first made" before the policy at issue
took effect and thus was not covered by that policy. We now vacate
the grant of summary judgment.
I.
Jiménez filed his suit for breach of contract under
Puerto Rico law against Liberty in the United States District Court
for the District of Puerto Rico in August of 2013. On appeal, the
core of the parties' dispute concerns the legal significance, if
any, of two amended complaints that had been filed in a related
lawsuit. An understanding of the parties' dispute, therefore,
1 A D&O policy generally "exist[s] to fund indemnification
covenants that protect corporate directors and officers from
personal liability." Med. Mut. Ins. Co. of Me. v. Indian Harbor
Ins. Co., 583 F.3d 57, 59 (1st Cir. 2009).
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first requires that we provide a brief description of certain
undisputed facts concerning that suit. And so we begin there.
On March 21, 2011, Lind Hernández and his sister, Nilda
Ester Hernández, (the "Hernándezes") filed a lawsuit in the United
States District Court for the District of Puerto Rico against a
Puerto Rico hospital and several of its employees. That hospital
is Hospital Episcopal San Lucas Guayama, which is also known as
Hospital Episcopal Cristo Redentor ("Hospital").
On the same day that the Hernándezes filed their original
complaint in their suit, they also amended their complaint. In
that first amended complaint, they claimed that, while Lind
Hernández was a patient at the Hospital, the negligence of the
Hospital and certain of its employees led to the amputation of
both of his legs and entitled the Hernándezes to, among other
damages, compensation for physical and emotional injuries. The
Hospital was served with the Hernándezes' first amended complaint
on June 24, 2011.
During the time period in which the events alleged in
the Hernándezes' first amended complaint occurred, Jiménez was
serving as the medical director of the Hospital. He was not,
however, named as a defendant in either the Hernándezes' original
complaint or their first amended complaint. Nor was any other
director or officer of the Hospital. Moreover, the Hernándezes'
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first amended complaint was "devoid of any allegations of wrongful
acts" against such persons or Jiménez.
The next event that is relevant to this appeal occurred
on February 28, 2012. That day, the Hernándezes, in connection
with their lawsuit, deposed Jiménez and questioned him
"extensively about his supervisory and managerial duties as the
Hospital's medical director, as well as the Hospital's bylaws and
other purely administrative matters."
After the deposition, but on the same day, Jiménez
conferred with the legal counsel for the Hospital. The two of
them concluded that the Hernándezes might either file a new
lawsuit, or amend their complaint in their existing suit, to bring
claims against Jiménez in his capacity as the medical director of
the Hospital. Accordingly, that same day -- February 28, 2012 --
the legal counsel for the Hospital forwarded a copy of the
Hernándezes' first amended complaint to the Hospital's insurance
broker. The insurance broker, also that same day, then forwarded
the Hernándezes first amended complaint to Liberty, on behalf of
"the insured," and requested that it be "process[ed] under the
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[Hospital's November 2011 to November 2012 D&O] policy and any
other issued policy that might apply."2
At that time, Liberty had issued the Hospital a D&O
policy with a policy period that ran from November 30, 2011 through
November 30, 2012.3 Subject to certain exclusions, this policy
obligated Liberty to provide coverage for "all Loss," including
damages, that various "Insured[s]" became legally obligated to pay
as a result of certain types of "Claim[s]" brought in a civil
lawsuit against them. Among the "Insured[s]" the policy covered
was the Hospital's medical "director[]."
Significantly, this policy is a "claims made" policy,
which is a type of policy that typically "covers acts and omissions
occurring either before or during the policy term, provided the
claim is discovered and reported to the insurer during the same
policy term." See DiLuglio v. New Eng. Ins. Co., 959 F.2d 355,
2 Notably, the email forwarding the first amended complaint to
Liberty does not expressly mention Jiménez, and in one place
describes the "insured" as the Hospital's parent organization.
3 Jiménez also asserts that there are three additional related D&O
policies that Liberty issued to the Hospital. According to
Jiménez, Liberty first issued the Hospital a D&O policy with a
coverage period from on or about November 30, 2008 through November
30, 2009. He contends that there were then two renewals of that
original policy -- one with a policy period of November 30, 2009
to November 30, 2010, and another with a policy period of November
30, 2010 to November 30, 2011 -- which issued prior to the November
30, 2011 to November 30, 2012 policy at issue. Of the alleged
prior policies, only the 2010-2011 policy is included in the record
in this appeal.
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358 (1st Cir. 1992) (emphasis omitted).4 This type of policy, we
have explained, is premised on the notion that, "[a]s it is often
difficult to ascertain the precise date of the act or omission
which constituted the alleged [wrongful act] on the part of the
insured, . . . the pivotal event for insurance coverage purposes
becomes the date the claim is made against the insured, rather
than the date of the act or omission forming the basis for the
claim." Id. (internal citation and alternations omitted).
The policy thus contained the following important
qualifications regarding when "Insureds" must notify Liberty of
any "Claim" made against them. The policy provided that any such
"Claim" for which an "Insured" sought coverage must not be "first
made" prior to the start of the policy period for that policy.
The policy further provided that a "Claim will be deemed first
made on the date an Insured receives a written . . . complaint."
Finally, the policy provided that a "Claim" must be reported to
Liberty "as soon as practicable but in no event later than 60 days
after the end of the Policy Period or [the twelve-month] Discovery
Period, if applicable."
4 "By contrast, 'occurrence policies' cover insured events that
occur during the policy period," and "the insured event is the
occurrence, not the claim." Edwards v. Lexington Ins. Co., 507
F.3d 35, 38 n.2 (1st Cir. 2007).
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Liberty denied the insurance broker's request for
coverage under the D&O policy on March 26, 2012. Liberty explained
that it was doing so for three reasons. First, Liberty cited what
it termed "the late notice" to Liberty of the first amended
complaint in the Hernándezes' lawsuit.5 Second, Liberty cited an
endorsement in the policy that excluded medical malpractice claims
from being covered. And, third, Liberty stated that the damages
sought by the Hernándezes in the first amended complaint related
to a loss for which there is no coverage under the policy.6
There is one more sequence of events that relates to the
issues presented in Jiménez's appeal of the District Court ruling
dismissing his suit against Liberty. This sequence begins almost
a month after Liberty had informed the insurance broker that it
was denying the request for coverage of "all Loss" resulting from
the Hernándezes' first amended complaint.
Specifically, on April 23, 2012, the Hernándezes filed
a second amended complaint in their lawsuit. This complaint, for
5 That complaint, as we have noted, had been received by the
Hospital on June 24, 2011. Thus, it appears that Liberty
considered that "Claim" to have been "first made" prior to the
start of the policy period for the November 2011 to November 2012
policy and to have been reported too late to comply with the
reporting requirements of any earlier D&O policy that Liberty had
issued to the Hospital.
6 It is unclear from the record as it comes to us if the denial of
coverage was as to a claim by Jiménez only, a claim by the Hospital,
or both.
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the first time, named Jiménez, as a co-defendant in the
Hernándezes' lawsuit. In doing so, the second amended complaint
alleged negligence by Jiménez in violation of Puerto Rico law due
to his conduct as the medical director of the Hospital. Jiménez
was served with the Hernándezes' second amended complaint on May
3, 2012.
On June 19, 2012, the insurance broker sent a copy of
the Hernándezes' second amended complaint to Liberty with a request
for coverage concerning the allegations against Jiménez as the
medical director of the Hospital.7 That same day, Liberty
reiterated to the insurance broker that Liberty was denying
coverage. Liberty also thereafter denied a request by the broker
for reconsideration.
Jiménez then filed, on August 21, 2013, this lawsuit
against Liberty in federal court. In the suit, he alleges that
Liberty breached the Hospital's 2011-2012 D&O policy by denying
him the requested coverage for the "Loss" that he would incur as
a result of the "Claim" made against him by the Hernándezes' in
their second amended complaint, and he seeks a declaratory judgment
7 On October 24, 2012, the Hernándezes filed a third amended
complaint simply to include Admiral Insurance Company as a co-
defendant. As the third amended complaint is coextensive with the
second amended complaint in relevant respects, we need not discuss
it separately.
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that he "should be afforded coverage under the insurance
agreement," monetary damages, and attorney' fees.
Jiménez's lawsuit was consolidated with the Hernándezes
suit. Liberty then filed a motion for summary judgment as to
Jiménez's claims alleging that Liberty had breached the terms of
the D&O policy, and the District Court granted that motion.
Jiménez subsequently filed a motion for reconsideration and a
motion to set aside the judgment, both of which the District Court
denied.
Jiménez now appeals the District Court's order granting
Liberty's summary judgment motion.8 Our review is de novo. See
Hill v. Walsh, 884 F.3d 16, 21 (1st Cir. 2018). "We may decide in
favor of the moving party -- here, [Liberty] -- 'only if the record
8 The District Court issued a judgment with respect to its summary
judgment ruling on May 4, 2015. Jiménez then timely filed both a
motion for reconsideration and a motion to set aside the judgment,
which tolled the time to take an appeal from the judgment. See
Fed. R. App. P. 4(a)(4). After the District Court issued an order
denying both motions on August 20, 2015, Jiménez timely filed a
notice of appeal of the summary judgment ruling. Jiménez's notice
of appeal, however, did not mention an appeal of the order denying
Jiménez's motion for reconsideration and his motion to set aside
the judgment. On appeal, Liberty asserts we thus lack jurisdiction
to review the District Court's ruling as to those motions. As
Jiménez timely appealed the summary judgment ruling -- a conclusion
Liberty does not dispute -- which we now vacate without reaching
the later-filed motions, mootness obviates the need to address the
parties' jurisdictional arguments concerning those later-filed
motions because those motions concern only additional arguments
for finding the District Court erred in arriving at the conclusion
that provides the basis for the summary judgment ruling that we
now vacate.
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reveals that there is no genuine dispute as to any material fact
and the movant is entitled to judgment as a matter of law.'" Soto-
Feliciano v. Villa Cofresi Hotels, Inc., 779 F.3d 19, 22 (1st Cir.
2015) (quoting Avery v. Hughes,
661 F.3d 690, 693 (1st Cir. 2011)).
Moreover, we note that "[t]he construction of an insurance policy
is a question of law, and the legal conclusions of the district
court are, of course, not binding on the court of appeals." Nieves
v. Intercontinental Life Ins. Co. of P.R.,
964 F.2d 60, 63 (1st
Cir. 1992), as amended (May 18, 1992). We, therefore, "may make
an independent examination of [the] insurance policy."
Id.
II.
We first provide a description of the law that guides
our construction of the D&O policy issued by Liberty. We then
describe the policy's relevant provisions. With that background
in place, we then explain why we agree with Jiménez's argument
that the District Court wrongly construed the policy in concluding
that Liberty did not breach it by denying Jiménez coverage for the
"Loss" that he would incur in consequence of the "Claim" that the
Hernándezes brought against him in their second amended complaint.
A.
As this is a diversity case, see 28 U.S.C. § 1332(c),
the law of Puerto Rico supplies the substantive rules of decision
concerning the interpretation of the insurance policy at issue.
See López & Medina Corp. v. Marsh USA, Inc., 667 F.3d 58, 64 (1st
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Cir. 2012). Under Puerto Rico law, we first turn to the Insurance
Code of Puerto Rico, P.R. Laws Ann. tit. 26 ("Insurance Code"), to
obtain guidance as to how we should interpret the insurance
contract. See Nieves, 964 F.2d at 63.
Pursuant to the Insurance Code, every insurance contract
"shall be construed according to the entirety of its terms and
conditions as set forth in the policy, and as amplified, extended,
or modified by any lawful rider, endorsement, or application
attached and made a part of the policy." P.R. Laws Ann. tit. 26,
§ 1125. The Puerto Rico Civil Code ("Civil Code"), however, may
provide a supplemental source of law if the Insurance Code fails
to provide an interpretive approach for a given situation. See
López & Medina Corp., 667 F.3d at 64.
Because insurance contracts are generally viewed as
contracts of adhesion under Puerto Rico law, ambiguous insurance
policy language must be liberally construed in favor of the
insured. See AJC Int'l, Inc. v. Triple-S Propiedad, 790 F.3d 1,
4 (1st Cir. 2015) (quoting Pagán Caraballo v. Silva Delgado,
22
P.R. Offic. Trans. 96, 101 (1988)). As provided in the Civil Code,
however, when "the terms of a contract are clear and leave no doubt
as to the intentions of the contracting parties, the literal sense
of its stipulations shall be observed." P.R. Laws Ann. tit. 26,
§ 3471.
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Finally, we note that, under Puerto Rico law, exclusions
in insurance policies are disfavored and "should be strictly
construed and in such a way that the policy's purpose of protecting
the insured is met." AJC Int'l, Inc., 790 F.3d at 4 (quoting Pagán
Caraballo, 22 P.R. Offic. Trans. at 101). But, when the meaning
and scope of a policy term or clause favoring the insurer is clear
and unambiguous, the unambiguous term is binding on the insured,
even if it eliminates coverage. See
id.
B.
The specific policy issued by Liberty to the Hospital at
the center of the parties' dispute on appeal appears to be
Executive Advantage Policy VKU-1000883-11.9 By its terms, the
"Policy Period" for that policy is defined as November 30, 2011 to
November 30, 2012.
The policy provides coverage to two types of "Insureds."
One type of "Insured" is an "Insured Person[]," a term which is
defined in section 25.10 of the policy, as modified by Endorsement
No. 1 to the policy. That type of "Insured" includes the
Hospital's "duly elected, appointed or hired directors or
9 The contract forming the policy at issue is actually comprised
of four parts -- the policy application, a policy declarations
page, the policy, and attached endorsements (collectively, the
"policy"). As the parties have not provided the policy application
to us on appeal, nor made any arguments with respect to such
application, we understand them to be conceding that the policy
application is irrelevant to our analysis.
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officers." Thus, as we have noted (and as the parties do not
dispute), Jiménez is within the definition of this term by virtue
of his position as the medical director of the Hospital. The other
type of "Insured" is an "Insured Organization," a term which is
defined in section 25.9 of the policy, as modified by Endorsement
No. 17 to the policy. That type of "Insured" exclusively includes
"Iglesia Episcopal Puertorriqueña" and "any Subsidiary," including
twelve listed organizations of which one is the Hospital.
The coverage provided to each type of "Insured" --
subject, that is, to certain exclusions set forth elsewhere in the
policy -- is spelled out in section 1 of the policy, which
establishes Liberty's obligation to pay for an "Insured['s]"
"Loss" in three distinct "Insuring Agreements." Those agreements
are denominated in section 1 as "Insuring Agreements 1.1,"
"Insuring Agreement 1.2," and "Insuring Agreement 1.3." Only two
of these insuring agreements, Insuring Agreement 1.1 and Insuring
Agreement 1.3, are relevant here.
Insuring Agreement 1.1, by its plain terms, establishes
Liberty's obligation to pay for "all Loss" for a "Claim" that is
made "against" "Insured Persons." By contrast, Insuring Agreement
1.3, as amended by Endorsement No. 1 to the policy, establishes
Liberty's obligation to pay for "all Loss" that results from a
"Claim" that is made against an "Insured Organization." Each of
the insuring agreements that is relevant here -- Insuring Agreement
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1.1 and 1.3, respectively -- further specifies Liberty's
obligations to the relevant type of insured to which each of these
insuring agreement applies. In particular, in each of these
insuring agreements, Liberty commits to pay "all Loss" that the
relevant type of insured "shall become legally obligated to pay as
a result of a Claim first made during the Policy Period . . .
against the" insured insofar as that "Claim" is "against the"
insured "for a Wrongful Act which takes place before or during the
Policy Period."
Thus, the terms "Loss" and "Claim" are also critical to
the operation of the insuring agreements at issue, as are the words
"first made during the Policy Period" and "Wrongful Act."
Helpfully, the policy expressly addresses the meaning of each of
these terms. And so, before turning to Jiménez's grounds for
challenging the District Court's dismissal of his suit, we first
briefly review how the policy does so, as the meaning of each of
these terms also figures in our analysis.
The term "Loss" is defined in section 25.12 of the policy
as amended by Endorsement No. 1 to the policy. That definition,
in relevant part, defines "Loss" to mean:
[S]ums which the Insured Persons, or with respect to
Insuring Agreement 1.3, the Insured Organization are
legally obligated to pay solely as a result of any
Claim insured by this Policy including Defense Costs,
damages, front pay . . . and back pay, judgments,
settlement amounts, legal fees and costs awarded
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pursuant to judgments, punitive, multiplied or
exemplary damages, where insurable by law.
The term "Claim" is defined in section 25.3 of the
policy, as modified by Endorsement No. 1 to the policy. That
definition states, in relevant part, that a "Claim" is "a civil or
criminal proceeding or arbitration against an Insured Person, or
with respect to Insuring Agreement 1.3, against the Insured
Organization."
The policy's definition of "Claim" also makes clear how
one goes about determining the time at which such a "Claim" has
been "first made." Specifically, the definition of "Claim" states,
in relevant part, that "[a] Claim will be deemed first made on the
date an Insured receives a written . . . complaint."
Finally, the term "Wrongful Act" is defined by section
25.20 of the policy. That provision defines the term to include:
(a) any actual or alleged error, misstatement,
misleading statement, act, omission, neglect, or
breach of duty, actually or alleged [sic] committed or
attempted by the Insured Persons in their capacities
as such . . . or, with respect to Insuring Agreement
1.3, by the Insured Organization; or (b) any matter
claimed against the Insured Persons solely by reason
of their status as Insured Persons.
C.
With these features of the D&O policy in mind, we now
turn to the parties' primary dispute. It concerns when the "Claim"
that triggers the "Loss" for which Jiménez seeks coverage from
Liberty under the policy should be "deemed first made."
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Jiménez contends that he is seeking to have Liberty pay
for "all Loss" that he would become legally obligated to pay solely
in consequence of the "Claim" that is represented by the
allegations set forth in the Hernándezes' second amended
complaint, given that he was not named in their first amended
complaint. And, he points out, there is no dispute either that
the Hernándezes' second amended complaint was first received by an
"Insured" -- namely, himself -- when he was served with it, or
that such service occurred within the "Policy Period." Thus,
Jiménez argues, the "Claim" giving rise to the "Loss" for which he
seeks coverage from Liberty was a "Claim" that was "first made" as
of the time that he received the Hernándezes' second amended
complaint, and not, as Liberty contends, as of the time that the
Hospital received the Hernándezes' first amended complaint, which
was before the "Policy Period" for the 2011-2012 policy began, as
that first amended complaint was not made "against" him.
In consequence of the plain text of the policy, we agree
with Jiménez.10 To explain why, it helps to clear away some key
points at the outset of our analysis. These key points bring into
10 As we conclude that the Hernándezes' second amended complaint
is a "Claim" that was "first made" within the "Policy Period" of
the policy at issue, we have no need to consider Jiménez's
arguments concerning the policy's "Prior Litigation Dates" or the
existence of, and any coverage liability that Liberty may have
pursuant to, prior D&O policies issued by Liberty to the Hospital.
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focus the conclusion that the "Claim" brought against the Hospital
for the purposes of Insuring Agreement 1.3 is distinct from and
does not merge with the "Claim" against Jiménez for the purposes
of Insuring Agreement 1.1 during the "Policy Period," whether one
focuses on the definition of "Claim" set forth in section 25.3, or
the language in section 9, which concerns Liberty's limit of
liability with respect to any "Loss" that an "Insured" suffers.
First, the plain text of the policy makes clear that, to
the extent that Liberty is obligated to pay for "all Loss" that
Jiménez, as an "Insured Person," becomes legally obligated to pay
as a result of a "Claim," such an obligation derives solely from
Insuring Agreement 1.1 and not from Insuring Agreement 1.3.11
Jiménez, after all, is an "Insured Person" and not an "Insured
Organization." And it is Insuring Agreement 1.1 that establishes
Liberty's obligation to pay for "all Loss" resulting from a "Claim"
made "against" an "Insured Person;" Insuring Agreement 1.3
establishes, only, Liberty's obligation to pay for "all Loss"
resulting from a "Claim" that is made "against" an "Insured
Organization."
Second, the Hernándezes' second amended complaint, in
and of itself, is a "Claim . . . against the Insured Person[]" --
i.e., Jiménez -- within the meaning of Insuring Agreement 1.1.
11As previously noted, Insuring Agreement 1.2 is not relevant to
this case.
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That is clear from the plain text of the definitions of the words
"Claim" and "Insured Person."
Third, the Hernándezes' second amended complaint was
received by an "Insured Person" at least by May 3, 2012, when
Jiménez was served with it. And that fact is significant because
that date is within the "Policy Period."
These three conclusions -- none of which are
controversial or even contested -- are, in combination, quite
important, even though they are not in and of themselves
dispositive. In consequence of them, we need to answer only one
question in order to decide whether Jiménez is right about when
the "Claim" that gives rise to the "Loss" that he seeks to make
Liberty cover should be "deemed first made." And that question is
the following: Is there any "Claim" that could qualify as a "Claim
. . . against the Insured Person[]" for purposes of Insuring
Agreement 1.1 other than the one that is represented by the
Hernándezes' second amended complaint? For, if there is no other
"Claim" that could so qualify, then the "Claim" that would result
in the "Loss" for which Jiménez seeks to make Liberty pay under
the policy is necessarily the "Claim" that is represented by the
Hernándezes' second amended complaint and thus a "Claim" that
should be "deemed first made" during the "Policy Period."
Liberty contends that there is another "Claim" that does
so qualify -- namely, the one that is premised on the Hernándezes'
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first amended complaint. And because the Hospital -- which is "an
Insured" -- received that complaint before the "Policy Period,"
Liberty argues that Jiménez is seeking to make Liberty pay for a
"Loss" that results from a "Claim" that should be "deemed first
made" before the "Policy Period" began. But, given the plain terms
of the policy, this argument lacks merit.
To be sure, the text of the D&O policy -- by virtue of
the definition of "Claim" in section 25.3 -- makes clear that the
Hernándezes' first amended complaint is a "Claim." The text of
the policy -- by virtue of the definition of "Insured[]" in section
25.8 -- also makes clear that the "Claim" represented by that first
amended complaint was received by an "Insured" -- namely, the
Hospital. But, that "Claim" is clearly not a "Claim" within the
meaning of Insuring Agreement 1.1, as it is not a "Claim" that is
made "against an Insured Person." After all, that "Claim" did not
name any "Insured Person." Thus, the Hernándezes' first amended
complaint cannot establish the date on which the "Claim . . .
against the Insured Person[]" that results in the "Loss" for which
Jiménez seeks coverage under Insuring Agreement 1.1 should be
"deemed first made."
Undeterred by the clear text of the policy on this
crucial point, Liberty nevertheless argues otherwise. To do so,
Liberty asks us to focus not on the text of Insuring Agreement
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1.1, but instead on one of the subsections in the "Limit of
Liability" section of the policy -- section 9.2, to be exact.
That subsection states that "[a]ll Claims arising from
the same Wrongful Act or Interrelated Wrongful Acts shall be deemed
one Claim and subject to a single limit of liability." That
subsection then further states that "[s]uch Claim shall be deemed
first made on the date the earliest of such Claims is first made,
regardless of whether such date is before or during the Policy
Period." Moreover, the definition of the term "Interrelated
Wrongful Acts," which is set forth in section 25.11 of the policy,
makes clear that the term encompasses any "Wrongful Acts that have
as a common nexus any fact, circumstance, situation, event,
transaction, cause or series of causally connected facts,
circumstances, situations, events, or causes."
Against this background, Liberty argues that the
allegations in the Hernándezes' first amended complaint and in
their second amended complaint "arise[] . . . from the same . . .
Interrelated Wrongful Acts." As a result, Liberty contends -- per
the language in section 9.2 -- that these two "Claims" should be
"deemed one Claim" and that "such Claim shall be deemed first made
on the date the earliest of such Claims is first made," which would
be June 24, 2011. After all, that is the date that the Hospital
received the first amended complaint.
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The problem with this argument, however, is a
fundamental one. As we have explained, the policy establishes
Liberty's obligation to pay for the "Loss" for which Jiménez seeks
coverage not in section 9, but in Insuring Agreement 1.1. And, as
we have seen, Liberty's obligation to pay for Jiménez's "Loss," to
the extent that it exists, arises out of Insuring Agreement 1.1
alone. Section 9, by contrast, merely delineates, by cross-
referencing the policy's declarations page, the most that Liberty
would be obligated to pay to the "Insured(s)" for "all Loss" under
the policy -- "$5,000,000 in any one Claim for the Policy Period
and in the aggregate for the Policy Period."
To be sure, the Insurance Code does dictate that the
policy "shall be construed according to the entirety of its terms
and conditions as set forth in the policy[.]" P.R. Ann. Laws tit.
26, § 1125. But, we do not see how the text of the policy permits
us to import the language in section 9.2 that defines what
constitutes "one Claim" into the term "Claim" as that term is used
in Insuring Agreement 1.1.
The word "Claim" does appear in both section 9.2 and
Insuring Agreement 1.1. But, that fact does not show that the
meaning of this term is invariant throughout the policy. After
all, although generally "[a]n expression to which a plain meaning
is attached in one part of an instrument is held to have the same
meaning in other parts of the same instrument," that presumption
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readily yields when the words are employed in different ways that
"plainly" reveal that they are being used differently in different
parts of the policy. 2 Couch on Ins. § 22:42 (3d ed.). And here,
the policy is quite express in using the word "Claim" differently.
The requirement to aggregate "Interrelated Wrongful
Acts" on which Liberty places such great weight appears only in
section 9.2. That requirement is conspicuously absent from either
the general definition of "Claim" in section 25.3 or the text of
Insuring Agreement 1.1 itself.12 Moreover, when section 9.2 states
that "[s]uch Claim shall be deemed first made on the date that the
earliest of such Claims is first made, regardless of whether such
date is before or during the Policy Period" (emphasis added), the
"such Claim" there referenced is clearly the "one Claim" that, per
section 9.2's special instruction, has been aggregated. And,
section 9.2 makes clear that this aggregated "one Claim" is then
"subject to a single limit of liability."
Thus, as this review shows, there is no text in section
9.2 that indicates that the reader of the policy must treat
interrelated "Claims" as "one Claim" for any purpose other than
12And, as we have pointed out already, it is clear that "Insured
Persons" and "Insured Organization[s]," respectively -- are
distinct. The text of the policy demonstrates this distinction
in, for example, section 25.8 of the policy, which defines the
general term "Insured(s)" to include first "Insured Persons" and
then "solely with respect to Insuring Agreements 1.2 and 1.3, the
Insured Organization." (Emphasis added).
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for the purpose of determining the limit of Liberty's liability
for a covered "Claim." Nor is there any text in that section that
indicates that the reader must do so in determining the threshold
question of whether, under Insuring Agreement 1.1, Liberty is
obligated to pay "all Loss" resulting for a "Claim" made "against"
an "Insured Person." And, as we have seen, there also is no text
in Insuring Agreement 1.1 that so indicates. Thus, the special
usage of "Claim" in the one portion of section 9.2 on which Liberty
relies says nothing -- and, in context, certainly nothing clearly,
see López & Medina Corp., 667 F.3d at 64 (explaining that ambiguous
insurance policy language must be liberally construed in favor of
the insured and maximizing coverage under Puerto Rico Law) -- about
what a "Claim" is under Insuring Agreement 1.1.13
We thus reject Liberty's assertion that the "Claim" for
which Jiménez seeks coverage from Liberty was "first made" prior
to the beginning of the policy at issue. And because that is the
only ground on which the District Court relied in dismissing
Jiménez's claim, we reject its reasoning for granting Liberty's
motion for summary judgment.
13 For the same reasons, the "Claim" referenced in the part of
section 25.3's definition that states that a "Claim" is "deemed
first made" when it is received by "an Insured" is not an
aggregated one. Rather, the "Claim" referenced in that sentence
clearly refers to a "Claim" as just defined in that section, which
is, as is relevant here, "a civil . . . proceeding . . . against
an Insured Person."
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D.
Liberty does argue, in the alternative, that we may
affirm the District Court's summary judgment ruling for reasons
that Liberty raised below but that the District Court did not reach
in its ruling. In particular, Liberty argues that, even if the
second amended complaint constituted a "Claim . . . first made"
within the Policy Period, two exclusions in that policy make clear
that the specific allegations against Jiménez in the second amended
complaint are not covered by the D&O policy.
Liberty argues first that the exclusion at section 5.1
of the policy, which states, in relevant part, that Liberty "shall
not be liable to make any payment for Loss in connection with any
Claim: for bodily injury, sickness, diseases, death, emotional
distress, [or] mental anguish," encompasses the "remedies and
compensatory damages" that the Hernándezes seek in their second
amended complaint. Jiménez, for his part, does not appear to
dispute that certain of the damages sought by the Hernándezes may
be characterized as claims for damages for "bodily injury,
sickness, diseases, death, emotional distress, [or] mental anguish
. . . ." But, Jiménez contends, at least some of the damages
sought -- such as the compensation that he seeks for loss of
enjoyment of life, loss of capacity to generate income, special
medical treatment and equipment and lifetime care and support --
are not within the scope of the section 5.1 exclusion.
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Liberty also argues that, even if the section 5.1
exclusion does not bar coverage, the "absolute medical
malpractice" exclusion does. That exclusion states that Liberty
is "not . . . liable for Loss . . . on account of any Claim made
against any Insured based upon, or arising out of, attributable to
or in any way involving, in whole or in part, the rendering [of],
or failure to render, professional services in connection with the
Insured's business as a provider of medical services." The
exclusion goes on to define "professional services" as including:
[W]ithout limitation: . . . providing medical,
surgical, dental, psychiatric or nursing treatment,
care, diagnosis or services, including the furnishing
of food or beverage in connection therewith; . . .
providing routine and/or esoteric testing services,
including MRI, radiology and/or X Ray, used in the
diagnosis, monitoring, and/or treatment of disease or
any other medical condition; . . . furnishing or
dispensing drugs or medical, dental or surgical
supplies or appliances; . . . providing services as a
member of or participant in a formal medical peer
review committee, board or similar medical peer review
group of the Insured Organization, hospital, or
professional society; or . . . giving advice in
connection with any of the above.
Jiménez responds by pointing out that there appear to be
no allegations in the second amended complaint that Jiménez ever
treated Lind Hernández or should have provided treatment to Lind
Hernández. Instead, the allegations against Jiménez appear to
relate only to his administrative duties as the medical director
of the Hospital. As such, Jiménez contends that Liberty's argument
that the "Claim" made against Jiménez via the Hernándezes' second
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amended complaint is "based upon, or arising out of, attributable
to or in any way involving, in whole or in part, the rendering
[of], or failure to render, professional services in connection
with the [Jiménez]'s business as a provider of medical services"
lacks support. And thus he contends that Liberty is wrong to argue
that this exclusion applies because "[t]he allegations asserted
against . . . Jiménez are clearly based upon, arise out of, are
attributable to, and involved, in almost exclusive part, the
rendering or failure to render appropriate medical care or medical
services to . . . Lind Hernández."
We may, in our discretion, affirm a ruling below on legal
grounds not addressed by the District Court. See Am. Steel
Erectors v. Local Union No. 7, Int'l Ass'n of Bridge, Structural,
Ornamental & Reinforcing Iron Workers, 815 F.3d 43, 63 (1st Cir.
2016)(explaining that the Court of Appeals "may affirm [a summary
judgment ruling] on any ground made manifest in the record,
untethered to the district court's rationale"). And the debates
over the scope of these exclusions concerns the proper construction
of the scope of the insurance policy and thus arguably present
pure questions of law.
But, in this case, we conclude that the prudent course
is to leave it to the District Court to consider these thus far
unaddressed arguments. That way the District Court may decide
whether, in light of any relevant record facts, and the general
- 27 -
directive in Puerto Rico law to interpret the exclusionary clauses
at issue narrowly, see AJC Int'l, Inc., 790 F.3d at 4 (quoting
Pagán
Caraballo, 22 P.R. Offic. Trans. at 101); Guerrido Garcia v.
U.C.B., No. CE-94-448,
1997 WL 321101 (P.R. May 30, 1997)
(explaining that under Puerto Rico law "exclusionary clauses must
be restrictively construed so that the policy's purpose of
protecting the insured is met"), these exclusions provide an
independent basis for granting summary judgment to the defendants.
Accordingly, we decline to address these issues in the first
instance.
III.
The District Court's entry of summary judgment is
vacated, and we remand the case for further proceedings consistent
with this opinion. The parties shall bear their own costs.
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