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Professional liability insurance is essential for the legal as well as other professions in our current world. Professional malpractice in the truest sense is a rare phenomenon, however, lawsuits between lawyers and former clients are not so rare especially when there are fee disputes or between accountants and clients when there is a misleading financial statement and a late filing on a tax return or between customer and broker after the account sustained significant losses in a down market. The costs of litigation and arbitration are significant and, accordingly, prudence dictates that professional liability insurance be purchased. However, it is especially important to examine what the insurance does cover and whether the claims management of the insurers fairly and honorably meets the needs of the insureds. Abusive Practices As a result of the abusive claims practices that this practicing lawyer has experienced in the last year in regard to a number of client insureds, I think it will be helpful to review the essentials of the “litigation insurance” component of professional liability insurance to more effectively protect not only the client but also your own firm and yourself when coverage disputes arise with the insurer and to assure that the carrier will not overstep and engage in abusive claims practices. Abusive practices start with initial evaluation of the claim and extend through the claims handling process even when the insurer provides a defense. To walk away from defense obligations insurers employ “the complaint taken as a whole” subterfuge, i.e., while the insured had the professional relationship covered by the policy, the insured was really serving another role and, according to the insurer, any professional services were incidental. Further exclusions in the policy not only expressly deny indemnity by virtue of the specific products or services but any “allegation” or any activity “related to” the product or service is excluded so the insurer disclaims defense coverage even when the insured denies being involved in such activity. This is specious since insurers are to defend even when the claims are false, fraudulent and groundless. Defense coverage where there is a reservation of rights and the insurer is obligated to respect the insured’s choice of counsel and pay its reasonable fees is diluted when the insurer attempts to limit the insured counsel’s hourly rate to the minimal rate set for panel counsel who defend when the insurer assumes the liability risks. Further, paying expert consultants and witnesses is often partially or wholly avoided with the contention that notwithstanding counsel’s tactical choice to engage the expert as a consultant and/or testifying witness, the expert is not needed and is not allowed for by the insurer’s “budget.” In one recent securities arbitration, this author experienced a claims person declaring the carrier would only pay for the expert’s time on the witness stand and not for preparation or attending the hearing so that he could render an opinion on the record as a whole. The foregoing, as will be demonstrated in this article, is bad faith and should be remedied by the industry and professional associations as well as the regulators because it defeats the purpose of “litigation insurance” paid for by substantial premiums. Settled Principles In professional liability insurance, the insurance covers both the risks of litigation and liability. 1It is a combination of litigation insurance and liability insurance that additionally provides indemnification for the insured in the event of an adverse award or judgment and/or settlement. 2Most policies indicate also that the insurer has both the right and duty to defend. When the insurer accepts the insured’s risks of liability it has no conflict and is entitled to control the defense, i.e., has the right to defend. However, when the insurer disclaims the risk of liability the insurer still must provide the defense for which it received premiums although the insured controls the defense by selecting his own counsel at the insurer’s reasonable expense. 3 If a reading of the policy in conjunction with the pleadings merely suggests the possibility of a covered claim or even if it does not, but the facts outside of the pleadings suggest a covered claim, the insurer must defend. 4It is the insurer’s burden to establish, as a matter of law, that the allegations of the complaint unambiguously “cast the pleading solely and entirely within the policy exception.” 5This is the settled law that is so deeply rooted that the insurer’s disregard more often than not has to be conscious and willful and a mandate for the court to swiftly remedy. 6 Further, if one claim in a multiple claim complaint potentially falls within the indemnity coverage provided for in the policy, the insurer must defend the entire action. 7The cases also stand for the proposition that even if the pleadings do not trigger the duty to defend there is such a duty when extrinsic facts outside of the complaint trigger the obligation. 8Moreover the cases also stand for the proposition that the insurer may not rely on outside facts to negate the obligation. 9 All jurisdictions including New York adhere to the above-stated propositions. In 1974, the Court of Appeals addressed a case where plaintiff sought to recover from its insurer the legal fees and disbursements incurred in defending an action brought by an employee in which damages were sought for personal injuries by reason of plaintiffs’ alleged negligence. The insurer disclaimed liability and refused to defend the negligence action. The plaintiff was required to retain counsel to represent it in the underlying litigation that resulted in a dismissal of the action. The Court in International Paper Company v. Continental Casualty Co., in determining the insurer breached its duty of defense held:
It is manifestly clear that the negligence complaint did not allege facts sufficient to find on its face, that it was subject to . . . [the] policy exclusions, and . . . if the insurer is to be relieved of a duty to defend it is obligated to demonstrate that the allegations of the complaint cast that pleading solely and entirely within the policy exclusions, and, further, that the allegations, in total are subject to no other interpretation.As a consequence, even if the complaint fails to articulate adequately an action grounded solely in negligence, the insurer is required to defend. An insured’s right to be accorded legal representation is a contractual right and consideration upon which his premium is in part predicated, and this right exists even if debatable theories are alleged in the pleading against the insured.(Emphasis added)
The Court further held, as would be true in every case a policy is purchased for litigation insurance:
In plain and concise language, and without equivocation, the defendant obligated itself to defend any action brought against the . . . insured whenever alleged a cause of action in negligence covered by the policy regardless of the ultimate factual determination of the occurrence . . . *** An insurer’s obligation to furnish its insured with a defense is heavy indeed, and of course, broader than its duty to pay. The rule to be followed is clearly set out in Goldberg v. Lumber Mut. Cas. Ins. Co. of New York(297 N.Y. 148, 154), wherein this Court wrote: ‘Indeed even in cases where the policies do not render the allegations by the injured party controlling,’ it has been said, the distinction between liability and coverage must be kept in mind. So far as concerns the obligation of the insurer to defend the question is not whether the injured party can maintain a cause of action against the insured, but whether he can state facts which bring the injury within coverage. If he states such facts the policy requires the insurer to defend irrespective of the insured’s ultimately liability . . . The insurer is cloaked with the burden of proving that the incident and claim thereunder came within the exclusions of the policy . . .(Emphasis added)
Clearly the duty to defend is broader than the duty to indemnify. 10 In Public Service Insurance Co. v. Goldfarb,the Court held that the determination of an insurer’s duty of indemnification comes after a finding of the facts and a special jury verdict is returned by the jury. Before that point the insurer “must . . . defend . . . in the pending lawsuit because a claim within the stated coverage has been made” and “[m]oreover, inasmuch as the insurer’s interest in defending the lawsuit is in conflict with the defendants’ interest – the insurer being liable only upon some of the grounds for recovery asserted and not upon others . . . [the insured] is entitled to defense by an attorney of . . . [the insured's] own choosing, whose reasonable fee is to be paid by the insurer.” 11 Litigation Insurance In regard to litigation insurance the Court of Appeals said:
An insurer must defend whenever the four corners of the complaint suggest – or the insurer has actual knowledge of facts establishing a reasonable possibility of coverage . . . the duty is broader than the insurer’s obligation to indemnify: [t]hough policy coverage is often denominated as ‘liability insurance,’ where the insurer has made promises to defend ‘it is clear that the [coverage] is, in fact, ‘litigation insurance’ as well.’(Emphasis added)
Moreover, it is the insurer’s burden to “establish as a matter of lawthat there is no possible factual or legal basis on which it might eventually be obligated to indemnify its insured under any policy provision” (emphasis added). If the complaint in the underlying action merely suggests a malpractice or breach of fiduciary claim by a professional, the action is squarely within the ambit of coverage and presents a burden that cannot be met by the defendant insurer. 12 In fact, any review of the cases demonstrates it is a virtual impossibility to preclude coverage if the insured is acting in the context to which the insurance applies. In Steadfast Insurance Company v. Stroock & Stroock & Lavan LLP, 13a lawyer liability case, the Court held:
An insurer may escape its duty to defend only if the insurer demonstrates that the allegations of the complaint cast the pleadings wholly within . . . [the] exclusion, that the exclusion is subject to no other reasonable interpretationand that there is no possible factual or legal basis upon which the insurer may eventually be held obligated to indemnify the insured under any policy provision. If any of the claims against the insured arguably arise from covered events, the insurer is required to defend the entire action.(Emphasis added). If the universe of claims against the insured requires proof of conduct that is excluded from coverage then the insurer has no duty to indemnify or defend its insured . . . The insurer bears the burden of proving that the exclusions apply in a particular case . . . ‘this burden is heavy, especially when the insurer is seeking to avoid the duty to defend.’ . . . . Exclusionary clauses are strictly construed to give the interpretation most beneficial to the insured . . . a construction favorable to the insurer will be sustained only if it is the only construction which may fairly be placed on the[words used]. (Emphasis added)
Insurer Avoiding Obligation An insurer can only avoid its obligation to defend if it can show as a matter of law no such duty. 14This can almost never be shown so it is incomprehensible there are as many coverage disputes relating to the duty to defend as occur today. Further, there is no prejudice to the insurer defending as observed in Steadfast Insurance Company v. Stroock & Stroock & Lavansince the insurer can issue a reservation of rights that precludes the insurer from waiving its coverage defense. Almost 30 years from the date the New York Court of Appeals articulated the breadth of the duty of defense and the standards for its interpretation and application the U.S. District for the Southern District of New York in Admiral Insurance Company v. Weitz & Luxenberg, et al. 15articulated and applied the same rooted principles to make a determination in regard to the insurer’s duty of defense. The case was also a lawyer liability action. The Court held:
Courts in New York have held that an insurer’s duty to defend and to pay defense costs under liability insurance policies must be construed broadly in favor of the policyholder. Further, it is broader than the duty to indemnify. an insurer’s duty to defend arises whenever the allegations in a complaint state a cause of action that gives rise to a reasonable possibility of recovery under the policy . . . . If the allegations of the complaint are even potentially within the language of the insurance policy, there is a duty to defend . . .If any of the claims against [an] insured arguably arise from covered events, the insurer is required to defend the entire action . . . . Indeed, ‘the duty to defend arises whenever the allegations in the complaint against the insured fall within the scope of the risks undertaken by the insurer . . . [and it is immaterial] that the complaint against the insured asserts additional claims which fall outside the policy’s general coverage or within its exclusionary provisions’ . . . the merits of the complaint are irrelevant. (Emphasis added)
If any segment of the complaint implicates a covered risk, then there is defense coverage. In Admiral Insurance Co. v. Weitz and Luxenberg PC, et al.,the Court further observed that if the insurer has a duty to defend “it has a duty to defend against the entirecomplaint.” Further, the Court in the case held “[a] policyholder may recover attorney’s fees incurred in successfully defending itself against an insurer’s attempt to free itself form its obligations under an insurance policy.” There should be no distinction between the insurer bringing an action to deny coverage and its stonewalling its obligations to provide a defense forcing its insured to bring an action for declaratory judgment. In the context the insured is in as much of a defensive posture after a disclaimer as the insured being required to defend against the insurer bringing a declaratory judgment action to deny coverage. In fact, an insured having to defend against liability and personally incur substantial litigation expenses after paying ever-increasing premiums on a yearly basis is clearly in a defensive posture. In Napoli Kaiser & Bern LLP v. Westport Insurance Corp., 16the Court addressed an equivocal breach of fiduciary claim asserted against a law firm as follows:
A breach of fiduciary duty claim can be based on negligence and the complaints carefully do not allege that the breach was intentional . . . . The Claimant Firms, in addition to the primary allegations of fraud, have alleged that . . . [the Claimant Firm] breached its fiduciary duty in obtaining low settlements for the referred clients. It is entirely possible that Claimant Firms will be unable to prove a scheme by . . . [Claimant Firm] to distort settlements, but that they will be able to show that . . . . [Claimant Firm] negligently represented the referred clients. Such a ‘reasonable possibility’ of coverage is sufficient to trigger the duty to defend. . . (Emphasis added)
As a result of the foregoing, insurers should better monitor their claims personnel and coverage counsel to make sure the insurer honors its duty to defend. Bar associations, professional organizations and insurance regulators should also be attentive to this issue. Bad Faith In Smith v. American Family Mutual Ins. Co., 17the court addressed the sufficiency of allegations against an insurer for breach of the implied covenant of good faith and fair dealing holding that such a cause of action can be sustained where the insurer objectivelyacts without justification. Further, neither the breach of the covenant of good faith and fair dealing, nor the claim of bad faith and fraudulent marketing and claims practices is limited to the duty of indemnification. In Hugo Boss Fashions Inc., et al v. Federal Insurance Co., 18the U.S. Court of Appeals held: ” . . . an insurance company could perfectly reasonably disclaim indemnify coverage, and yet be in bad faith in refusing to defend until the scope of coverage was determined.” To be entitled to attorney’s fees and costs for securing coverage and a punitive damage award there must be “ a gross disregard for its policy obligations” by the insurer. Citing New York case law the Court held:
. . . [t]here remains a strong presumption in New York against a finding of bad faith liability by an insurer . . . . ‘It is . . . well-settled that an insured cannot recover his legal expenses in a controversy with a carrier over coverage, even though the carrier losses the controversy, and is held responsible for the risk.’ The presumption against bad faith liability can be rebutted only by evidence establishing that the insurer’s refusal to defend was based on ‘more than an arguable difference of opinion’ and exhibited ‘a gross disregard for its policy obligations.’(Emphasis added)
In the case cited above the bad faith issue was decided by the Court after a jury trial. The policyholder did not adduce sufficient evidence “as a matter of law, to overcome the presumption.” The court drawing a similar conclusion to a cited New York State case held “‘the record shows merely an arguable case in which the carrier was held wrong . . . [and] (t)hat is not enough to impose a liability beyond the terms of the contract.’” Where the policy language and pleadings clearly indicate the possibility of a covered claim there is not nor can there be any reasonable difference on the issue of the duty to defend, i.e., what is written cannot be ignored. As noted in Pavia v. State Farm Mutual Automobile Insurance Co., 19when the facts show “an extraordinary . . . disingenuous or dishonest failure to carry out the insurance contract,” bad faith is demonstrated. Bad faith is more apt to be shown by the comparison of the language in the policy and the pleadings and therefore a breach of the duty to defend can more easily fit in the bad faith category than other acts or omissions of insurers. Nor is the cause of action for breach of the duty of good faith and for fair dealing duplicative of plaintiffs’ cause of action for bad faith and fraudulent marketing and claims practices. The insurer’s breach of its obligations under its insuring agreement with the individual plaintiffs when there is serious misconduct also constitutes “acts or practices” that “must . . . [and does] have a broad impact on consumers at large.” 20It is not strictly a matter of private contract. Claims for breach of the covenant of good faith and fair dealing distinctly permit insureds to recover defense costs in the underlying action and the bad faith and fraudulent marketing and claims practice claims encompass recovery for the attorney’s fees and costs in securing defense coverage and do justify the courts upon the evidence to submit a special verdict form to the jury as to whether punitive damages should be awarded. The cause of action based on bad faith and fraud is also based on facts relating to the marketing and claims practices that predate the particular claims made policy in issue because the insurer continues to offer “litigation insurance” and collects significant premiums with apparently no intent to honor its defense obligation under the policy when circumstances would trigger that obligation. Such conduct breaches duties independent of the specific insuring agreement and relates to ongoing and continuous acts and omissions of the insurer to collect premiums based upon publicly stated commitments it has no intent to honor. The bad faith and fraudulent marketing and claims practices are not merely limited to a breach of a specific contract or a private wrong. Recovery for such deceptive marketing and claims practices are also permissible under General Business Law (GBL) �349. 21Over the years when insureds purchase and renew their lawyer’s professional liability policy and pay significant yearly premiums, and the insurers repeatedly represent and promise that the policy will be providing “litigation insurance,” with no intent to perform; there should be no doubt that a case is made out for bad faith. Such a wrong is consumer-related and adversely affects the public interest. The insurer should not be entitled to avoid liability for the insured’s attorney’s fees and costs in bringing the coverage action by itself and not bringing the action to settle coverage issues, because the insured, by virtue of having to defend an underlying action without the defense coverage provided by the policy, is truly in a defensive posture created by the insurer’s unjustified disclaimer. Even if New England Mutual Life Insurance Co. v. Johnson 22and Mighty Midgets Inc. v. Centinental Insurance Co., 23are given restrictive scope, the insurer, by virtue of its bad faith denial of coverage, should be estopped from such a defense. 24In any event �349 of the GBL allows for such recovery. 25 A bad faith denial of defense coverage is also appropriate for punitive damages. In Walker v. Sheldon 26the Court held:
Punitive or exemplary damages have been allowed in cases where the wrong complained of is morally culpable or is actuated by evil and reprehensible motives, not only to punish the defendant but to deter him, as well as others who might otherwise be so prompted from indulging in similar conduct in the future. *** Although they have been refused in [an] ‘ordinary’ fraud deceit case . . . we are persuaded that on the basis of analogy, reason and principle there may be exemplary damages in fraud and deceit actions where the fraud, aimed at the public generally is gross and involves high moral culpability.
It is unlawful in New York to engage in “[d]eceptive acts or practices on the conduct of any business trade or commerce.” 27Any person injured by such violation of the deceptive acts or practices prohibition is entitled to bring an action in his own name to recover his damages not to exceed one thousand dollars. The court may award a prevailing plaintiff attorney’s fees. Id. In order to plead a claim under Gen Bus. Law �349, it must be shown the unlawful conduct is consumer-oriented, that it is deceptive and has injured the plaintiff. 28Conduct is considered deceptive if it is likely to mislead a reasonable consumer acting reasonably under the circumstances. 29In order for conduct to be consumer-oriented, it does not need to be repetitive or recurring but . . . must have a broad impact on consumers at large . . . .” 30Denying wrongfully an essential feature of professional liability insurance that is the prime reason for insureds buying the insurance is a wrong that, when it occurs, has to be a consumer-oriented wrong fitting within the General Business Law’s prohibitions, as well as an independent wrong actionable under the common law of torts. Conclusion To maximize one’s professional liability insurance coverage and to effectively resist a wrongful denial of coverage one merely has to start with the proposition that when the policy language read in conjunction with one specific allegation in the pleading indicates there is the mere possibility of at least one covered claim, the insurer cannot squirm out of its obligations. When a reservation-of-rights letter is issued indicating there is a conflict between the insurer and insured, the insurer thus has given up its right to control the defense although it still may have a clear duty to defend for which it will be held strictly responsible. In such instances the insurer should pay the reasonable fees of the insured’s counsel and other litigation costs that it cannot “skimp on,” as exceeding its guidelines, because it no longer controls or should control the defense. Professional liability insurance is very important today. The underwriting process, if done right, can lead to sound risk management and avoidance. Professional insureds will be protected against catastrophic economic injuries but most significantly the ever- increasing economic burdens of litigation will be ameliorated for the individual and small firm professional. Justice Louis Brandeis once observed, “Sunlight is the best disinfectant.” This is why the claims practices relating to “litigation insurance” need to receive the “sunlight” of our attention, so that bad and fraudulent practices can be eliminated and both the insurers and the professional insureds can and shall engage in best practices. Norman B. Arnoff practices law in New York City. Endnotes: 1. Inter. Paper Co. v. Continental Cas. Co.,35 N.Y.2d 322, 325, 361 N.Y.S.2d 873 (1974). 2. Hugo Boss Fashions, Inc. v. Federal Ins. Co.,252 F.3d 608, 615 (2d Cir. 2001) citing Hanover Ins. Co. v. Cowan, 172 A.D.2d 490, 568 N.Y.S.2d 115, 116 (2d Dept. 1991). 3. Public Service Mut. Ins. Co. v. Goldfarb, 53 N.Y.2d 392, 401, 442 N.Y.S.2d 422 (1981). 4. Continental Cas. Co. v. Rapid Am. Corp.,80 N.Y.2d 640, 648, 593 N.Y.S.2d 966 (1993). 5. Inter. Paper Co.,35 N.Y.2d at 325, 361 N.Y.S.2d 873 accord Allstate Ins. Co. v. Riggio,125 A.D.2d 515, 509 N.Y.S.2d 594 (2d Dept 1986). 6. See also the following cases that hold that as long as the allegations of the complaint give rise to the possibility of recovery on a covered claim there is a duty to defend: Continental Cas. Co. v. Rapid-American Corp.,80 N.Y.2d 640, 593 N.Y.S.2d 966 (1993); Lusalon, Inc. v. Hartford Acc. & Indem. Co.,400 Mass. 767, 511 N.E.2d 595 (1987). 7. See, e.g., Public Service Mut. Ins. Co. v. Glodfarb,53 N.Y.2d 392, 401, 442 N.Y.S.2d 422 (1981); Ruder & Finn., Inc. v. Seabord Sur. Co.,52 N.Y.2d 663, 439 N.Y.S.2d 858 (1981). 8. See, e.g., < ahref=”http://www.law.cornell.edu/nyctap/I91_0083.htm” target=”new” Fitzpatrick v. American Honda Motor Co., 78 N.Y.2d 61, 571 N.Y.S.2d 672 (1991); United States Fidelity & Guar. Co. v. United States Underwrites Ins. Co.,194 A.D.2d 1028, 599 N.Y.S.2d 654 (3d Dept. 1993). 9. See, e.g., Fitzpatrick v. American Honda Motor Co.,78 N.Y.2d 61, 571 N.Y.S.2d 672 (1991); Petr-All Petroleum Corp. v. Fireman’s Ins. Co.,188 A.D.2d 139, 593 N.Y.S.2d 693 (4th Dept. 1993) (same). 10. See Emery v. Capital Mut. Ins. Co.,151 A.D.2d 854, 542 N.Y.S.2d 289 (3d Dept. 1989); Colon v. Aetna Life & Cas. Ins. Co.,66 N.Y.2d 6, 494 N.Y.S.2d 688 (1985). 11. See also, 225 East 57th Street Owners Inc. v. Greater New York Mutual Insurance,187 AD 2d, 589 NYS 2d 481 (First Dept. 1992). 12. See also the following cases holding that the duty to defend which is essentially “litigation insurance” requires the insurer even to defend “groundless, false or fraudulent claims.” See Monroe County Water Auth v. Travelers Ins. Co.,195 A.D.2d 1043, 600 N.Y.S.2d 862 (4th Dep’t 1993); Trizec Properties Inc. v. Biltmore Constr. Co.,767 F.2d 810 (11th Cir. 1985). 13. 227 F.Supp.2d 245 (SDNY 2003), 14. The following cases stand for this proposition: New York v. Blank,745 F.Supp. 841 (N.D.N.Y. 1990), aff’d in part, vacated in part, 27 F.3d 783 (2d Cir. 1994); Nancie D. v. New York Cent. Ut. Fire Ins. Co.,195 A.D.2d 535, 600 N.Y.S.2d 472 (2d Dept. 1993). 15. 2002 U.S. Dist. Lexis 20306 (SDNY 2002) 16. 293 F.Supp. 2335, 2003 U.S. Dist. Lexis 22497 (SDNY 2003). 17. 294 NW 2d 751 (N.D. 1980). 18. 252 F3d 608; 2001 US App. Lexis 12080; 59 U.S.P.Q.2d (DNA) 1161 (2d Cir. 2001). 19. 82 NY2d 445, 626 NE2d 24 (Court of Appeals 1993). 20. Rosenberg & Estes P.C., et al v. Chicago Insurance Co., 2003 WL 21665680 (N.Y. Supp.), 2003 NY Slip Op. 51085 (U) and Binder v. National Life of Vermont,2003 WL 21180417 (SDNY 2003). 21. Zawaher v. Berkshire Life Ins. Co., 22AD 3d 841, 804 NYS2d 405 (2d Dept. 2005). 22. 155 Misc.2d 680, 589 NYS 2d 736 NY Supp. 1992 (Sup. Ct. NY Co. 1992). 23. 47 N.Y.2d 12, 389 NE2d 1080, 416 NYS2d 559 (1979). 24. Harradine v. The Board of Supervisors of Orleans County,73 A.D.2d 118, 425 N.Y.S.2d 182 (4th Dept 1980); United Pickle Co., Inc. v. Omanoff,63 A.D.2d 892, 892, 405 N.Y.S.2d 727, 728 (1st Dept. 1978). 25. See Gaidon v. Guardian Life Insurance Co. of America,94 NY 2d 330, 704 NYS 2d 177 (1999). 26. 10 NY2d 401, 405, 223 NYS2d 488, 179 NE2d 497 (N.Y. Court of Appeals). 27. Gen. Bus. Law �349(a). 28. New York University v. Continental Ins. Co., 87N.Y.2d 308, 318, 639 N.Y.S.2d 283, 289 (1995); Gaidon v. Guardian Life Insurance Co. of America,94 N.Y.2d 330, 334, 704, NYS 2d 177, 183 (1999). 29. Gaidon94 N.Y.2d at 344, 704, N.Y.S.2d at 183. 30. 87 N.Y.S.2d at 320, 639, N.Y.S.2d at 290.

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