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ONCE MORE UNTO THE BREACH: HOW
COUNSEL SHOULD HELP CLIENTS
PREPARE FOR AND RESPOND TO DATA
INCIDENTS
AUTHORS
Sharon R. Klein
Partner | 949.567.3506
7/01/2016
Alex C. Nisenbaum
Associate | 949.567.3511
NEWS
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7/12/2016
Jan P. Levine Quoted in The Legal
Intelligencer Article, 'Judge Approves $8.4M
Settlement in Egg Class Action'
7/12/2016
Todd B.
Reinstein Quoted in Bloomberg
Article, 'Wells Fargo's Partial Tax Victory May
Spur Billions in Refunds'
PUBLICATIONS
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7/14/2016
Federal Circuit Finds That Use of a Contract
Manufacturer Does Not Trigger the On-Sale
Bar Provision
Reprinted from California Busines Law Practitioner, copyright 2016 by the Regents of
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7/08/2016
Materiality Is the New Condition of Payment:
The Implied False Certification Theory After
. the University of California. Reproduced with permission of Continuing Education of
the Bar - California (CEB). No other republication or external use is allowed without
permission of CEB. All rights reserved.
(For information about CEB publications,
telephone toll free 1-800-CEB-3444 or visit our web site - CEB.com)
The statistics are staggering: In the last 4 years, the California Office of the Attorney
General (COAG) received reports of 657 data breaches affecting 49 million records. In
2015 alone, 24 million records of Californians were affected by reported data breaches
—that’s three out of five Californians—according to the COAG’s February 2016 Data
Breach Report. California Data Breach Report (Feb.
2016), available at
https://oag.ca.gov/breachreport2016 (COAG 2016 Breach Report).
Statistics like these show that data breaches can and will affect any organization.
Today, it is not “if” but “when” your client will be the victim of a data breach. The legal
and business consequences in terms of remedial costs, litigation, regulatory
enforcement, and reputational harm have compelled businesses to focus on data
privacy and security preparedness. The continued emergence of data as one of the
most highly valued assets of the digital economy lends urgency to these preparations.
Businesses increasingly are using the cloud—transferring data over vulnerable
network connections and engaging in data analytics—and using targeted marketing
and mobile and social media to increase a company’s brand and reach.
Despite the growing risks and many high-profile breaches, there are still businesses
that remain woefully underprepared.
In a recent BDO survey of corporate directors, 55
percent of directors stated their company either did not have, or they were not sure
whether their company had, an incident response plan in place. 2015 BDO Board
Survey (Oct. 2015), available at https://www.bdo.com/getattachment/71efe245-f2b7–
4106-bc25-c76b3d1d3244/attachment.aspx .
Businesses that are unsure of whether
they are prepared to handle data breaches and ongoing compliance with privacy and
data security issues increasingly need guidance from legal counsel on the scope of
their obligations with respect to cybersecurity.
Preparation is key. Although an organization may contact its legal counsel for the first
time on data breach issues in the midst of an ongoing incident, a counsel’s role in
mitigating risk associated with these issues should begin well before an incident
occurs. Applicable law and regulatory guidance make clear that an organization’s
responsibility for the privacy and security of data does not begin with discovery of a
data incident.
Rather, organizations that collect personal information have a legal
responsibility to take reasonable steps to safeguard such information in their
possession, and regulators are fining companies if proper measures have not been
taken to prevent risk, not merely because a breach has occurred.
California law requires that a business “implement and maintain reasonable security
procedures and practices appropriate to the nature of the information, to protect
personal information from unauthorized access, destruction, use, modification, or
disclosure.” CC §1798.81.5(b). Other states have similar requirements. For example,
Massachusetts requires organizations to implement and maintain a comprehensive
written information security program.
201 Mass Code Regs §17.00 (2009). Federal
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The Implied False Certification Theory After
Escobar
EVENTS
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July 18-20, 2016
Opal Financial Group, Family Office &
Private Wealth Management Forum: The
Race for Returns
July 20-21, 2016
2016 New York Venture Summit
WEBINARS
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7/20/2016
Independent Contractor Classification: What
to Do and Not Do After Uber
7/29/2016
The Role of Indemnity and Insurance in
Business Litigation (Mechanicsburg,
Simulcasts and Webcast)
PODCASTS
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6/02/2016
Evolution of Blockchain for Investment
Management Companies and Hedge Funds
6/01/2016
Exploring the Large Role of Successor
Liability in Bankruptcy Cases
BLOGS
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7/09/2016
Status Quo At The PTAB for Now: Supreme
Court Makes No Changes to IPR Practice
7/06/2016
Court of Federal Claims Rules Contracting
Officer's Failure to Exercise Independent
Business Judgment Renders Partial
Termination for Conveniencea an Abuse of
Discretion and Breach, but Holds
Subsequent Termination for Cause of
Remainder of Contract to Be Appropriate
. laws, such as the Gramm-Leach-Bliley Act (GLBA) (Pub L 106–102, 113 Stat 1338)
and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Pub L
104–191, 110 Stat 1936), mandate general security requirements for financial services
organizations and health care organizations, respectively. In addition, the Federal
Trade Commission (FTC) has pursued a number of enforcement actions alleging
“unfair” trade practices under section 5 of the Federal Trade Commission Act (FTC
Act) (15 USC §45) against companies for failure to employ adequate cybersecurity
safeguards. See, e.g., FTC v Wyndham Worldwide Corp. (3d Cir 2015) 799 F3d 236.
Accordingly, organizations cannot ignore their responsibility to appropriately address
the privacy and security of sensitive personal information.
This article outlines an organization’s legal responsibilities with respect to cyber risk,
suggests how legal counsel can better prepare clients to mitigate risks before and
during a data incident, and reviews the legal obligations and issues that counsel must
address with a client in navigating a data breach.
The article begins by addressing data security-related issues on which legal counsel
should advise an organization before any data incident.
These matters include
advising the client’s directors and management on their responsibilities to provide
appropriate oversight and direction of an organization’s cybersecurity program,
implementing appropriate training programs for the client’s personnel, helping to
manage data security issues in an organization’s supply chain, assisting the client
organization in establishing and testing an incident response plan, and reviewing
insurance issues. The article then discusses legal requirements that counsel should
help a client navigate in the event a security incident results in a reportable data
breach, including California and other state and federal breach notification laws and
best practices for the maintenance of attorney-client privilege and work product
protections for data breach investigations. Finally, the article summarizes potential
liability for noncompliance with privacy and security laws.
Counseling the Client Before the Breach
Board Duties
Regulators and the courts have repeatedly reminded us that cybersecurity is a
business issue and not merely an IT issue, and that it must be dealt with as part of
the overall management of an organization.
Commissioner Luis A. Aguilar of the
Securities and Exchange Commission (SEC) has warned directors that “boards that
choose to ignore, or minimize the importance of cybersecurity oversight responsibility,
do so at their own peril.” Aguilar, Boards of Directors, Corporate Governance and
Cyber-Risks: Sharpening the Focus , Remarks at the “Cyber Risks and the
Boardroom” Conference (June 10, 2014), available at
http://www.sec.gov/News/Speech/Detail/Speech/1370542057946.
As a business issue, the executives responsible for managing the organization play a
critical role in determining whether the appropriate time, money, and resources are
being expended to address cybersecurity issues. Indeed, top-down guidance within
the organization is not only critical from an operational perspective; leaders may also
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have legal duties to their organizations to address cybersecurity issues. As a result,
counsel should prepare client organizations for a data breach by providing advice to
directors and executives about how to comply with their fiduciary responsibilities in
the realm of cybersecurity.
Corporate directors owe the corporations they manage fiduciary duties of good faith,
care, and loyalty. To fulfill these fiduciary obligations, corporate directors are required
to perform their duties as a director “in the best interests of the corporation and its
shareholders and with such care, including reasonable inquiry, as an ordinarily prudent
person in a like position would use under similar circumstances.” Corp C §309.
Directors are generally safe from judicial scrutiny of their management decisions due
to the application of the business judgment rule, which in California is codified in Corp
C §309. Will v Engebretson (Cal App 1989) 213 CA3d 1033, 1040.
To take advantage
of the business judgment rule shield, however, directors must exercise appropriate
oversight of their organization’s cybersecurity program. This oversight duty does not
require that directors undertake day-to-day management of cybersecurity issues, but
it does demand that directors and others in corporate leadership positions put in place
reporting and control systems regarding cybersecurity. Counsel should advise the
board and executives on the evaluation, selection, and implementation of appropriate
cybersecurity oversight mechanisms and help corporate directors fulfill their fiduciary
duties before a breach occurs.
Counsel should review cybersecurity oversight mechanisms that may already be in
place at the client organization, analyze the gap between current policies and best
practices, and assist the board and executives in establishing other mechanisms to
develop a comprehensive enterprise risk management program.
Every organization is
unique and the mechanisms chosen should be tailored to the needs of the particular
organization. The cybersecurity program must be integrated into the fabric of the
organizational processes or risk being ignored, which itself could lead to liability. For
example, under HIPAA, having a compliance program that is not implemented
exposes clients to liability for willful neglect, which may subject organizations and
their directors, officers and employees to civil and criminal liability.
See 42 USC
§1320d–5.
Operational mechanisms to help ensure that the board has access to appropriate
information to quantify and mitigate risk and that infrastructure is in place to execute
an enterprise-wide cybersecurity risk management plan can include
Regularly devoting time in board meetings to review cybersecurity issues and listen
to presentations from management responsible for cybersecurity at the
organization, and documenting these activities in minutes;
Appointing a chief information security, privacy, or similar officer to have
accountability for, and report to the board on, cybersecurity issues; and
Assigning a board audit committee with responsibility for cybersecurity issues and
requiring the committee to report regularly to the board in person and in writing.
See Klein & Nuñéz, Cybersecurity: Could It Be Your Next Fiduciary Duty? (Middle
Market Growth, May 2014), available at
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. http://www.pepperlaw.com/publications/cybersecurity-could-it-be-your-nextfiduciaryduty-2014–05–01/ .
Boards should ensure that adequate resources and money are devoted to remediate
identified deficiencies, consistent with the level of risk and organizational resources
and priorities. Boards should also monitor the effectiveness of cybersecurity risk
management plans through ongoing internal and external monitoring of the
organization’s cybersecurity controls.
Documented board attention to cybersecurity issues can be helpful in shielding
corporate directors from shareholder derivative suits. For example, in a derivative suit
against board members of Wyndham Worldwide Corporation, a federal district court in
New Jersey noted that directors had discussed cybersecurity issues at 14 meetings
and Wyndham’s audit committee discussed the same issues in at least 16 committee
meetings. As a result, the court determined that the Wyndham board had investigated
adequately and had a clear understanding of the relevant issues when the board
rejected the plaintiff’s demand that the corporation bring a lawsuit based on data
breaches suffered by Wyndham.
See Palkon v Holmes (D NJ, Oct. 20, 2014, No.
2:14-cv-01234) 2014 US Dist Lexis 148799.
A Holistic Operational Approach
Although organizational preparation for a data breach may start at the top with
management oversight, adequate preparation for a breach requires a holistic view that
should also involve bottom-up efforts to train personnel and instill a culture of security
at the organization. People, not technology, still remain one of the most commonly
exploited cyber vulnerabilities.
Together, errors by authorized users, such as
employees and service providers, and misuse of access privileges by authorized
users accounted for 24 percent of breaches reported to the COAG from 2012 to 2015.
See COAG 2016 Data Breach Report. Phishing and social engineering ruses, and
simple mistakes made by employees and vendors with access to personal
information, commonly result in expensive breaches. Counsel should advise and
assist their clients to establish annual security and privacy training programs for
organization personnel.
Depending on the needs of the organization, the training
programs can include general privacy and security compliance training for all
personnel, as well as specialized training for individuals in functional groups that face
unique or heightened privacy and cybersecurity compliance issues, such as customer
service, sales and marketing, and human resources. Counsel should assist in
identifying legal obligations and cybersecurity needs specific to these groups and
tailor training programs for them.
A holistic view that devotes attention to organizational preparation and establishes
policies and procedures to minimize the risk that personal data could be compromised
is consistent with regulatory guidance in this area by the FTC—which advocates
privacy and security by design within an organization. See FTC Commissioner Edith
Ramirez’s Privacy By Design and the New Privacy Framework of the U.S.
Federal
Trade Commission, Remarks at the Privacy by Design Conference (June 13, 2012),
available at
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. https://www.ftc.gov/sites/default/files/documents/public_statements/privacy-designand-new-privacyframework-u.s.federal-trade-commission/120613privacydesign.pdf.
In June 2015, the FTC released Start with Security: A Guide for Business (available
at https://www.ftc.gov/system/files/documents/plain-language/pdf0205startwithsecurity.pdf ), which distills lessons learned from more than 50 cybersecurityrelated enforcement actions by the FTC. The guidance provides ten principles to help
ensure compliance with the FTC Act when an organization uses personal information
in its business.
Principles from the FTC’s Start with Security guidance:
1. Start with security.
2. Control access to data sensibly.
3.
Require secure passwords and authentication.
4. Store sensitive personal information securely and protect it during transmission.
5. Segment your network and monitor who’s trying to get in and out.
6.
Secure remote access to your network.
7. Apply sound security practices when developing new products.
8. Make sure your service providers implement reasonable security measures.
9.
Put procedures in place to keep your security current and address vulnerabilities
that may arise.
10. Secure paper, physical media, and devices.
A fundamental principle of the FTC framework is that organizations must factor
security into decision-making in every department of the organization’s business and
that organizations must make conscious data decisions every step of the way. For
example, counsel should be involved early to analyze privacy and security risks in
new product development, from registration screens to data capture and database
storage.
According to the FTC guidance, it is important to maintain privacy and
security of personal information throughout the life cycle of data—collection, use,
transmission, storage, and destruction. Data of the typical organization passes
through many hands, from internal users to external service providers. Counsel for the
organization must therefore have a firm grasp of assets and data, including the
location of sensitive data, its transmission routes and its destinations, the risks to
which the data is subject, and the controls required to protect data as it flows within
and outside of the organization.
This holistic approach is stressed in the COAG 2016 Data Breach Report, which
notes that information security is a process that requires a risk management
approach, with basic steps informing and reinforcing each other: identifying assets
and data to be protected, assessing the risks to that data, implementing security
controls, and monitoring the effectiveness of those controls.
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The COAG also advocates the use by organizations of authoritative, comprehensive
security standards to achieve an appropriate standard of care for personal information.
Specifically, COAG guidance states that the 20 controls in the Center for Internet
Security’s Critical Security Controls (CIS Top 20), available at
https://www.cisecurity.org/critical-controls.cfm, identify a “minimum level of
information security that all organizations that collect personal information should
meet” and further provide that an organization’s “failure to implement relevant controls
constitutes a lack of reasonable security.” COAG 2016 Data Breach Report. The CIS
Top 20 are listed in the table below:
CSC
Inventory of Authorized and Unauthorized Devices
1
CSC
Inventory of Authorized and Unauthorized Software
2
CSC Secure Configurations for Hardware and Software on Mobile Devices,
3
Laptops, Workstations, and Servers
CSC
Continuous Vulnerability Assessment and Remediation
4
CSC
Controlled Use of Administrative Privileges
5
CSC
Maintenance, Monitoring, and Analysis of Audit Logs
6
CSC
E-mail and Web Browser Protection
7
CSC
Malware Defenses
8
CSC
Limitation and Control of Network Ports, Protocols, and Services
9
CSC
Data Recovery Capability
10
CSC Secure Configurations for Network Devices such as Firewalls, Routers,
11 and Switches
CSC
Boundary Defense
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. CSC
Boundary Defense
12
CSC
Data Protection
13
CSC
Controlled Access Based on the Need to Know
14
CSC
Wireless Access Control
15
CSC
Account Monitoring and Control
16
CSC
Security Skills Assessment and Appropriate Training to Fill Gaps
17
CSC
Application Software Security
18
CSC
Incident Response and Management
19
CSC
Penetration Tests and Red Team Exercises
20
Other common industry-accepted security standards that may be employed by an
organization, such as the National Institute of Standards and Technology (NIST)
Special Publication 800–53, the International Organization for Standardization’s ISO
27002, and the Payment Card Industry Data Security Standards (PCI DSS), provide
for types of controls similar to the CIS Top 20.
Supply Chain Issues and Third-Party Cyber Risk
Organizations often entrust third-party vendors with sensitive personal information.
This creates data privacy and security supply chain issues that can potentially
compromise the data. Legal counsel can play an integral role in managing these
supply chain issues by helping to conduct appropriate due diligence review of vendors
and ensuring that each vendor contract appropriately addresses privacy and security
issues so that the confidentiality, integrity, and availability of the personal information
entrusted to the vendor organization remains intact.
Before contracting, counsel should make sure that the client understands a vendor’s
cybersecurity practices, which can be achieved through appropriate due diligence.
Counsel should review the vendor’s data security-related policies, procedures, and
other controls and should facilitate the proper level of review by the client to ensure
that the vendor’s policies and procedures are consistent with the client’s
requirements. Often, this can be accomplished by reviewing the results of
independent third-party audits of the vendor’s internal controls related to data
processing, such as a Service Organization Control (SOC) 2 report (see
http://www.aicpa.org/InterestAreas/FRC/AssuranceAdvisoryServices/Pages/AICPASOC2Report.aspx ).
In addition, any vendor that handles sensitive personal information should perform
internal audits and risk assessments in the ordinary course of its business and make
the results or summaries available to customers annually and on request.
Clients in regulated industries may be required to contractually bind their vendors to
specific privacy and security requirements. Vendor compliance with these
requirements is meant to ensure that vendors are not the weak link in the chain,
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requirements is meant to ensure that vendors are not the weak link in the chain,
exposing the regulated company to compliance risk. For health care entities subject
to HIPAA, these agreements are called business associate agreements. Even in the
absence of a special regulatory regime, regulators have made clear that companies
that outsource data security functions to third parties can still be liable in enforcement
actions in the event their vendors fail to provide adequate security. See In re GMR
Transcription Servs., Inc.
(FTC, Aug. 14, 2014, No. C-4482), available at
https://www.ftc.gov/enforcement/casesproceedings/122–3095/gmr-transcriptionservicesinc-matter; In re Upromise, Inc.
(FTC, Mar. 27, 2012, No. C-4351), available
at https://www.ftc.gov/enforcement/cases-proceedings/102–3116/upromiseinc .
When reviewing contracts, it is extremely important to determine the vendor’s
contractual commitments with regard to data privacy and security.
At a minimum,
agreements should address the issues below in an appropriate manner given the
sensitivity of the data at issue. In addition to these issues, counsel should advise
their clients to consider what steps may be appropriate to shift risk through the use of
cyber insurance and the limitations of liability and indemnities in the contract. Vendor
contracts should
Commit the vendor to maintain and enforce reasonable administrative, technical,
and physical safeguards appropriate to the sensitivity of the personal information
being processed;
Maintain client control over sensitive personal information by specifying that the
client organization owns the data and prohibiting the vendor from using the data for
any purpose other than to provide services to the client (to prevent a vendor from
using personal data in unexpected ways for its own profit);
Appropriately address integration with the organization’s incident response plan by
obligating the vendor to share breach-related evidence from the organization’s
cloud provider’s environment;
To the extent possible, make the responsible vendor pay for first-party costs (e.g.,
forensics, credit monitoring, remediation, and notification) as well as third-party
costs (damages to the victim associated with a data breach caused by the vendor);
Make sure that the vendor can meet the organization’s data and document
retention requirements, including those related to any “litigation hold”; and
Require the vendor to return or destroy personal data at the end of the agreement.
Incident Response Plan
Adequate preparation for a security incident requires the development and testing of
an incident response plan well before an incident occurs.
Privacy counsel can play an
essential role in developing and testing such a plan. At a minimum, counsel should
read and understand the organization’s incident response plan before being called on
to assist in responding to a security incident.
The incident response plan should identify the internal interdisciplinary incident
response team and any third parties that an organization has selected to assist in the
event of an incident, such as computer forensics, public relations specialists, and
outside counsel. The plan should provide a flexible approach for categorizing security
events and responding appropriately, from identification and assessment to recovery
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and resumption of normal operations. The plan should also identify which disaster
recovery and business continuity plans are triggered.
Counsel should participate with the client in regular testing of the organization’s
incident response plan. Counsel and client should hold a dry-run exercise by selecting
a hypothetical scenario to run through with all key players in the data breach
response, including the internal incident response team and third parties such as
outside privacy counsel and forensic specialist firms. The response plan should be
well documented, and a roster of participants in the exercise and awareness training
should be maintained.
The plan should be reviewed annually and should be updated
and informed by the client’s experience in privacy and security incidents. The team
should exchange all phone numbers and other contact information, and counsel
should be involved in communications to provide attorney-client privilege protections.
Insurance
Cyber insurance plays a key role in an organization’s overall strategy to mitigate risks
related to data incidents. Although an in-depth discussion of insurance issues is
beyond the scope of this article, counsel should be aware that traditional insurance
policies have over time come to include limitations and exclusions to coverage that
may preclude recovery in the event of a data incident.
Even when cyber insurance is
obtained, it is incumbent on the organization to make sure that the coverage is broad
enough to address the risks that the organization is trying to insure against. Coverage
for potential liability to third parties can generally be obtained, including coverage for
costs related to defense, judgments and settlements, regulatory investigations, fines
and penalties, noncompliance with the Payment Card Industry Data Security Standard
(PCI DSS), and crisis management expenses, such as breach notification costs,
forensic investigations, credit monitoring, and public relations specialists.
Counsel should review the state of the client organization’s cyber insurance to assist
in identifying coverage gaps that may be important to address given the nature of the
client’s business. When obtaining cyber insurance, counsel should collaborate with
the organization’s information technology professionals and compliance experts.
Use
of experienced insurance coverage counsel is also advisable; cyber insurance
policies are negotiable in the current state of the market, and an in-depth
understanding of the nuances of insurance coverage law can help avoid costly
missteps in policy language.
Counseling the Client During a Breach
State Breach Notification Laws
When a security incident occurs, an organization needs knowledgeable privacy
counsel to help guide it through compliance with its obligations under the various state
data breach notification laws. In addition to understanding the timing and content of
notices, counsel must assess whether a breach notice should be sent at all. Many
security incidents do not require breach notification.
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For example, in California, unauthorized disclosure of a credit card number would not
trigger a breach notification unless a PIN or other security code, access code, or
password that would permit access to an individual’s financial account was also
disclosed. See CC §1798.82(h)(1)(C). Given that litigation can ensue within 24 hours
of a breach notice, the decision to issue a breach notice is as important as what to
include and to whom the notice should be sent. California’s general data breach law is
codified at CC §1798.82.
California also has a data breach law specific to breaches of
medical information applicable to licensed health facilities, codified at Health & S C
§1280.15. This article focusses on California’s general data breach law but also
provides an overview of breach notification obligations under specialized regulatory
regimes, including health care.
Forty-seven states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin
Islands have enacted data breach notification laws.
Only Alabama, New Mexico, and
South Dakota have no data breach legislation. The notification triggers and other
aspects of the data breach notification laws can vary, creating the potential for
multiple obligations for an organization that is required to provide notice. To ensure
that the organization can meet its obligations under each of the applicable laws,
counsel must help determine whether obligations to notify individuals and regulatory
agencies are triggered, how long the organization has to provide notice, and what
information is required in the notice.
Notification to Individuals
Who Is Required to Notify?
Data breach notification laws place the burden to notify affected individuals on the
organization that owns or licenses the data.
California and other state laws do not
define the terms “owns” or “licenses,” but the California Office of Privacy Protection
(COPP) states that, for purposes of California's breach law, the term “data owner”
means “the individual or organization with primary responsibility for determining the
purpose and function of a record system.” COPP, Recommended Practices on Notice
of Security Breach Involving Personal Information (Jan. 2012), available at
http://oag.ca.gov/sites/all/files/agweb/pdfs/privacy/recom_breach_prac.pdf . Service
providers or other organizations that maintain data they do not own are responsible for
notifying the data owner (but not affected individuals) of a reportable breach.
Unauthorized Access to Personal Information
Although precise legal requirements differ, data breach notification laws typically
require that a data owner organization notify individuals when there has been
unauthorized access to the individuals’ unencrypted personal information.
Depending
on the applicable state or federal law, personal information is generally defined as a
person’s name together with one or more of that person’s Social Security number,
driver’s license number, or financial information, such as an account number or credit
or debit card number. See, e.g., CC §1798.82(h). Many states have included
additional data elements in their definitions of “personal information,” including health
information, biometric data, date of birth, and mother’s maiden name, to name a few.
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See, e.g., CC §1798.82(h)(1)(D) (medical information).
California defines “personal information” as either (1) an individual’s first name or first
initial and last name in combination with any one or more of the following data
elements: Social Security number; driver’s license number or California identification
card number; account number or credit or debit card number, in combination with any
required security code, access code, or password that would permit access to an
individual’s financial account; medical information; health insurance information; or
information or data collected through the use or operation of an automated license
plate recognition system; or (2) a user name or e-mail address in combination with a
password or security question and answer that would permit access to an online
account. “Personal information” does not include publicly available information that is
lawfully made available to the general public from federal, state, or local government
records. CC §1798.82(h).
Encrypted or Redacted Personal Information
Many breach notification laws, including California’s, do not require notification if
compromised data is encrypted, providing organizations with an incentive to
implement robust encryption to protect personal information. See, e.g., CC
§1798.82(h)(1).
Some states also do not require notification if information is redacted.
See, e.g., Mich Comp Laws §§445.63–445.72. Under California law, an organization is
not required to notify individuals if either the individual’s name or one of the
enumerated data elements is encrypted. CC §1798.82(h)(1).
Although the California
statute does not reference encryption with respect to an individual’s user name or email address in combination with a password or security question and answer,
notification duties with respect to that type of information are only triggered if the
compromised data would “permit access to an online account.” CC §1798.82(h)(2).
Since properly encrypted data would not permit access, California law impliedly does
not require notice if such data elements are encrypted.
Amendments to California’s data breach notification law in 2015 define the term
“encrypted” to mean “rendered unusable, unreadable, or indecipherable to an
unauthorized person through a security technology or methodology generally accepted
in the field of information security.” CC §1798.82(h)(4). Use of proprietary
cryptographic technologies no longer satisfies the “encrypted” standard. Counsel
should advise clients to document the industry-accepted technology the client
chooses to use with respect to the personal information that it processes.
Harm Thresholds
California and some other state breach notification laws require that organizations
provide notice to any individual whose unencrypted personal information was, or is
reasonably believed to have been, acquired by an unauthorized person.
However, 36
of 47 state breach laws (but not California’s) contain harm thresholds. Under these
laws, unauthorized access by itself does not trigger a notification obligation unless the
organization determines that there is a reasonable likelihood that the unauthorized
access would result in harm to the affected individuals. See, e.g., Ohio Rev Code Ann
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§1349.19.
If a breach involves data of a resident of a state with a harm threshold law, counsel or
experts may be required to work with the organization to conduct a risk assessment
to determine whether the threshold has been met. In conducting such an assessment,
counsel may follow a framework similar to that provided under the Final Omnibus
HIPAA Rule (Final Rule) promulgated by the U.S. Department of Health and Human
Services (HHS). See Modifications to the HIPAA Privacy, Security, Enforcement, and
Breach Notification Rules under the Health Information Technology for Economic and
Clinical Health Act and the Genetic Information Nondiscrimination Act; Other
Modifications to the HIPAA Rules, 78 Fed Reg 5566 (Jan.
25, 2013) (codified at 45
CFR pts 160, 164). Under the Final Rule, one of the criteria that must be met for an
incident to constitute a reportable breach is that there is more than a low probability
that “protected health information” has been compromised. See 78 Fed Reg 5566,
5642.
The Final Rule provides four factors to consider in an organization’s risk assessment
that counsel may wish to evaluate if faced with a harm threshold statute: (1) the
nature and extent of the personal information involved; (2) the person to whom the
unauthorized disclosure was made; (3) whether personal information was actually
acquired or viewed; and (4) the extent to which the risk to the personal information
has been mitigated.
78 Fed Reg 5566, 5695. Of course, as stated above, California
and many other states do not provide for a harm threshold. Consequently, if a breach
involves the data of residents of states that lack a harm trigger as well as states that
provide for a harm trigger, an organization may reasonably decide to notify all affected
individuals, regardless of the results of a risk assessment, for customer relations
purposes.
Notification and Timing Requirements
Each state law describes how organizations must give notice to affected individuals.
Typically, laws (1) require written notice, (2) allow electronic notice in limited
circumstances, and (3) allow substitute notice (usually consisting of e-mail notice,
conspicuous posting on the home page of the organization’s website, and notification
to statewide media, e.g., newspapers and television) if (a) notifying individuals will
exceed a specified cost threshold, (b) the number of individuals affected by the
breach exceeds a certain number, or (c) the organization does not have sufficient
contact information to provide notice.
California law allows notice to be provided by written notice; by electronic notice if
such notice is consistent with the federal Electronic Signatures in Global and National
Commerce Act (E-Sign) (15 USC §§7001–7031); and by substitute notice if the
organization demonstrates that the cost of providing notice would exceed $250,000,
that the affected class of subject persons to be notified exceeds 500,000, or that the
person or business does not have sufficient contact information.
Similar to other state
statutes, substitute notice must consist of e-mail notice, conspicuous posting on the
home page of the organization’s website for a minimum of 30 days, and notification to
major statewide media. CC §1798.82(j).
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. Several breach notification laws, including California’s, include specific content
requirements for notice to individuals. In 2015, California amended the breach notice
format required under California law. As of January 1, 2016, California law requires
data breach notices to be titled “Notice of Data Breach” and to follow a standard
format, in which required content is organized under the headings “What Happened,”
“What Information Was Involved,” “What We Are Doing,” “What You Can Do,” and “For
More Information.” It also provides a model breach notice form that affected
organizations may use to notify data breach victims. CC §1798.82(d).
Organizations
are required to include specific information in the notification, including a general
description of the breach, the approximate date of the breach, and the types of
personal information that were affected by the breach. CC §1798.82(d)(2). California
law is typical in the types of information it requires to be included in the notice,
although atypical in the detailed notice format requirements.
Requirements under each state data breach notification law differ, so each state’s
applicable law should be consulted when crafting breach notifications to ensure the
notice complies with each state’s requirements.
In addition, published guidance from
state attorneys general may include specific recommendations concerning actions to
take and information to provide in a notice to individuals. For example, the COAG
2016 Data Breach Report recommends that an organization’s data breach notice
prominently encourage individuals affected by a breach of Social Security numbers or
driver’s license numbers to place a fraud alert on their credit files. Third-party vendors
and knowledgeable privacy counsel assisting with the preparation of notices in various
jurisdictions will be able to identify applicable jurisdictional differences to build into the
notices.
Timing of Notification to Individuals
State breach laws, including California’s, generally require data owners to provide
notice of a breach to affected individuals “in the most expedient time possible and
without unreasonable delay.” CC §1798.82(a).
A few state breach laws require
notification to affected individuals within 30 or 45 days of discovery of the incident
giving rise to the breach. See, e.g., Wis Stat §134.98(3)(a); Fla Stat §501.171(3)(a).
California’s data breach law specific to licensed health facilities requires clinics,
health facilities, home health agencies, and hospices to report breaches of patient
information to patients and the California Department of Public Health within 15
business days after detection of the breach, unless the notice would impede a law
enforcement investigation. Health & S C §1280.15.
Given the detail required by the
notification requirements, providing notification within such timeframes can be a
significant challenge. Clients often want to provide notice immediately, but it is
advisable to gather all facts first to ensure that the notice provides the most accurate
picture of the incident and to minimize the likelihood of having to reissue notices on
discovery of new information.
In California and nearly all other jurisdictions, organizations that own or license the
data subject to the breach are permitted to delay notification (1) to comply with a
request for delay by law enforcement authorities, (2) to restore the security of the
affected system, or (3) to determine the scope of the breach. See, e.g., CC
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.
§1798.82(a), (c). However, California law requires that service providers must notify
the owner or licensee of the data “immediately” following discovery of the acquisition
of the data by an unauthorized person. CC §1798.82(b). Counsel for service-provider
organizations that process personal information of California residents on behalf of
other organizations should therefore be aware that the law does not give a serviceprovider organization leeway with respect to its obligation to report a breach to the
owner or licensor of the data.
California law does not contain a hard-and-fast deadline for owners and licensors by
which notice must be provided to affected individuals.
Consequently, what constitutes
the “most expedient time possible” and “without unreasonable delay” under CC
§1798.82(a) is a fact-specific inquiry based on the nature of each breach. In 2014, a
California court dismissed claims against Sony relating to a breach of its Sony
PlayStation Network for failure to state a claim because the plaintiffs had not
substantiated an injury attributable to the fact that Sony took 10 days to notify
claimants after Sony became aware of the breach. See In re Sony Gaming Networks
& Customer Data Sec.
Breach Litig. (SD Cal 2014) 996 F Supp 2d 942, 965. Also in
2014, Kaiser Foundation Health Plan, Inc.
agreed to pay $150,000 to settle claims by
the COAG that Kaiser’s notification to its employees of unauthorized access to their
personal information 6 months after it first learned of the breach constituted an
unreasonable delay. The 6-month period included 4 months of forensic examination in
an attempt to determine the scope of the breach. See People v Kaiser Found.
Health
Plan, Inc. (Super Ct, Alameda Cty, Jan. 24, 2014, No.
RG14711370) (unpublished
order). Thus, while immediate notice may not be required, organizations must balance
their own efforts to determine exactly what happened with what notification period is
reasonable to protect individuals affected by the breach.
Other Breach Notification Laws and Requirements
To determine the full scope of an organization’s compliance responsibilities, counsel
must understand whether any special regulatory regimes apply to the client.
Numerous industry-focused federal laws govern data breaches. For example, the
GLBA applies to financial institutions (see 15 USC §§6801–6809); HIPAA and the
Health Information Technology for Economic and Clinical Health Act (HITECH Act)
(Pub L 111–5, 123 Stat 115) apply to the health care industry; and the Family
Educational Rights and Privacy Act (FERPA) (20 USC §1232g) applies to educational
institutions.
Any of these special regulatory regimes could affect an organization’s
obligations under state data breach laws. For example, California and many other
states exempt covered entities from compliance with California data breach notice
requirements if the covered entity has complied with its notification requirements
under HIPAA. CC §1798.82(e).
Further, as stated above, licensed health facilities in
California are subject to separate data breach notification requirements under Health &
S C §1280.15.
Gramm-Leach-Bliley Act
The GLBA, among other things, requires “financial institutions” to develop, implement,
and maintain administrative, technical, and physical safeguards to protect the
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. security, integrity, and confidentiality of “nonpublic personal information.” 15 USC
§6801(a). The GLBA guidelines provide that when a financial institution becomes
aware of an incident of unauthorized access to sensitive customer information, the
institution should conduct a reasonable investigation to promptly determine the
likelihood that the information has been or will be misused. If the institution
determines that misuse of its information about a customer has occurred or is
reasonably possible, it should notify the affected customers as soon as possible. See
12 CFR pt 364, App A.
This analysis is similar to the analysis required under state
data breach laws that contain a harm threshold.
HIPAA and the HITECH Act
HIPAA and the HITECH Act set forth privacy and security protections required for the
health care industry. Breach notification requirements for “covered entities” and
“business associates” subject to HIPAA (see 45 CFR §160.103) are provided in
HIPAA’s breach notification rule. See 45 CFR pt 164.
The breach notification rule
requires covered entities to provide notification for breaches of unsecured or
unencrypted protected health information to the affected individuals, HHS, and major
print or broadcast media for breaches affecting more than 500 residents of a state or
jurisdiction. 45 CFR §§164.404, 164.406, 164.408.
Family Educational Rights and Privacy Act
FERPA applies to any public or private elementary, secondary, or post-secondary
school and any state or local education agency that receives federal funds. See 34
CFR §99.1.
FERPA does not contain specific breach notification requirements.
Rather, it protects the confidentiality of education records by requiring documentation
of each disclosure. The federal regulations, nonetheless, encourage direct notification
if, for example, the compromised data includes student Social Security numbers or
other identifying information that could lead to identity theft. See 34 CFR pt 99.
Similarly, FERPA does not require that an institution notify the Family Policy
Compliance Office of the U.S.
Department of Education in the event of a data breach.
However, it is nonetheless generally considered a best practice to do so.
Notification to Regulators, Law Enforcement, and Others
In addition to notifying affected individuals and consumer reporting agencies,
numerous state breach laws may also require affected entities to notify state
attorneys general or other state regulators of an incident. Under these laws, the
obligation to notify state regulators typically belongs to the entity that owns or
licenses the data. In certain states, service providers must cooperate with data
owners during the notification process.
California requires organizations to notify the
Attorney General (by submitting to the Attorney General an electronic copy of the
individual breach notification letter, excluding any personally identifiable information) if
the organization is notifying more than 500 California residents. CC §1798.82(f). As in
the case of notification to individuals, timing requirements for required notifications
differ across jurisdictions.
At the extreme, Puerto Rico law requires that companies
inform Puerto Rico’s Department of Consumer Affairs within 10 days after a violation
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. of a system’s security has been detected. The Department of Consumer Affairs is
obligated to make a public announcement related to the incident within 24 hours of
being notified. PR Laws Ann, tit 10, §§4051—4055. Such compressed timing could
affect an organization’s legal and business strategies following a breach.
Counsel
must review regulatory notification thresholds and timing requirements in each
jurisdiction in which affected individuals reside.
It is also important to identify appropriate law enforcement contacts to notify regarding
security incidents that may involve illegal activities. Counsel should be involved in
making the assessment of whether law enforcement should be notified and should
establish relationships with appropriate law enforcement contacts before an incident
occurs to facilitate communications in the event of an incident. From a practical
perspective, counsel should provide advice on how and when to notify regulators and
law enforcement.
In the case of a major breach, discussions with and notice to
regulators should generally precede notice to individual victims. In addition, it is
critical to have a consistent description of the facts and to arm customer support
personnel with appropriate responses to questions about the breach.
Organizations may also have contractual obligations to notify third parties, such as
insurers or contracting partners. A client should notify its insurance carrier in
accordance with policy requirements.
Failure to provide prompt notice could be used
by the insurer as part of a basis to deny the claim. Counsel should also assist the
client in the review of any contractual obligations it may have to business partners to
provide notification in the event of a data breach. For example, merchants that
process payment card data are obliged to notify payment card issuers in the event of
a data breach.
Attorney-Client Privilege and Work Product Protection
In addition to providing organizations with guidance on the legal and regulatory
minefield of laws governing data privacy and security, the retention of counsel to
address a data breach provides an organization with the added benefit of preserving
confidential communications and strategy discussions on legal matters related to a
breach.
Attorney-Client Privilege
In general, a communication between a client and attorney is protected by the
attorney-client privilege if the communication is confidential and for the purpose of
securing or obtaining legal advice.
Fisher v U.S. (1976) 425 US 391, 403. The
attorney-client privilege line, however, becomes murky when communications may
have business as well as legal purposes, which may occur when in-house counsel is
involved.
In these cases, courts will look to the dominant purpose of the
communication to determine whether it was for a legal purpose rather than a business
purpose. See Soltani-Rastegar v Superior Court (1989) 208 CA3d 424, 427. When inhouse counsel has both legal and business responsibilities, the line between the two
can become blurred and a court may be less inclined to find an attorney-client
privilege.
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.
Given the potential uncertainty regarding application of the attorney-client privilege in
a corporate setting, outside counsel should be retained to direct the breach
investigation for the purpose of gathering the information necessary to provide legal
advice to the organization. In that way, to maximize the chances that
communications regarding the investigation will be privileged, the organization can
avail itself of the simpler test for privilege: whether the communication between the
client and attorney was confidential and for the purpose of obtaining legal advice.
Before or, if necessary, during a breach, counsel should engage third-party vendors
and coordinate the breach response from the organization’s personnel and vendors so
that the efforts of all parties are focused on ensuring that counsel can provide
appropriate legal advice to enable privilege protection for breach investigation
communications. Members of the response team must be educated by counsel on
basic guidelines for communications to help keep them privileged. For example,
communications should stay within the circle of the breach response team to maintain
confidentiality, and all communications should be marked as “attorney-client
privileged.” Education of the team on these basic points should be a part of counsel’s
role before a breach in preparing the organization to respond, but counsel should also
be alert for communications that do not fall in line with best practices during the fastpaced breach response.
If necessary, counsel should step in quickly to ensure that
behavior that could threaten the ability to claim attorney-client privilege is immediately
corrected.
Work Product Doctrine
The work product doctrine is another tool that can protect documents that are
prepared as part of the investigation of a data breach. Federal Rule of Civil Procedure
26(b)(3) states:
Ordinarily, a party may not discover documents and tangible things that are
prepared in anticipation of litigation or for trial by or for another party or its
representative (including the other party’s attorney, consultant, surety,
indemnitor, insurer, or agent).
If such documents are requested during discovery, an organization must show that
the documents it is attempting to shield from discovery through the work product
doctrine were prepared in anticipation of litigation. The work product doctrine clearly
applies to documents created by investigators working for attorneys if the documents
were created in anticipation of litigation.
U.S. v Nobles (1975) 422 US 225, 239.
Conversely, documents created as part of routine business or investigations will not
receive the benefit of work product protection. See 2,022 Ranch, LLC v Superior Court
(2003) 113 CA4th 1377, 1390, disapproved on other grounds in Costco Wholesale
Corp.
v Superior Court (2009) 47 C4th 725. For example, if an organization’s
information technology staff is investigating the breach to determine the extent of any
compromise of the organization’s systems without the involvement of counsel, the
organization may not be able to protect the results of the investigation from discovery
under the work product doctrine.
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. Consequently, outside counsel should engage consultants such as forensic
specialists to assist in the data breach investigation. When outside counsel hires
third-party experts to assist in an investigation, courts will generally extend work
product protection to the documents created by that third party as part of the
investigation. See U.S. v Torf (In re Grand Jury Subpoena) (9th Cir 2003) 357 F3d
900, 907.
When it is necessary for in-house counsel to hire third-party consultants to
assist in a data breach investigation, the organization should state as part of the
terms of the engagement that the third party has been hired in anticipation of litigation
related to the data breach.
The recent class action litigation related to the Target Corporation breach, which
involved financial information of nearly 40 million consumers, provides a good
blueprint for structuring a data breach investigation in a way that helps preserve the
attorney-client privilege and work product doctrine for investigation-related
communications and materials. In that case, the plaintiffs sought to compel
production of documents related to the organization’s investigation of the data breach.
The documents were created by a data breach task force that was established at the
request of the company’s in-house and outside counsel “so that the task force could
educate Target’s attorneys about aspects of the breach and counsel could provide
Target with informed legal advice.” In re Target Corp. Customer Data Sec.
Breach
Litig. (D Minn, Oct. 23, 2015, MDL No.
14–2522 PAM/JJK) at 2 (unpublished order)
(Target Unpublished Order). The task force engaged two teams from Verizon to
investigate the data breach. One Verizon team was engaged by Target’s outside
counsel to “enable counsel to provide legal advice to Target, including legal advice in
anticipation of litigation and regulatory inquiries.” Target Unpublished Order at 3.
The
other Verizon team conducted a separate investigation on behalf of several credit card
brands. The Verizon teams did not communicate with each other about the attorneyled investigation. The court found that this two-track investigation was structured in a
way that properly shielded most of the information that was the subject of the
discovery request.
Target Unpublished Order at 5.
Finally, as with any litigation, a party has a duty to preserve reasonably accessible
information. Litigants are required to initiate a legal hold when litigation is reasonably
anticipated. Organizations should reasonably anticipate that they will be involved in
litigation related to the breach on discovery.
Accordingly, when a data breach occurs,
organizations should take care to preserve and collect evidence as soon as
practicable in accordance with the organization’s litigation hold policy. Counsel should
document the actions taken by the organization in response to a breach to evidence
compliance with the organization’s discovery obligations.
Liability for Noncompliance
Potential costs to a client organization for failure to comply with its obligation to
maintain reasonable security safeguards can be substantial. Civil actions can be a
significant source of potential liability following a breach, and civil suits by
consumers, notably class actions, are nearly always filed immediately after a large
data breach.
Thanks to the U.S. Supreme Court decision in Clapper v Amnesty Int’l
USA (2013) ___US ___, 133 S Ct 1138, plaintiffs face challenges in establishing
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. standing in such cases because of the difficulty of showing actual injury, but success
is not unheard of. Class action plaintiffs in the Target breach litigation were found by
the court to have standing to sue. See In re Target Corp. Customer Data Sec.
Breach
Litig. (D Minn 2015) 309 FRD 482. That ruling quickly led to a $10 million settlement
of the case.
California residents that are injured by an organization’s violation of
California’s requirement to implement and maintain reasonable security procedures or
a violation California’s data breach notification law may sue for damages and
injunctive relief, raising the specter of such civil suits in California. See CC §1798.84.
Given an opportunity based on the type of data at issue, plaintiffs may avoid issues in
establishing actual injury and standing under laws that provide statutory damages for
data incidents. The Video Privacy Protection Act of 1988 (VPPA) (18 USC §2710) is a
favorite vehicle for plaintiffs for this reason.
The VPPA prohibits a video tape service
provider (which can broadly include providers of video content over the Internet) from
knowingly disclosing information identifying an individual as having requested or
obtained specific video materials or services. It creates a private right of action with
liquidated damages available for aggrieved consumers for VPPA violations. 18 USC
§2710.
In the event a law such as the VPPA is invoked, disentangling the
organization from the lawsuit may be more difficult than prevailing on standing issues.
Moreover, case law regarding standing issues is in flux. The U.S. Supreme Court is
currently considering whether congressional authorization of a private right of action
based on a technical statutory violation may confer standing on a plaintiff who has
suffered no concrete harm (see Spokeo, Inc.
v Robins (US, Apr 27, 2015, No. 13–
1339) 2015 US Lexis 2947 (granting cert)), and the U.S. Court of Appeals for the
Seventh Circuit ruled recently that the risk of future injury related to a data breach is
sufficient to survive the pleadings stage (see Remijas v Neiman Marcus Group LLC
(7th Cir 2015) 794 F3d 688).
The shifting legal landscape on standing could have a
significant impact on potential liability in the event of a data incident.
Organizations can also be subject to enforcement actions by federal and state
regulators. In the event of a breach at a health care organization, HHS can bring an
enforcement action if it finds that the organization has violated HIPAA. WellPoint,
Inc., a managed care company now known as Anthem, Inc., settled alleged HIPAA
violations for $1.7 million in 2013, and HHS imposed a $4.3 million civil penalty for
HIPAA violations on Cignet Health of Prince George’s County, Maryland, in 2011.
The FTC can also bring actions to prosecute deceptive and unfair trade practices
against companies that do not adhere to their stated privacy and security standards or
do not provide adequate security.
In an enforcement action against a repeat offender,
LifeLock Inc., the FTC fined the company $100 million not for a data breach, but for
violating a previous FTC order to secure customer information and stop deceptive
advertising. See FTC v LifeLock Inc. (D Ariz, Jan.
4, 2016, No. CV-10–00530-PHXJJT) 2016 US Dist Lexis 17973. In addition to monetary penalties, FTC enforcement
actions typically result in 20-year consent decrees, under which organizations must
regularly monitor and obtain independent assessments of their privacy practices.
Monitoring and assessment activities can be incredibly expensive over such a long
period.
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.
State attorneys general can also bring enforcement actions that may result in heavy
penalties. The COAG has not been shy in bringing privacy enforcement actions. For
example, in 2013, Citibank, N.A. agreed to pay a $420,000 penalty under a stipulated
final judgment arising out of a breach of its Citibank Online website resulting from a
known technical vulnerability that affected more than 80,000 California account
holders.
People v Citibank, N.A. (Cal Super Ct, Aug. 29, 2013, No.
RG13693591)
(unpublished order).
Derivative suits brought by shareholders alleging a breach of fiduciary duty by officers
and directors are also becoming increasingly common for public companies that find
themselves the subject of data breaches. However, the Wyndham case, discussed
above, shows that plaintiffs may have difficulty succeeding if the board exercises
appropriate care and due diligence. In addition to Wyndham, breach of fiduciary duty
lawsuits have been brought in connection with the Target and Home Depot data
breaches.
Conclusion
Businesses have long understood that the technical aspects of cybersecurity need
the attention of dedicated IT and security professionals.
The same holds true for the
legal aspects of cybersecurity. Experienced legal counsel are needed to prepare for
and to help prevent data incidents. Experienced counsel are also needed to ensure
that any response to a breach not only meets all legal and regulatory requirements,
but also best positions the client to weather the perfect storm of litigation, reputational
harm, and other business impacts resulting from a breach.
The material in this publication was created as of the date set forth above and is
based on laws, court decisions, administrative rulings and congressional materials
that existed at that time, and should not be construed as legal advice or legal opinions
on specific facts.
The information in this publication is not intended to create, and the
transmission and receipt of it does not constitute, a lawyer-client relationship.
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