Metropolitan Life Insurance v. Smith

209 A.2d 693, 3 Conn. Cir. Ct. 169, 1965 Conn. Cir. LEXIS 146
CourtConnecticut Appellate Court
DecidedFebruary 1, 1965
DocketFile No. CV 18-6305-0990
StatusPublished
Cited by5 cases

This text of 209 A.2d 693 (Metropolitan Life Insurance v. Smith) is published on Counsel Stack Legal Research, covering Connecticut Appellate Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Metropolitan Life Insurance v. Smith, 209 A.2d 693, 3 Conn. Cir. Ct. 169, 1965 Conn. Cir. LEXIS 146 (Colo. Ct. App. 1965).

Opinion

Pruyn, J.

The plaintiff sues to recover certain alleged overpayments made by it to the defendant under a group medical payments policy of insurance. The essential facts alleged in the amended complaint are admitted by the defendant in her answer thereto, which denies only those allegations necessary to raise the only issue in the case, namely, the interpretation of the policy of insurance. The court has formulated this memorandum of decision in the form of a finding pursuant to § 993 of the Practice Book.

I

The following facts are found:

1. The plaintiff is a corporation, organized and existing under the laws of the state of New York, engaged in the insurance business generally.

2. The defendant at all the times hereinafter set forth was an employee of the General Electric Company at Norfolk, Connecticut.

3. On or about November 1, 1955, the plaintiff insured the employees of General Electric Company against certain medical expenses under its group policy No. 17500-G.

4. The policy, a certified copy of which was filed in court with the complaint as exhibit A, provides that the plaintiff “promises to pay the Benefits, other than Life Insurance, described in the Schedule of Exhibits which are attached hereto as Schedule A of this Policy as such Booklets are applicable to the Employees of General Electric Company.”

5. The applicable booklet listed in schedule A is “General Electric Insurance Plan with Comprehensive Medical Expense Benefits Revised October 1960 Form 32A,” a copy of which was filed in court with the complaint as exhibit B, applicable to [171]*171employees of all units (with certain exceptions not material to this case) who are employed outside California, Rhode Island and New York.

6. This booklet provides for insurance coverage in respect to certain specified medical expenses with certain exceptions.

7. Under the heading “Exclusions” appear the following (pages 21 and 22 of form 32A): “Expenses for the following are not Covered Medical Expenses under the Plan: . . . (k) Expenses to the extent of benefits provided under any employer group plan other than this plan, except for any such employer group plan for which those insured under that plan are required to pay the full premium cost or subscription fee.”

8. On or about April 25, 1962, the defendant filed with the plaintiff a claim for medical expenses in connection with her own illness in the sum of $1260.

9. On or about July 31, 1962, the defendant filed with the plaintiff a claim for medical expenses in connection with another illness of hers in the sum of $1157.80.

10. In submitting each of said claims mentioned in findings 8 and 9, the defendant answered “No” to the question: “Are any hospital, surgical, or medical benefits or services for any expenses included in' this claim provided under an insurance plan or program whose premium or subscription fee is paid in whole or in part, either directly or indirectly, by another employer?”

11. In reliance on the defendant’s answer of “No” to the question set forth in finding 10, the plaintiff paid $1083.93 on account of the defendant’s hospital and surgical expenses of $1260 mentioned in finding 8 and $984.13 on account of the defend[172]*172ant’s hospital and surgical expenses of $1157.80 mentioned in finding 9.

12. The medical expenses referred to in finding 8 to the extent of $597.50, and the medical expenses referred to in finding 9 to the extent of $415.80, were paid to the defendant’s husband, Melton Smith, pursuant to another group plan under which the Prudential Insurance Company insured the employees of Keuffel and Esser and its subsidiary Salisbury Products, Inc., of which the defendant’s husband was an employee and for which those insured thereunder were not required to pay the full premium cost or subscription fee.

13. The amounts paid by the plaintiff, the amounts admitted by plaintiff as owing, the amounts paid to the defendant’s husband under the Prudential group plan and the amounts claimed by the plaintiff as overpayments are as follows:

Amounts Paid Amounts Admittedly Owing
First Count $1083.93
Second Count 984.13
$576.05
630.70
$2068.06
$1206.75
Amounts Paid to Husband
Under Prudential Plan
Amounts of Overpayments Claimed by Plaintiff
First Count $597.50
Second Count 415.80
$507.88
353.43
$1013.30
$861.31

II

The following conclusions have been reached:

1. The employer group plan under which the defendant’s husband was insured is included within paragraph (k) (quoted in finding 7) of the “Exclusions” contained in the policy of insurance covering the defendant.

[173]*173The general rules relating to the construction of contracts apply to the construction of insurance policies. A contract is to be construed according to what is fairly to be assumed to be the understanding and intent of the parties as expressed in it. Bridge-Mile Shoe Corporation v. Liggett Drug Co., 142 Conn. 313, 318; Downs v. National Casualty Co., 146 Conn. 490, 494; Lyon v. Aetna Casualty & Surety Co., 140 Conn. 304, 311. If the terms used are ambiguous and susceptible to more than one interpretation, that which is more favorable to the insured must be adopted. Smedley Co. v. Employers Mutual Liability Ins. Co., 143 Conn. 510, 513. On the other hand, if the terms are plain and clear, there is then no need to construe the policy, the terms must be given their natural and ordinary meaning, and the policy enforced according to its terms. Downs v. National Casualty Co., supra; Smedley v. Employers Mutual Liability Ins. Co., supra; Raffel v. Travelers Indemnity Co., 141 Conn. 389, 392.

Exclusion (k) excludes “Expenses to the extent of benefits provided under any employer group plan other than this plan,” with the one exception of a plan for which the insured pays the full premium or subscription fee. This exception may be disregarded, as it does not apply to the plan insuring the defendant’s husband. The defendant argues that the other plan referred to in exclusion (k) must be one which covers the defendant and that the language used is ambiguous, as it does not mention the source of the other plan, and must be construed in favor of the insured. We cannot agree with this argument. The language is clear and unambiguous. Exclusion (k) is couched in extremely broad language; it refers to “any” other employer group plan; there is no limitation except the one heretofore noted. If the plaintiff had intended to exclude a plan such as that of the defendant’s hús[174]*174band or limit it to the employees of its insured employer, it naturally, having made one exception, would have explicitly so provided.

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Bluebook (online)
209 A.2d 693, 3 Conn. Cir. Ct. 169, 1965 Conn. Cir. LEXIS 146, Counsel Stack Legal Research, https://law.counselstack.com/opinion/metropolitan-life-insurance-v-smith-connappct-1965.