Griswold v. Union Labor Life Ins. Co.

Decision Date23 March 1982
Citation442 A.2d 920,186 Conn. 507
CourtConnecticut Supreme Court

David M. Reilly, New Haven, for appellants (plaintiffs).

Wiggin & Dana, New Haven, for appellee (defendant).


ARTHUR H. HEALEY, Associate Justice.

The plaintiffs have sued on a group health insurance policy issued by the defendant, Union Labor Life Insurance Co., to the Trustees of Local 443 Transportation Health Services and Insurance Plan. The plaintiffs are husband and wife with Sally Griswold an insured dependant under her husband's policy.

On March 5, 1977, Sally Griswold was injured in a one-car accident and, as a result, incurred certain medical and hospital expenses totaling under $5000. At the time of the accident, the plaintiffs maintained no insurance policy or acceptable substitute 1 on their automobile which would provide basic reparations benefits as required by the Connecticut No-Fault Motor Vehicle Insurance statutes. General Statutes §§ 38-319 through 38-351. 2 The plaintiffs sought reimbursement for their expenses, which would have qualified for basic reparations benefits under the no-fault statutes, by presenting a claim to the defendant. The defendant denied the claim on the basis that the policy excluded coverage for basic reparations benefits as required by the statutes referred to above. The plaintiffs then brought this action claiming that they were entitled to benefits under the policy and that the defendant had not paid any benefits under the policy despite their demands for payment.

By way of special defense to the plaintiffs' complaint, the defendant claimed that the plaintiffs were required, by statute, to provide security for basic reparations benefits and that, by virtue of their failure to provide such security, they became personally liable for the payment of these expenses. Therefore, pursuant to a policy exclusion (known as a "co-ordination of benefits" or "anti-duplication" clause), the defendant alleged that it was not liable to the plaintiffs for any expenses which would have been otherwise covered by the security for basic reparations benefits as required by statute. After a motion to strike this special defense was denied, 3 the plaintiffs answered the special defense and also alleged that the defendant was bound, under the principles of res judicata and collateral estoppel, by a Superior Court decision rendered in Conroy v. Union Labor Life Ins. Co., 37 Conn.Sup. 117, 442 A.2d 470 (1978). That case held that the same exclusionary language of the same insurance policy as is involved here precluded the defendant from denying benefits to another claimant in the same position as the plaintiff.

The defendant moved for summary judgment on January 24, 1979 and the court, Celotto, J., granted this motion on October 9, 1979. From this judgment, the plaintiffs have appealed.

The defendant's anti-duplication clause, which the court relied upon in granting summary judgment, provides as follows: "1. Effective January 1, 1975, benefits otherwise payable under the Group Policy for Allowable Expenses incurred during a Claims Determination Period shall be reduced to the extent necessary so that the sum of such reduced benefits under all Plans shall not exceed the total of such Allowable Expenses .... 2. Definitions: a. 'Plan' refers to any plan providing benefits or services for or by reason of Allowable Expenses, which benefits or services are provided by ... (iv) any coverage under governmental programs, and any coverage required or provided by any statute, and (v), any group or individual automobile 'No-Fault' insurance policy." The court found that the "defendant's policy clearly states that benefits are to be reduced by coverage required or provided by any statute and any no-fault insurance policy." In support of this, the court relied upon Neagle v. Connecticut Blue Cross, Inc., 36 Conn.Sup. 561, 420 A.2d 1169 (1980). In that case, the Appellate Session of the Superior Court held that coverage for any benefits required to be provided under General Statutes § 38-320(a) was excluded, without regard to whether any benefits were actually provided, by "an exclusion clause which denied benefits for expenses which were 'paid, payable or required to be provided as Basic Reparations Benefits under Section 38-320(a) of Connecticut General Statutes or similar benefits under any other no-fault automobile insurance law.' " (Footnote omitted.) Id., 562.

The trial court also stated that the defendant was not bound, under the doctrine of collateral estoppel, by Conroy, supra, because to do so would allow the plaintiffs, who were not parties to the Conroy case, to use that judgment offensively and in derogation of that doctrine's requirement of mutuality.

We conclude that the trial court erred in its interpretation of the anti-duplication clause and reverse the decision granting summary judgment.

General Statutes § 38-373(c)(1)(B) states that a health care insurance plan, otherwise providing minimum standard benefits, need not provide benefits for "(a)ny charge for any care for any injury or disease ... to the extent benefits are payable without regard to fault under a coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance." The major dispute in this matter is whether the language contained in the defendant's anti-duplication clause operates to exclude such benefits.

The plaintiffs claim that the purpose of the anti-duplication clause is to prevent a claimant from multiple recoveries if his expenses are covered by more than one policy. The plaintiffs point to the lower court's interpretation of the same clause in Conroy, supra, where Judge O'Sullivan stated that the clause "does not state that benefits are not payable where, as the present situation, the claimant did not have 'No-Fault' insurance. The Special Defenses of the defendants therefore have no legal significance." Conroy, supra.

The defendant, on the other hand, argues that the "policy states in clear and unambiguous language that its coverage is secondary to 'any coverage required or provided by any statute.' " The defendant buttresses its argument with the fact that, under General Statutes § 38-327(e), an owner of a private passenger motor vehicle who does not maintain the required insurance or acceptable substitute shall be personally liable for the payment of basic reparations benefits and shall also have all of the rights and obligations of an insurer. Under § 38-320(a), the owner's insurer is liable for the payment of basic reparations benefits, without regard to fault, up to $5000 per person per accident.

"Under our law, the terms of an insurance policy are to be construed according to the general rules of contract construction. See, e.g., Weingarten v. Allstate Ins. Co., 169 Conn. 502, 509-10, 363 A.2d 1055 (1975); A. M. Larson Co. v. Lawlor Ins., Agency, Inc., 153 Conn. 618, 622, 220 A.2d 32 (1966). 'The determinative question is the intent of the parties, that is, what coverage the ... (plaintiff) expected to receive and what the defendant was to provide, as disclosed by the provisions of the policy.' Marcolini v. Allstate Ins. Co., 160 Conn. 280, 283, 278 A.2d 796 (1971). If the terms of the policy are clear and unambiguous, then the ' "language, from which the intention of the parties is to be deduced, must be accorded its natural and ordinary meaning." ' Weingarten v. Allstate Ins. Co., supra, 169 Conn. at 509, 363 A.2d 1055. However, '(w)hen the words of an insurance contract are, without violence, susceptible of two interpretations, that which will sustain the claim and cover the loss must, in preference, be adopted.' Raffel v. Travelers Indemnity Co., 141 Conn. 389, 392, 106 A.2d 716 (1954); see also 4 Williston, Contracts (3d Ed.) § 621.

"This rule-that the construction most favorable to the insured be adopted-' rests upon the ground that the company's attorneys, officers or agents prepared the policy, and it is its language that must be interpreted.' Roby v. Connecticut General Life Ins. Co., 166 Conn. 395, 402, 349 A.2d 838 (1974). The rule itself derives from the established principle of contract construction that, where the terms of a contract are equally susceptible to two different meanings, that favoring the party who did not draw up the contract will be applied. 'The premise operating behind the rule would seem to be a psychological one. The party who actually does the writing of an instrument will presumably be guided by his own interests and goals in the transaction. He may choose shadings of expression, words more specific or more imprecise, according to the dictates of these interests.' Ravitch v. Stollman Poultry Farms, Inc., 165 Conn. 135, 146 n.8, 328 A.2d 711 (1973). A further, related rationale for the rule is that '(s)ince one who speaks or writes, can by exactness of expression more easily prevent mistakes in meaning, than one with whom he is dealing, doubts arising from ambiguity are resolved in favor of the latter.' 4 Williston, op. cit. § 621, p. 760." Simses v. North American Co. for Life & Health Ins., 175 Conn. 77, 84-85, 394 A.2d 710 (1978). "Courts follow that rule because the insurance company's attorneys, officers, or agents prepare the policy and it is their language that must be interpreted. Scranton v. Hartford Fire Ins. Co., 141 Conn. 313, 316, 105 A.2d 780 (1954); King v. Travelers Ins. Co. (123 Conn. 1, 4, 192 A. 311 (1937)); Rinaldi v. Prudential Ins. Co., 118 Conn. 419, 424, 172 A. 777 (1934); Westmoreland v. General Accident F. & L. Assurance Corporation, 144 Conn. 265, 274, 129 A.2d 623 (1957) (Daly, J., dissenting)." Griffith v. Security Ins. Co., 167 Conn. 450, 460-61, 356 A.2d 94 (1975) (Bogdanski, J., dissenting).

We cannot say that the clause...

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