Case Title: Shaffer v. WINhealth Partners

Citation: 

Docket Number: S-11-0005

State: wyoming

Court: Wyoming Supreme Court

Date: 2011-09-20T00:00:00Z

Document:
KIMBERLY SHAFFER v. WINHEALTH PARTNERS2011 WY 131Case Number: No. S-11-0005Decided: 09/20/2011NOTICE: This opinion is subject to formal revision before publication in Pacific Reporter Third. Readers are requested to notify the Clerk of the Supreme Court, Supreme Court Building, Cheyenne, Wyoming 82002, of any typographical or other formal errors so correction may be made before final publication in the permanent volume.
APRIL 
TERM, A.D. 2011
 
KIMBERLY 
SHAFFER,Appellant (Plaintiff),v.WINHEALTH 
PARTNERS,Appellee (Defendant).
 
Appeal 
from the District Court of Laramie County
The 
Honorable Thomas T.C. Campbell, Judge
 
Representing 
Appellant:
Blair 
J. Trautwein of Wick & Trautwein, LLC, Fort Collins, 
CO.
 
Representing 
Appellee:
Michael 
Rosenthal and Lucas Buckley of Hathaway & Kunz, P.C., Cheyenne, WY.  Argument by Mr. 
Rosenthal.
 
Before 
KITE, C.J., and GOLDEN, HILL, VOIGT, and BURKE, 
JJ.
 
HILL, 
J., delivers the opinion of the Court; GOLDEN, J. files a dissenting opinion in 
which VOIGT., J. joins; and VOIGT, J., files a dissenting opinion, in which 
GOLDEN, J., joins.
 
HILL, 
Justice.
 
[¶1]      Appellant, 
Kimberly Shaffer (Shaffer), challenges an order of the district court granting 
summary judgment in favor of the Appellee, WINhealth Partners (WIN).  Shaffer contends that there are 
ambiguities in the insurance contract which the district court interpreted 
incorrectly as a matter of law, and that there are genuine issues of material 
fact with respect to terminology used in the insurance contract that governs in 
this case.  We will reverse the 
district court’s order granting summary judgment in favor of WIN, direct the 
entry of a partial summary judgment in favor of Shaffer on her claims for 
benefits, and remand this matter to the district court for further proceedings 
so as to address Shaffer’s other claims, including “bad faith” and attorney’s 
fees.
 
ISSUES
 
[¶2]      Shaffer raises 
these issues:
 
A.   Did 
the trial court improperly grant summary judgment on all issues in favor of 
[WIN]?
 
            
1.  Is Article VI, Part II, (Exclusions and Limitations) 
subpart 45 ambiguous as to whether it applies only to cosmetic breast reduction 
surgeries or all breast reduction surgeries?
            
2.  Does the term “reduction mammoplasty” have a single plain 
meaning or two plain meanings?
            
3.  Did the trial court err in considering the affidavit of Dr. 
Wyatt as it is parol evidence in determining the meaning of subpart 
45?
            
4.  Did the trial court err in finding Dr. Wyatt’s affidavit 
was not disputed by competent evidence?
            
5.  Did the trial court err in failing to consider other parts 
of the WINhealth contract when determining that subpart 45 (reduction 
mammoplasty) was an exclusion applying to all breast reduction surgeries rather 
than a limitation applying only to cosmetic surgeries?
 
B.  Did 
the trial court err in failing to grant partial summary judgment on the contract 
issues in favor of Shaffer?
            
1.  Did the trial court err in finding Article VI, Part II 
(Exclusions and Limitations) subpart 28 dealing with complications of operations 
excluded by the WINhealth policy applies and denies coverage for Shaffer’s 
penicillin-resistant MRSA infection?
            
2.  Did the court err in failing to consider the differences in 
language between subparts 8 and 28 in interpreting subpart 
28?
            
3.  Does subpart 8 provide a basis to deny a medically 
necessary surgery?
 
WIN 
restates the issues as follows:
 
1.    
The 
district court’s grant of summary judgment was appropriate as no material issue 
of fact exists as to the definition of a “reduction mammoplasty” and a judgment 
was appropriate as a matter of law.
 
2.    
[Shaffer] 
was not entitled to a summary judgment.
 
FACTS 
AND PROCEEDINGS
 
[¶3]      In her complaint, 
Shaffer alleged that on August 17, 2005, her primary care physician, James G. 
Haller, M.D. (Dr. Haller), examined her regarding ongoing shoulder pain and back 
pain, as well as a recurring interiginous rash beneath her breasts.  Dr. Haller referred Shaffer to William 
J. Wyatt, M.D. (Dr. Wyatt) for further treatment.  Shaffer then consulted with Dr. Wyatt on 
September 8, 2005, and he advised her that her “symptoms could be improved upon 
greatly by a Bilateral Breast Reduction Mammoplasty.”  On October 18, 2005, Shaffer consulted 
with Jeffery K. Chapman, M.D., (Dr. Chapman) regarding her symptoms.  He observed bruising on Shaffer’s 
shoulders from her bra straps and a rash beneath her breasts.  Shaffer also advised Dr. Chapman of her 
ongoing low back pain.  Dr. Chapman 
advised her that breast reduction surgery is very much medically indicated to 
control the symptoms described above.
 
[¶4]      Shaffer had 
health care coverage through her husband’s employment with the City of 
Cheyenne.  Shaffer provided her 
medical records to that health care insurer, Great West Healthcare, and breast 
reduction surgery was authorized upon its determination that the surgery was 
medically necessary.  The surgery 
was accomplished in late December of 2005.
 
[¶5]      At the turn of 
the year 2006 (i.e., January 1, 2006), the health care insurer for the City of 
Cheyenne changed from Great West to WIN.  
On or about January 2, 2006, Shaffer noticed redness and swelling around 
the areas affected by the surgery, and she immediately sought medical 
attention.  She was hospitalized for 
an MRSA (Methicillin-resistant Staphylococcus aureus) infection and was treated 
aggressively as that condition is life threatening.  MRSA is frequently contracted during 
surgery and in hospitals and is then described more accurately as health-care 
associated MRSA (see http://www.mayoclinic.com/health/mrsa/DS00735).
 
[¶6]      Shaffer presented 
the bills for the treatment she received in early 2006 to WIN and her claims 
were denied, in part on the basis that the treatment she received for her MRSA 
infection arose from treatment to improve appearance.  Shaffer went through three levels of 
appeal with WIN but was not successful in getting WIN to change its original 
decision.
 
[¶7]      On January 2, 
2009, Shaffer filed a complaint alleging that because of WIN’s 
actions/omissions, she suffered economic damages, pain, suffering, and emotional 
damages.  She alleged breach of 
contract, bad faith breach of contract, and she asked for attorney’s fees and 
prejudgment interest.  The parties 
filed cross motions for summary judgment regarding the interpretation of the 
insurance contract.  They submitted 
sections of the insurance contract, which is entitled “Medical Benefit Plan 
Information and Evidence of Coverage” (EOC), as part of the summary judgment 
materials.
 
[¶8]      The district 
court reviewed the insurance contract and concluded that the language clearly 
and unambiguously excluded coverage for Shaffer’s breast reduction surgery.  Because the contract also excluded 
coverage for treatment of complications arising from non-covered services, the 
district court concluded that Shaffer was not entitled to benefits for treatment 
of her MRSA infection.  
Consequently, it granted summary judgment in favor of WIN.  Shaffer appealed.
 
STANDARD 
OF REVIEW
 
[¶9]      We will affirm a 
summary judgment provided there is no genuine issue of material fact and the law 
clearly entitles the moving party to prevail.  An insurance policy constitutes a 
contract between insurer and insureds.  
When the parties have stipulated to all material facts, summary judgment 
is proper if such an insurance contract is found to be unambiguous.  Aaron v. State Farm Mut. Auto. Ins. Co., 
2001 WY 112, ¶ 8, 34 P.3d 929, 931 (Wyo. 2001) (internal citations 
omitted).
 
[¶10]   In addition,
It 
is well established through this court’s precedent that general principles of 
construction will be followed when interpreting conditions of an insurance 
agreement.  Basic tenets stated in 
McKay v. Equitable Life Assurance Society 
of the United States, 421 P.2d 166, 168 (Wyo.1966), and applied in 
controversies involving insurance policies in the state of Wyoming 
are:
 
1.  “[T]he 
words used will be given their common and ordinary meaning.... Neither will the 
language be 'tortured' in order to create an ambiguity.”
2.  “The 
intention of the parties is the primary consideration and is to be ascertained, 
if possible, from the language employed in the policy, viewed in the light of 
what the parties must reasonably have intended.”
3.  “Such 
[insurance policy] contracts should not be so strictly construed as to thwart 
the general object of the insurance.... [T]he parties have the right to employ 
whatever lawful terms they wish and courts will not rewrite 
them.”
4.  “Absent 
ambiguity, there is no room for construction and the policy will be enforced 
according to its terms.”
5.  “[W]here 
such [insurance policy] contracts are so drawn as to be ambiguous and uncertain 
and to require construction, the contract will be construed liberally in favor 
of the insured and strictly against the insurer.  Also, if the contract is fairly 
susceptible of two constructions, the one favorable to the insured will be 
adopted.”
 
Commercial 
Union 
[Ins. Co. v. Stamper, 732 P.2d 534] at 539 (citations 
omitted); see also State ex rel. Farmers 
Ins. Exch. v. District Court of Ninth Jud. Dist., 844 P.2d 1099, 1101 
(Wyo.1993).
 
Aaron, 
¶ 15, 34 P.3d  at 933; and see Mena 
v. Safeco Ins. Co., 412 F.3d 1159, 1163 (10th Cir. 2005).
 
DISCUSSION
 
[¶11]   Several provisions of the insurance 
contract were provided with the parties’ summary judgment submissions.  Section 5.2.A states in relevant 
part:
 
2. 
OVERVIEW OF DIRECT BENEFITS
 
A.  Members 
are entitled to receive Covered Services
specified 
in Section 6 if ALL of the 
following requirements
are 
satisfied:
 
1)  The 
Covered Services are medically necessary;
 
. 
. . .
 
6)  No Exclusion or 
limitation applies to the Covered Services.
 
[¶12]   Section 6 of the EOC is entitled 
“Covered Services” and includes the “Description of Plan Benefits” in Section 
6.I and the “Benefit Plan Exclusions and Limitations” in Section 6.II.  The parties point to the following 
provisions in Section 6.I as being relevant: 
I.              
DESCRIPTION 
OF PLAN BENEFITS
. 
. . .
 
23. 
RECONSTRUCTIVE SURGERY.  

. 
. . .
Not 
Covered:
Cosmetic 
Surgery – any surgical procedure (or any portion of a procedure) performed 
primarily to improve physical appearance through change in bodily form, except 
repair of accidental injury.
 
·                     
Penile 
prosthesis (any type)
·                     
Breast 
reduction surgery1 
 
The 
referenced portions of Section 6.II state:
 
II.  BENEFIT 
PLAN EXCLUSIONS AND LIMITATIONS:
 
The 
following services are not covered or are subject to limitations:
 
….
 
8.  For 
the correction of, or complications arising from, treatment or an operation to 
improve appearance if the original treatment or operation either was not a 
covered expense under this plan of benefits or would not have been covered if 
the patient had been insured.
….
 
28.  For 
complications or side effects arising from services, procedures, or treatments 
excluded by this policy.
….
 
45.  Reduction 
Mammoplasty.
 
WIN’s 
motion for summary judgment also included an affidavit from William J. Wyatt, 
M.D.  Dr. Wyatt attests to the fact 
that in his area of specialty (plastic surgery), there is no difference between 
“breast reduction,” “reduction mammoplasty,” or “reduction 
mammaplasty.”
 
[¶13]   The district court’s decision 
letter summarized its interpretation of the EOC as 
follows:
 
1.    
The 
WINhealth policy generally covers services that are medically necessary and 
listed in Article 6, Part 
I.
2.    Article 
6, Part II, Subpart 45 imposes 
a blanket exclusion of coverage for reduction mammoplasty, a term which is 
synonymous with breast reduction surgery. . . .
3.    Article 
6, Part II, Subpart 28 excludes 
from coverage complication and side effects which result from surgeries not 
covered by the policy.  Because 
breast reduction surgery is an excluded surgery, WINhealth is not obligated to 
provide benefits for treatment of Shaffer’s resulting “MRSA” infection.  It makes no difference that Shaffer was 
insured prior to the infection by a different carrier who covered the underlying 
procedure.
 
[¶14]   It is undisputed that Shaffer’s 
breast reduction surgery was medically necessary and was not performed for 
cosmetic purposes.  It is likewise 
clear that the MRSA infection was a complication of her breast reduction 
surgery.  Section 6.II, ¶ 28, 
excludes from coverage complications and side effects resulting from surgeries 
not covered by the policy.  We 
start, then, with a determination of whether Shaffer’s breast reduction surgery 
was covered by WIN’s policy.  The 
parties disagree as to whether Shaffer’s non-cosmetic breast reduction surgery 
falls within the definition of reduction mammoplasty referred to in 6.II, 
¶ 45.  WIN claims the term 
refers to all breast reduction surgeries, while Shaffer argues that it only 
applies to cosmetic breast reductions.
 
[¶15]   In accordance with our contract 
interpretation principles, we begin with the plain language of the 
contract.  The term “reduction 
mammoplasty” is not defined in the insurance contract.  We, therefore, apply the ordinary and 
common meaning of the term.  See, 
e.g., Aaron, ¶ 15, 34 P.3d  at 933.  4A Lawyer’s Medical Cyclopedia, § 31.26 
(6th ed. 2011) describes reduction 
mammoplasty as:
 
            
Reduction mammaplasty is occasionally performed for purely cosmetic 
purposes.  More often, women seek 
surgical relief from the discomfort caused by massive, heavy, pendulous 
breasts.  The female breast can 
become large enough to restrict physical activity, interfere with breathing, 
prevent sleep, and cause constant pain.  
Operations to relieve such distress are certainly not purely cosmetic 
surgery.  Sagging of the breast 
tissue (ptosis) tends to occur naturally with age.  Ptosis occurs because a large breast is 
a heavy organ.  The gland is 
somewhat loosely attached to the anterior chest wall, and with aging, these 
attachments stretch and loosen.  The 
skin envelope that covers the breast is also distensible and will gradually 
stretch under the constant weight of the sagging, heavy 
gland.
 
This 
description of reduction mammoplasty confirms that the term is synonymous with 
breast reduction surgery and applies whether the procedure is performed for 
cosmetic or non-cosmetic purposes.  
The definition is also consistent with Dr. Wyatt’s testimony that in his 
specialty of plastic surgery, there is no difference between “breast reduction,” 
“reduction mammoplasty,” or “reduction mammaplasty.”2
 
[¶16]   Applying the ordinary and common 
meaning of the words used in the insurance contract, we conclude that Shaffer’s 
breast reduction surgery fell within the definition of “reduction 
mammoplasty.”  Consequently, if 
Section 6, Part II simply stated that mammoplasty reduction was “excluded,” we 
would agree with the district court that all breast reductions are excluded from 
coverage under the policy.  However, 
the contractual language states that reduction mammoplasty is either “not 
covered or subject to limitations,” without specifying which of those 
alternatives applies.  The district court did not consider the 
effect of the “subject to limitations” language.
 
[¶17]   Our rules of contract 
interpretation require us to give effect to each word if possible, and we 
“strive to avoid construing a contract so as to render one of its 
provisions meaningless, because each provision is presumed to have a 
purpose.” Scherer v. Laramie Reg’l 
Airport Bd., 2010 WY 105, ¶ 11, 236 P.3d 996, 1003 (Wyo. 
2010) (citing Wyoming 
Game & Fish Comm’n v. Mills Co., 701 P.2d 819, 822 (Wyo.1985)).  Thus, we cannot ignore the contractual 
language that states that coverage for reduction mammoplasty may be subject to 
limitations, as opposed to excluded altogether.
 
[¶18]   Looking at the contract as a whole, 
we note that Section 6.I, ¶ 23, excludes coverage for cosmetic procedures 
and specifically refers to breast reductions.  This would seem to be a limitation on 
coverage of reduction mammoplasty as contemplated by Section 6.II, 
¶ 45.  However, WIN argues that 
¶ 23 should not be considered when interpreting Section 6.II’s “subject to 
limitations” language because that language only pertains to limitations 
specifically stated within Section 6.II.  
The problem with WIN’s argument is Section 6.II. does not state that the 
“subject to limitations” language is restricted to limitations set out in that 
section.  Looking at the contract as 
whole, it makes no sense to disregard the limitations set out in Section 6.I., 
when interpreting the “subject to limitations” language in Section 
6.II.
 
[¶19]   If, as WIN advocates (and the 
district court decided), Section 6.II, ¶ 45, is meant to exclude all 
reduction mammoplasty (whether cosmetic or not), then it would not be necessary 
to include the specific exclusion of cosmetic breast reductions in Section 6.I, 
¶ 23.  The district court’s 
interpretation renders that part of ¶ 23 meaningless, in violation of our 
rules of contract interpretation.  
Scherer, 
¶ 11, 
236 P.3d  at 1003.  The only interpretation which gives effect to both §§ 6.I, 
¶ 23, and 6.II, ¶ 45, is that coverage for reduction mammoplasty is 
not wholly excluded but, rather, coverage is limited to non-cosmetic breast 
reduction surgeries.
 
[¶20]   Furthermore, even if we were to 
find an ambiguity in the contract language, our precedent would require a ruling 
in favor of Shaffer.  Where 
insurance contracts are drawn so as to be ambiguous and uncertain and require 
construction, the contract will be construed liberally in favor of the insured 
and strictly against the insurer.  
Consequently, if the contract is fairly susceptible of two constructions, 
the one favorable to the insured will be adopted.  Aaron, ¶ 15, 34 P.3d  at 
933.
 
CONCLUSION
 
[¶21]   We hold that the district court 
erred in granting summary judgment to WIN.  
Indeed, we conclude that based upon the evidence in the record, much of 
it submitted by WIN, Shaffer is entitled to summary judgment on her claims for 
the treatment of her MRSA infection.  
Our ruling on this issue is dispositive, so we do not need to address the 
parties’ other arguments.  The bad 
faith claim remains as an issue to be resolved.3
 
[¶22]   The district court’s summary 
judgment order is reversed, and we direct that the district court enter summary 
judgment in favor of Shaffer on her claims for treatment of her MRSA 
infection.  In addition, we remand 
this matter to the district court for further proceedings to dispose of all 
other remaining issues/claims.
 
GOLDEN, 
Justice, dissenting, in which VOIGT, Justice, joins. 
 
[¶23]   I join Justice Voigt’s dissenting 
opinion and write separately to record a few additional thoughts about 
resolution of this appeal.
 
[¶24]   In my study of the issues in this 
appeal, I have come across a substantial body of interesting, scholarly 
literature on the subject of the readability of insurance contracts, including 
health insurance contracts, similar to the one in this case.  In that 
literature there appears to be broad agreement among those law professors, 
treatise authors, and commentators active in this area of the law that health 
insurance contracts are contracts of adhesion.  As one commentator states 
it: 
 
                Health 
insurance contracts have historically been recognized as contracts of 
adhesion.  As such, the terms of health insurance contracts are never fully 
discussed between the parties.  In the case of individual market health 
insurance policies, the contract is always “off the rack.”  It is sold “as 
is” with no negotiation.  In the case of group-based health insurance 
policies, the kind of health insurance an employee might obtain from her 
employer, for example, the ability to meaningfully negotiate terms is 
negligible.  While there may appear to be some room for negotiation by the 
employer (the entity actually purchasing the insurance) and some variability 
as to terms (e.g., cost-sharing components, such as copayments and deductibles, 
and network requirements), in reality, 
there is no opportunity for significant bargaining as to standard 
terms.  Thus, regardless of the source of one’s health insurance, there 
is severely limited opportunity for negotiation as to the standard terms of the 
health insurance contract. 
 
John 
Aloysius Cogan, Jr., Readability, Contracts of Recurring Use, and the Problem 
of Ex Post Judicial Governance of Health Insurance Policies, 15 Roger 
Williams U. L. Rev. 93, 101 (2010) (emphasis added).  Appellee’s health insurance policy is 
such a group-based policy.  

 
[¶25]   An initial question for me in my 
study of the issues in this appeal was whether the Court’s interpretation of 
this adhesive health insurance policy is a question of law or a question of 
fact.  It is clear that the 
interpretation of an ordinary, arms-length negotiated contract is a fact 
question concerning the parties’ intent (think “meeting of the minds”/mutual 
assent).  I would not use that standard here; rather, I’m inclined to 
accept the thesis that the interpretation of this adhesive health insurance 
contract is a legal question.  See Hon. Randall H. Warner, All Mixed Up About Contract:  When Is 
Contract Interpretation a Legal Question and When Is It a Fact Question, 5 
Virginia L. & Bus. Rev. 81, 84 (2010).  I would treat the 
interpretation of this health insurance policy in the same way the Court treats 
the interpretation of a statute as a question of law.  Id. at 93.  About our 
interpretation of statutes, we have said:  
 
In 
interpreting statutes, our primary consideration is to determine the 
legislature’s intent.  All statutes 
must be construed in pari materia 
and, in ascertaining the meaning of a given law, all statutes relating to the 
same subject or having the same general purpose must be considered and construed 
in harmony.  Statutory construction 
is a question of law, so our standard of review is de novo.  We endeavor to interpret statutes in 
accordance with the legislature’s intent.  
We begin by making an inquiry respecting the ordinary and obvious meaning 
of the words employed according to their arrangement and connection.  We construe the statute as a whole, 
giving effect to every word, clause, and sentence, and we construe all parts of 
the statute in pari materia. When a 
statute is sufficiently clear and unambiguous, we give effect to the plain and 
ordinary meaning of the words and do not resort to the rules of statutory 
construction.  Moreover, we must not 
give a statute a meaning that will nullify its operation if it is susceptible of 
another interpretation. 
 
            
Moreover, we will not enlarge, stretch, expand, or extend a statute to 
matters that do not fall within its express provisions.  Only if we determine the language of a 
statute is ambiguous will we proceed to the next step, which involves applying 
general principles of statutory construction to the language of the statute in 
order to construe any ambiguous language to accurately reflect the intent of the 
legislature.  If this Court 
determines that the language of the statute is not ambiguous, there is no room 
for further construction.  We will 
apply the language of the statute using its ordinary and obvious meaning.  
 
Ball 
v. State ex rel. Workers’ Safety & Comp. Div., 
2010 WY 128, ¶ 29, 239 P.3d 621, 629-30 (Wyo. 2010) (internal citations 
omitted).
 
[¶26]   In this health insurance coverage 
dispute, we are asked whether the contract covers medical services for treating 
complications arising from a medically necessary reduction mammoplasty.  I agree with the majority that the term 
“reduction mammoplasty” is synonymous with the term “breast reduction surgery” 
as these terms appear in this contract.  From this point forward, I will 
use the term “reduction mammoplasty” for simplicity sake.  

 
[¶27]   I think all agree that the contract 
does not include cosmetic reduction mammoplasty as a covered service:  
Section 6, Part I (Covered Services – Description of Plan Benefits), Paragraph 
23, Reconstructive Surgery, Not Covered:  Cosmetic surgery – Reduction 
mammoplasty.  I think all agree that 
the contract does not include medical services for complications arising from 
services excluded by the contract:  Section 6, Part II (Covered Services – 
Benefit Plan Exclusions and Limitations), Paragraph 28.  In light of the 
above provisions, I think all agree that the contract does not include 
medical services for complications arising from cosmetic reduction 
mammoplasty.
 
[¶28]   What we are looking for in this 
contract is whether medical services for complications arising from medically necessary reduction 
mammoplasty are included as a covered 
service.  In Section 5, Part I 
(Obtaining Plan Benefits – Overview of Benefits), it is stated that a member is 
entitled to receive “Covered Services as described in Section 6” “subject to the 
terms, conditions, limitations and Exclusions of this Section 5 and Exclusions 
contained  in the Benefit Plan.”  In Section 5, Part II (Obtaining 
Plan Benefits – Overview of Direct Benefits), it is stated that a member is 
entitled to receive “Covered Services specified in Section 6” if certain 
requirements are satisfied, the pertinent ones for our discussion being “1) The 
Covered Services are medically necessary” and “6) No Exclusion or limitation 
applies to the Covered Services.”  
 
[¶29]   I would now go to Section 6 of the 
contract, entitled Covered Services, to see whether medical services for 
complications arising from medically necessary reduction mammoplasty are 
included as a covered service.  The first words one sees under the heading 
of Section 6 are these:     
 
Section 
6
 
Covered 
Services
 
             
All 
benefits are subject to plan limitations and exclusions as defined in Section 
6(II).   Services that are not 
specifically identified in this Section are not a covered benefit.  [Emphasis added.]
 
The 
emphasized language tells one that medical services for complications arising 
from medically necessary reduction mammoplasty must be specifically identified 
in Section 6 in order to be a covered service.
 
[¶30]   Section 6 consists of two 
parts.  Part I is entitled DESCRIPTION OF PLAN BENEFITS.  Under that 
heading are thirty-two numbered paragraphs.  One does not find “medical 
services for complications arising from medically necessary reduction 
mammoplasty” in any of those numbered paragraphs.  In particular, one does 
not find those medical services in Paragraph 23, entitled RECONSTRUCTIVE 
SURGERY, which does cover all stages of breast reconstruction surgery following 
a mastectomy in identified instances, and which does not cover cosmetic 
reduction mammoplasty.
 
[¶31]   Part II of Section 6 is entitled 
BENEFIT PLAN EXCLUSIONS AND LIMITATIONS, and the introductory sentence 
applicable to each of the ensuing forty-six numbered paragraphs states “The 
following services are not covered or are subject to limitations.”  Among 
the ensuing forty-six numbered paragraphs, several are of interest for our 
discussion.  Paragraph 28 states:  “For complications . . . arising 
from services, procedures, or treatments excluded by this policy.”  
Paragraph 35 states:  “Non-emergent or pre-operative days of Confinement unless approved as Medically Necessary 
by the Plan” (emphasis added).  Paragraph 44 states:  “Any Health 
Care Service that is not a covered service regardless of the recommendation or 
order by a Participating or Non-Participating Provider.”  Paragraph 45 
simply states:  “Reduction 
mammoplasty.”  
 
[¶32]   The plain meaning of the 
introductory sentence applicable to each of the ensuing forty-six numbered 
paragraphs, “The following services are not covered or are subject to 
limitations,” is that if there is no wording of limitation within the numbered 
paragraph in question, then that particular medical service listed in that 
numbered paragraph is a service not covered by the contract.  If, however, 
there is wording of limitation within the numbered paragraph in question, then 
that particular medical service listed in that numbered paragraph is a medical 
service covered by the contract to the extent of the particular 
limitation.  In the case of Paragraph 45 (Reduction mammoplasty), there is 
no wording of limitation, and, therefore, that medical service is not covered by 
the contract.  As it is excluded by the contract, Paragraph 28, mentioned 
above, states that medical services for complications arising from reduction 
mammoplasty are not covered by this contract.  In Paragraph 35, mentioned 
above, the significance of the explicit wording of limitation “unless approved 
as Medically Necessary by the Plan” is that it demonstrates that Appellee knows 
how to designate a particular medical service as medically necessary, and, in 
the case of the medical service for reduction mammoplasty in Paragraph 45, it 
plainly chose not to so designate.
 
[¶33]   Just as one does not find coverage 
for “medically necessary reduction mammoplasty” in Section 6, Part I, of the 
contract, one also does not find coverage for those particular medical services 
in Section 6, Part II.  It is important to recall the introductory sentence 
of Section 6, applicable to both Parts I and II:  
 
Services 
that are not specifically identified in this Section are not a covered 
benefit.
 
[¶34]   In summary, the relevant provisions 
of this health insurance contract are sufficiently clear and unambiguous, and I 
would give effect to the plain and ordinary meaning of the words.  In my 
view, I do not find in this contract any provision that specifically identifies medical 
services for treating complications arising from a medically necessary reduction 
mammoplasy as a covered benefit.  Accordingly, I would affirm the decision 
of the district court.   
 
VOIGT, 
Justice, 
dissenting, in which GOLDEN, 
Justice, joins.
 
[¶35]   I join in Justice Golden’s 
dissenting opinion but write separately to emphasize a few points.
 
[¶36]   The majority attempts to create 
insurance coverage for the appellant where none exists.  The appellant underwent breast reduction 
mammoplasty surgery in December 2005.  
Her insurer at that time, Great West, provided coverage and paid her 
medical claim.  After January 1, 
2006, the appellant sought medical care for a MRSA infection that resulted from 
the surgery.  Her insurance policy 
then in effect, provided by the appellee, excluded coverage for cosmetic 
surgery, including breast reduction surgery, excluded coverage for reduction 
mammoplasty, and excluded coverage for “complications or side effects arising 
from services, procedures, or treatments excluded by this policy.”
 
[¶37]   Where the intent of an insurance 
policy is clear within its four corners, ambiguity is not created by a 
subsequent disagreement between the parties as to its meaning.  Colo. Cas. Ins. Co. v. Sammons, 2007 WY 
75, ¶ 12, 157 P.3d 460, 465 (Wyo. 2007); Principal Life Ins. Co. v. Summit Well 
Serv., Inc., 2002 WY 172, ¶ 19, 57 P.3d 1257, 1262 (Wyo. 2002); Hulse v. First Am. Title Co. of Crook 
County, 2001 WY 95, ¶ 37, 33 P.3d 122, 134 (Wyo. 2001).  Furthermore, one party’s subjective 
intent or interpretation of a contract is not controlling; we look instead to 
the objective intent of the language used.  
Comet Energy Servs., LLC v. Powder 
River Oil & Gas Ventures, LLC, 2010 WY 82, ¶ 14, 239 P.3d 382, 387 
(Wyo. 2010).  This policy is not 
ambiguous.  The exclusions are not 
ambiguous.  There is nothing to 
construe or interpret.  We do not 
torture the language of a policy to create an ambiguity, and where there is no 
ambiguity, “there is no room for construction and the policy will be enforced 
according to its terms.”  Aaron v. State Farm Mut. Auto. Ins. Co., 
2001 WY 112, ¶ 15, 34 P.3d 929, 933 (Wyo. 2001) (quoting McKay v. Equitable Life Assurance Society of 
the United States, 421 P.2d 166, 168 (Wyo. 1966)).  I would affirm.
 
FOOTNOTES
 
1It is not clear if ¶ 23 has additional provisions, as the page ends with 
the bulleted reference to “Breast Reduction Surgery” and the following page of 
the insurance contract is not included in the 
record.
 
2Shaffer argues that the district court erred by considering extrinsic 
evidence in the form of Dr. Wyatt’s testimony defining the medical terms.  In addition, she argues that if it was 
appropriate to consider Dr. Wyatt’s testimony, then the district court also 
should have considered her testimony as to her understanding of the meaning of 
the terms.  We do not need to 
address this issue because we accept Dr. Wyatt’s definition but conclude, in any 
event, that the insurance contract covers Shaffer’s breast reduction 
surgery.
 
3Both parties discuss in their briefs the facts surrounding WIN’s various 
notifications to Shaffer that it would not cover her breast reduction surgery 
and her actual knowledge of WIN’s position on the matter.  These facts do not have any bearing on 
our interpretation of the contractual language.  They may, however, be relevant in future 
proceedings on Shaffer’s bad faith claim.