Title: THE STATE OF WYOMING, ex rel., SANDY ARNOLD V. RON OMMEN, in his Official Capacity as Director of the Wyoming Department of Administration and Information, and SANDY PADILLA, in her Official Capacity as Risk Manager

State: wyoming

Issuer: Wyoming Supreme Court

Document:

THE STATE OF WYOMING, ex rel., SANDY ARNOLD V. RON OMMEN, in his Official Capacity as Director of the Wyoming Department of Administration and Information, and SANDY PADILLA, in her Official Capacity as Risk Manager2009 WY 24201 P.3d 1127Case Number: S-08-0091Decided: 02/24/2009
OCTOBER 
TERM, A.D. 2008

 
 
THE 
STATE OF WYOMING, ex rel., SANDY 
ARNOLD,Appellant(Petitioner),v.RON OMMEN, in his 
Official Capacity as Director of the Wyoming Department of Administration and 
Information, and SANDY PADILLA, in her Official Capacity as Risk 
Manager,Appellees(Respondents).

 
 

Appeal 
from the District Court of Laramie County

The 
Honorable Peter G. Arnold, Judge

 
 
Representing 
Appellant:

Ron 
Arnold, Cheyenne, Wyoming.

 
 
Representing 
Appellees:

Bruce 
A. Salzburg, Wyoming Attorney General; Michael L. Hubbard, Deputy  Attorney General; Ryan T. Schelhaas, 
Senior Assistant Attorney General; Elizabeth B. Lance, Assistant Attorney 
General.  Argument by Ms. 
Lance.

 
 
Before 
VOIGT, C.J., and GOLDEN, HILL, KITE, and BURKE, JJ.

 
 

KITE, 
Justice.

 
 
[¶1]  After her claim for medical benefits 
under the State Employees' and Officials' Group Plan (Group Plan) was denied, 
Sandy Arnold filed a grievance with the Employees' and Officials' Group 
Insurance Program (Group Insurance Program) section of the Wyoming Department of 
Administration and Information (A&I).  
The Office of Administrative Hearings (OAH) dismissed the grievance and 
Ms. Arnold presented the State Office of Risk Management with a notice of claim 
pursuant to the Wyoming Governmental Claims Act (WGCA) in which she asserted the 
State breached the insurance contract by failing to pay her claim.  

 
 
[¶2]  The risk manager forwarded the notice of 
claim to the Group Insurance Program.  
Ms. Arnold then filed a petition for writ of mandamus and complaint for 
declaratory judgment in district court seeking a writ requiring the risk manager 
to process her notice of claim and a declaration of her rights under the Group 
Plan.  The district court granted 
summary judgment, and dismissed Ms. Arnold's claims.  She appeals, claiming error in two 
respects:  first, she claims she was 
entitled to issuance of a writ of mandamus requiring the risk manager to settle 
or deny her claim; second, she claims that she was entitled to a district court 
declaration of her rights under the Group Plan and under the WGCA.  We affirm the district court's denial of 
a writ of mandamus.  However, we 
conclude that Ms. Arnold was entitled to a declaration of her rights and, 
proceeding to declare her rights, we hold that she was required to complete the 
Group Plan appeals process before filing a legal action. 

 
 
ISSUES

 
 
[¶3]  Ms. Arnold presents the following issues 
for our determination:

 
 
1.         
Did Appellant's Verified Petition for Writ of Mandamus, affidavits and 
supporting documents present a justiciable controversy?

 
 
2.         
Did Appellant's Complaint for Declaratory Judgment, affidavits and 
supporting documents present a justiciable controversy?

 
 
The 
State rephrases the issues as follows:   

 
 
I.          
Did the District Court properly grant Appellees' Converted Motion for 
Summary Judgment regarding Appellant's Petition for Writ of Mandamus, when 
Appellant has not cited to any Wyoming law which requires the State Risk Manager 
to assume jurisdiction and investigate her governmental 
claim?

 
 
II.         
Did the District Court properly grant Appellees' Converted Motion for 
Summary Judgment regarding Appellant's Complaint for Declaratory Judgment, when 
Appellant seeks an advisory opinion in anticipation of future legal actions 
without a current justiciable controversy?

 
 
FACTS

 
 
[¶4]  Ms. Arnold is an employee of the State 
of Wyoming covered by the Group Plan.  
Ron Ommen was the director of A&I, which is responsible for 
administering and managing the state employees' group insurance program.  Sandy Padilla is the manager of the risk 
management section of the general services division of A&I, and is 
responsible for administering the State Self-Insurance Program established in 
Wyo. Stat. Ann. §§ 1-41-101 through 1-41-111 (LexisNexis 2007).  

 
 
[¶5]  An understanding of the interplay 
between the State Self-Insurance Program and WGCA and between the Group Plan and 
the State Employees and Officials Group Insurance Act (Group Insurance Act) is 
necessary for resolution of the issues presented in this case.  We begin with consideration of the State 
Self-Insurance Program and WGCA.      

 
 
[¶6] 
In the 1980s the State was unable to procure affordable commercial liability 
insurance coverage for claims brought against it and its employees under the 
WGCA and federal law.  The 
legislature passed the State Self-Insurance Program Act which established a 
self-insurance account to cover such claims.  The WGCA requires that written notice of 
a liability claim against the State or its employees be presented to the general 
services division of A&I.  
Pursuant to § 1-41-105(a)(iii) of the State Self-Insurance Program Act, 
the risk manager is required to supervise and manage the investigation, 
adjustment and settlement of liability claims brought against the State and its 
employees under the WGCA.  

 
 
[¶7]  We next consider the interplay between 
the Group Plan and the Group Insurance Act, Wyo. Stat. Ann. §§ 9-3-201 through 
9-3-210 (LexisNexis 2007).  The 
health benefits provided to state employees under the Group Plan are self-funded 
by the State of Wyoming.  Great-West 
contracts with the State to process claims and benefits under the Group Plan but 
does not insure or guarantee benefits.  
The Group Plan sets forth procedures for filing claims for health 
benefits and for contesting claims determinations.  Additionally, in accordance with § 
9-3-205 of the Group Insurance Act, A&I has adopted rules establishing 
procedures for hearing insured employee complaints concerning benefit 
claims.

 
 
[¶8]  As authorized by § 9-3-209 of the Group 
Insurance Act, Ms. Arnold elected to have her dependent spouse covered under the 
Group Plan.  He incurred healthcare 
consultation fees and drug prescription costs for which Ms. Arnold requested a 
determination of medical necessity and benefits under the Group Plan.  Great-West's physician reviewer 
concluded there was "insufficient documentation of the underlying condition and 
proven benefits of treatment to establish that this treatment is medically 
necessary" and denied her request.  In the denial letter, Great-West notified 
Ms. Arnold that she could appeal the determination.    

 
 
[¶9]  Ms. Arnold did not appeal.  Instead, she filed a grievance with the 
Group Insurance Program.  The Group 
Insurance Program forwarded the grievance to the OAH.  The OAH issued an order dismissing the 
grievance for lack of jurisdiction, concluding Ms. Arnold had failed to exhaust 
the Great-West appeals process before filing a grievance as required by the 
Group Plan.    

 
 
[¶10]  Ms. Arnold then presented a notice of 
claim to the risk manager under the WGCA, Wyo. Stat. Ann. § 1-39-101 through 
1-39-121 (LexisNexis 2007), claiming the State, by and through Great-West, 
breached the Group Plan when it failed to pay her benefits claim.  She sought $9,368.20 in damages.  The risk management office responded 
with a letter notifying Ms. Arnold that the State Self-Insurance Program was not 
the proper venue for her claim and that it had forwarded her claim to the Group 
Plan Program.  

 
 
[¶11]  Ms. Arnold then filed her petition for 
writ of mandamus and complaint for declaratory relief in district court.  She alleged that the risk manager was 
required to accept, investigate and act on her notice of claim in accordance 
with the WGCA.  Instead, she 
asserted, the risk manager improperly treated her notice of claim as falling 
under the Wyoming Administrative Procedure Act (WAPA), Wyo. Stat. Ann. §§ 
16-3-101 through 16-3-115 (LexisNexis 2007).  She sought a writ of mandamus ordering 
the risk manager to accept and investigate her claim and settle or deny it.  She also sought a declaration of her 
rights under the WGCA, the State Self-Insurance Program and the Group 
Plan.

 
 
[¶12]  A&I's director and risk manager 
filed a motion to dismiss Ms. Arnold's petition and complaint, claiming that she 
had not exhausted available administrative remedies and was seeking an advisory 
opinion on her legal claims.  They 
supplemented the motion with documents outside of the pleadings.  After hearing argument on the motion, 
the district court converted it to one for summary judgment and entered an order 
granting the motion.  The district 
court held that Ms. Arnold had failed to exhaust her administrative remedies; a 
declaratory judgment action will not lie to allow a court to prejudge issues 
that should be decided by an agency; judicial involvement was premature and 
inappropriate until an administrative decision had been made; and a judicial 
declaration of Ms. Arnold's rights under the Group Plan was inappropriate 
because it would be an advisory opinion with no binding effect.  Ms. Arnold appealed the district court's 
order to this Court.          

 
 
STANDARD 
OF REVIEW

 
 
[¶13]  When this Court reviews a grant of summary 
judgment entered in response to a petition for declaratory judgment, we invoke 
our usual standard for review of summary judgments.  Goglio v. Star Valley Ranch Ass'n, 2002 
WY 94, ¶ 12, 48 P.3d 1072, 1076 (Wyo. 2002).  Summary judgment motions are governed by 
W.R.C.P. 56(c):

 
 
The 
judgment sought shall be rendered forthwith if the pleadings, depositions, 
answers to interrogatories, and admissions on file, together with the 
affidavits, if any, show that there is no genuine issue as to any material fact 
and that the moving party is entitled to a judgment as a matter of law.  

 
 
We 
review a district court's summary judgment rulings de novo, using the same materials and 
following the same standards as the district court.  Winship v. Gem City Bone & Joint, 
P.C., 2008 WY 68, ¶ 8, 185 P.3d 1252, 1254 (Wyo. 2008).  The facts are reviewed from the vantage 
point most favorable to the party opposing the motion, and we give that party 
the benefit of all favorable inferences that may fairly be drawn from the 
record.  Id.    

 
 
[¶14]  Interpretation of a statutory duty in 
the context of mandamus is a question of law, reviewed de novo, following the general rules of 
statutory construction.  State ex rel. Sublette County Bd. of County 
Comm'rs v. State (In re: Bd. of County Comm'rs), 2001 WY 91, ¶ 11, 33 P.3d 107, 111 (Wyo. 2001).  Whether or 
not to issue a writ of mandamus is left to the sound discretion of the trial 
court.  Id., ¶ 10, 33 P.3d  at 112.  An abuse of discretion occurs when the 
trial court could not reasonably conclude as it did.  Id.   

 
 
DISCUSSION

 
 

1.            
Writ 
of Mandamus 

 
 
[¶15]  Ms. Arnold claims the district court 
erred in dismissing her petition for writ of mandamus because her notice of 
claim was facially valid, the risk manager was required to accept and process 
it, and her failure to do so created a justiciable controversy properly 
redressed by a writ of mandamus.  
A&I's director and risk manager contend the district court correctly 
dismissed the petition because it did not satisfy the requirements for issuance 
of a writ of mandamus.  
Specifically, they assert Ms. Arnold had an adequate remedy at law and 
the "duty" she sought to have the district court enforce was discretionary, not 
ministerial.  

 
 
[¶16]  "Mandamus is a writ issued in the name 
of the state to an inferior tribunal, a corporation, board or person commanding 
the performance of an act which the law specially enjoins as a duty resulting 
from an office, trust or station."  
Wyo. Stat. Ann. § 1-30-101 (LexisNexis 2007).  The function of mandamus is to command 
performance of a ministerial duty which is plainly defined and required by 
law.  Sublette County, ¶ 10, 33 P.3d  at 
111.  Mandamus will not lie unless 
the duty is absolute, clear, and indisputable.  Id.  The law must not only authorize the 
demanded action but require it.  Id.  If the lower tribunal has the right to 
exercise discretion regarding an issue, mandamus is not an appropriate 
remedy.  Id.  

 
 
[¶17]  We begin by reviewing the pertinent 
statutory provisions to determine whether the risk manager had a clear duty to 
perform a particular act upon receipt of Ms. Arnold's notice of claim.  The following standards govern our 
review:

 
 
            
When construing statutes, we first review the language of the statute to 
determine whether it is ambiguous.  
If we find it to be unambiguous, we apply its plain meaning and do not 
consult the numerous rules of statutory construction.  If, however, we find the statute 
ambiguous, that is "its meaning is uncertain, doubtful, or if a single term can 
fairly be said to mean different things," then we may resort to the rules of 
statutory construction.  

 
 

W.A.R.M. 
v. Bonds, 
866 P.2d 1291, 1294 (Wyo. 1994).  

 
 
[¶18]  Section 1-39-115 of the WGCA provides in 
relevant part:  

 
 
(a)  Upon receipt of a claim against the 
state which is covered by insurance, the general services division of the 
department of administration and information shall send the claim to the 
insurance company insuring the risk involved for investigation, adjustment, 
settlement and payment.      

. 
. . .

(d)  Claims under this act which are not 
covered by insurance may be settled as provided by W.S. 1-41-106 . . . 
.

 
 
As 
it pertains to this case, § 1-41-106 of the State Self-Insurance Program Act 
provides:

 
 
  (a)  Any claim covered under this act may be 
compromised or settled according to the requirements in subsection (b) of the 
section. . . .              

  (b) The following parties are authorized 
to make compromises or settlements of claims in the following 
amounts:

         
. . . .

        (ii) 
The risk manager is authorized to settle claims for an amount not to exceed 
fifty thousand dollars ($50,000.00);

 
 
Section 
1-41-105 of the same Act further provides that the risk manager shall 
"administer, supervise and manage the investigation and adjustment and 
settlement of claims covered by this act. . . ."

 
 
[¶19]  The first question these provisions 
raise is whether Ms. Arnold's claim was "covered by insurance" within the 
meaning of § 1-39-115(a) such that the risk manager properly forwarded it to the 
Group Insurance Program, or "not covered by insurance" under § 1-39-115(d) 
meaning the risk manager was required to address it in accordance with § 
1-41-106.  Given that Ms. Arnold's 
underlying claim was one for medical insurance benefits payable under the Group 
Plan, it would seem to be one covered by insurance and properly forwarded to the 
Group Insurance Program for processing.  
However, Ms. Arnold's claim was also for breach of contract under the 
WGCA, precisely the sort of claim the State Self-Insurance Program is intended 
to address.  Section 1-41-101 states 
expressly that the self-insurance account was created to remedy the "need to 
develop a method to handle [WGCA] claims. . . ."  Section 1-39-104(a) provides that 
immunity from liability in actions based on a contract entered into by a 
government entity is waived except to the extent provided by the contract and 
the WGCA procedures apply to contractual claims against governmental 
entities.  Thus, the State 
Self-Insurance Program requires the risk manager to handle the investigation, 
adjustment and settlement of WGCA claims and gives her authority up to $50,000 
to settle such claims.

 
 
[¶20]  Upon careful review of all of the 
relevant statutory provisions, it is clear Ms. Arnold's notice of claim included 
claims that fell under the State Self-Insurance Program and the risk manager was 
required to administer, supervise and manage the investigation, adjustment and 
settlement of the claim.  The risk 
manager was mistaken in treating it solely as a claim for medical benefits 
covered by insurance and forwarding it to the Group Insurance Program.  Ms. Arnold is not, however, entitled to 
the issuance of a writ of mandamus commanding the risk manager to do so.  

 
 
[¶21]  As we have said, mandamus is appropriate 
only where a clearly defined, statutorily-required duty to perform exists. Sublette County, ¶ 10, 33 P.3d  at 
111.  Absent a clear ministerial 
duty, mandamus is not an appropriate remedy.  Id.  Owing to the extraordinary character of 
mandamus and the caution courts exercise in awarding it, the right sought to be 
enforced must be clear and certain.  
Id., ¶ 10, 33 P.3d  at 112, citing LeBeau v. State ex rel. White, 377 P.2d 302, 303 (Wyo. 1963).  The writ does 
not issue in cases where the right in question is doubtful.  Sublette County, ¶ 10, 33 P.3d  at 112.

 
 
[¶22]  Under the particular circumstances 
presented here, where the notice of claim sought payments denied under the Group 
Plan, the risk manager's duty was not clear and certain.  Arguably, the claim was one covered by 
insurance and properly forwarded to the Group Insurance Program.  While a careful review of the statutory 
provisions and the notice of claim make it clear that the risk manager's duty 
was to begin an investigation into the breach of contract claim pursuant to the 
State Self-Insurance Program, that duty was not as clear and certain as to make 
the extraordinary remedy of mandamus appropriate.  Additionally, as discussed in the 
following paragraphs, had the risk manager investigated the claim as required 
she likely would have denied it on the ground that Ms. Arnold had not exhausted 
the Group Plan appeals process.  The 
district court did not abuse its discretion in declining to issue a writ of 
mandamus. 

 
 

2.         
Declaratory Judgment

 
 
[¶23]  Ms. Arnold contends the district court 
erred in granting summary judgment for A&I's director and risk manager on 
her complaint for declaratory judgment.  
Summary judgment is appropriate in a declaratory judgment action so long 
as there are no genuine issues of material fact.  Coffinberry v. Town of Thermopolis, 2008 
WY 43, ¶ 4, 183 P.3d 1136, 1137 (Wyo. 2008).  In the present case, the district court 
concluded there was no justiciable controversy and Ms. Arnold was not entitled 
to a declaration of her rights under the Group Plan or the 
WGCA.

 
 
[¶24]  The Uniform Declaratory Judgments Act 
(Declaratory Judgments Act), Wyo. Stat. Ann. § 1-37-101 through § 1-37-115 
(LexisNexis 2007), authorizes Wyoming courts to "declare rights, status and 
other legal relations whether or not further relief is or could be 
claimed."  Section 1-37-102.  Section 1-37-103 provides 
further:

 
 
Any 
person interested under a deed, will, written contract or other writings 
constituting a contract, or whose rights, status or other legal relations are 
affected by the Wyoming constitution or by a statute, municipal ordinance, 
contract or franchise, may have any question of construction or validity arising 
under the instrument determined and obtain a declaration of rights, status or 
other legal relations. 

 
 
[¶25]  Insurance contracts come within the 
purview of the Declaratory Judgments Act.  
Mountain West Farm Bureau Mut. 
Ins. Co. v. Hallmark Ins. Co., 561 P.2d 706 (Wyo. 1977).  Likewise, questions of statutory 
interpretation come within the plain language of the statute. Pursuant to § 
1-37-104, "A contract may be construed either before or after there has been a 
breach thereof."  Likewise, a 
statute upon which administrative action was, or is to be, based may be 
interpreted before or after the agency acts.  Wyoming Community College Comm'n v. 
Casper Community College Dist., 2001 WY 86, ¶ 13, 31 P.3d 1242, 1248 (Wyo. 2001). 

 
 
[¶26]  Section 1-37-114 provides that the 
Declaratory Judgments Act is remedial; "[i]ts purpose is to settle and to afford 
relief from uncertainty and insecurity with respect to legal relations, and is 
to be liberally construed and administered."  Although a declaratory judgment action 
should not be used to replace specific administrative relief, the existence of 
another remedy will not, of itself, preclude declaratory judgment relief.  City of Cheyenne v. Sims, 521 P.2d 1347, 1350 (Wyo. 1974); Rocky Mountain Oil 
& Gas Ass'n v. State, 645 P.2d 1163, 1168 (Wyo. 1982).  Where the desired relief concerns the 
interpretation of a statute upon which the administrative action is, or is to be 
based, the action should be entertained.  
Id.  As we have 
explained:

 
 
Ordinarily, 
a declaratory judgment action is not a substitute for an appeal [from 
administrative decisions.] . . .  
If, however, such desired relief concerns the validity and construction 
of agency regulations, or if it concerns the constitutionality or interpretation 
of a statute upon which the administrative action is, or is to be, based, it 
should be entertained.

 
 

Wyoming 
Community College Comm'n, 
¶ 13, 31 P.3d  at 1248 (quoting Rocky Mountain Oil & Gas Ass'n v. 
State, 645 P.2d 1163, 1168 (Wyo. 1982)).  "The Act is an appropriate vehicle, not 
for prejudging issues that should be decided by an administrative agency, but 
for interpreting the statute . . . upon which the administrative action is 
based."  Wyoming Dep't of Revenue v. Exxon Mobil 
Corp., 2007 WY 21, ¶ 18, 150 P.3d 1216, 1223 (Wyo. 2007).  A complaint seeking declaration of 
rights under a contract also should be entertained.  §§ 1-37-103 and 104.   

 
 
[¶27]  Ms. Arnold sought an interpretation of 
her contractual rights under the Group Plan.  She also sought an interpretation of the 
risk manager's statutory duties under the WGCA and the State Self-Insurance 
Program.  Both of these matters fall 
within the purview of the Declaratory Judgments Act.  The district court concluded, however, 
that Ms. Arnold's complaint did not involve a justiciable controversy and she 
was not entitled to declaratory relief.  

 
 
[¶28]  Generically, a justiciable controversy 
is defined as a controversy fit for judicial resolution.  Cox v. City of Cheyenne, 2003 WY 146, ¶ 
9, 79 P.3d 500, 505 (Wyo. 2003). Many doctrines are encompassed within the 
concept of justiciability including standing, ripeness, and mootness.  Id.  The district court based its decision in 
part on the doctrine of ripeness.  

 
 
[¶29]  The ripeness doctrine is a category of 
justiciability "developed to identify appropriate occasions for judicial 
action."  Tarraferro v. State ex rel. Wyo. Med. 
Comm'n, 2005 WY 155, ¶ 8, 123 P.3d 912, 916 (Wyo. 2005), quoting 13 Wright, 
Miller & Cooper, Federal Practice and Procedure:  Jurisdiction § 3529, p. 146 (1975).  The doctrine of ripeness is a judicially 
created limitation on the availability of judicial review in administrative law 
cases.  

 
 
[I]ts 
basic rationale is to prevent the courts, through avoidance of premature 
adjudication, from entangling themselves in abstract disagreements over 
administrative policies, and also to protect the agencies from judicial 
interference until an administrative decision has been formalized and its 
effects felt in a concrete way by the challenging parties.  

 
 

BHP 
Petroleum Co., Inc. v. State, Wyoming Tax Comm'n, 
766 P.2d 1162, 1164-65 (Wyo. 1989).  
We evaluate ripeness in two prongs, which include, first, an evaluation 
of the fitness of the issues presented for judicial review and, second, an 
evaluation of the hardship to the parties if judicial review is denied.  Id.  

 
 
[¶30]  By her complaint, Ms. Arnold sought a 
determination as to whether:  1) the 
Group Plan allowed her to bring a legal action to recover benefits allegedly due 
without first having completed the Group Plan appeals process; and 2) the WGCA 
required the risk manager to settle or deny her notice of claim rather than 
forwarding it to the Group Insurance Program.  As discussed above, these issues fall 
squarely within the scope of the Declaratory Judgments Act because they involve 
interpretation of contractual and statutory rights and duties.  We conclude, therefore, that they are 
fit for judicial review.  

 
 
[¶31]  We further conclude hardship would 
result from a denial of judicial review.  If, as a matter of law, the Group Plan 
allowed Ms. Arnold to bring an action in court without first completing the 
Group Plan appeals process, a judicial determination to that effect would have 
allowed her to move forward with her breach of contract claim without further 
delay.  If, as matter of law, the 
WGCA required the risk manager to investigate, and settle or deny, the notice of 
claim, a judicial determination to that effect would have caused the risk 
manager to act on the claim in accordance with § 1-41-105 of the State 
Self-Insurance Program.  More was at 
issue here than an abstract disagreement about what Ms. Arnold and the risk 
manager could and could not do with respect to the Group Plan and the WGCA.  A judicial determination of those issues 
was and is appropriate.  

 
 
[¶32]  We have already determined that upon 
receipt of Ms. Arnold's notice of claim, the risk manager was required to 
initiate and oversee an investigation and settle or deny the claim.  Under ordinary circumstances, we would 
remand the case at this stage to the district court for a determination of Ms. 
Arnold's rights under the Group Plan.  
However, these are not ordinary circumstances.  Ms. Arnold has already presented four 
separate claims in four different forumsher request for a medical necessity 
determination through Great-West's medical management program; the grievance she 
filed with the Group Insurance Program which the OAH denied; the WGCA notice of 
claim she filed with risk management; and the petition and complaint she filed 
in district court.  It is time her 
rights under the Group Plan were determined.  We have the same information the 
district court had and would have upon remand.  Ms. Arnold has fully presented her 
argument that the Group Plan allows her to bring a legal action. The facts are 
not in dispute and the issue is one requiring de novo review.  We conclude, therefore, for reasons of 
judicial economy that it is appropriate for this Court to proceed to determine 
whether the Group Plan allowed Ms. Arnold to file a legal action without first 
completing the Group Plan appeals process.  
See Wells Fargo Bank Wyoming, N.A., v. 
Hodder, 2006 WY 128, ¶ 32, 144 P.3d 401, 412 (Wyo. 2006), concluding for 
reasons of judicial economy that this Court should decide the issue rather than 
remand. 

 
 
[¶33]  In support of her claim that she was 
allowed to bring legal action, Ms. Arnold cites the following Group Plan 
provision found under the heading, "Other Information a Member Needs to Know": 

 

Legal 
Actions

 
 
You 
may bring a legal action to recover under the Plan.  Such legal action may be brought no 
sooner than 60 days, and no later than 3 years, after the time written proof of 
loss is required to be given under the terms of the Plan.

 
 
A&I's 
director and risk manager assert that A&I's rules for contested case 
hearings under the Group Plan provided the appropriate mechanism for Ms. Arnold 
to pursue her claim.   

 
 
[¶34]  Before considering the contested case 
rules, we look to the Group Plan itself.  
We begin with the provisions addressing medical management decisions 
because Ms. Arnold's claim arose after medical management denied her request for 
a determination that the services her husband received and for which she sought 
coverage were medically necessary. As it relates to Ms. Arnold's claim, the 
Group Plan states that medical management will review the medical necessity of 
services that have already been provided.  
In the event medical management determines the services were not 
medically necessary, the insured can appeal the decision.  

 
 
[¶35]  The Group Plan provides two levels of 
appeal.1  The first level is an internal review in 
which a board certified physician reviewer in the same or similar specialty as 
the services provided reviews the services and makes a determination whether 
they were medically necessary.  If 
the internal review denies authorization, a second level of appeal is available 
in which an external review is conducted by a doctor or group of doctors in the 
same or similar specialty as the services under review.  The Group Plan states:  

 
 
One 
level of appeal must be completed for appeals involving urgent care and two levels of appeal must be completed for 
all other appeals involving a [medical management] adverse determination, before 
a Member may bring civil action.  
The appeal review will consider written comments, documents and any other 
information submitted by the Member, Authorized Representative or Doctor, 
regardless of whether the documentation was reviewed as part of the initial 
determination. 

 
 
[¶36]  It is undisputed that Ms. Arnold 
requested a determination under the Group Plan that the services her husband had 
received were medically necessary.  
Great-West's physician reviewer denied the request because there was 
insufficient documentation to establish that the treatments were medically 
necessary. With the denial, Ms. Arnold was advised of her appeal rights, 
including her rights to submit additional documentation and to an external 
review by an independent entity not affiliated with Great-West.  Ms. Arnold did not submit additional 
documentation nor did she appeal.  
Instead, she filed a grievance with the Group Insurance Program 
presumably under the following Group Plan provision:

 
 
Grievance 
Procedure

 
 
If 
you are not satisfied with how a claim has been settled, you may file a 
grievance with the [Group Insurance Program].  You must exhaust your Great-West appeals 
process before filing a Grievance.  
* * * 

 
 
[¶37]  As we have said: 

 
 
An 
insurance policy constitutes a contract between the insurer and the 
insured.  As with other types of 
contracts, our basic purpose in construing or interpreting an insurance contract 
is to determine the parties' true intent.  
We must determine intent, if possible, from the language used in the 
policy, viewing it in light of what the parties must reasonably have 
intended.  The nature of our inquiry 
depends upon how clearly the parties have memorialized their intent.  Where the contract is clear and 
unambiguous, our inquiry is limited to the four corners of the document.  

 
 
            
We interpret an unambiguous contract in accordance with the ordinary and 
usual meaning of its terms.  The 
parties to an insurance contract are free to incorporate within the policy 
whatever lawful terms they desire, and the courts are not at liberty, under the 
guise of judicial construction, to rewrite the policy.  It is only when a contract is ambiguous 
that we construe the document by resorting to rules of construction.  Whether a contract is ambiguous is a 
question for the court to decide as a matter of law.  

 
 

Cathcart 
v. State Farm Mut. Auto. Ins. Co., 
2005 WY 154, ¶ 18, 123 P.3d 579, 587-588 (Wyo. 2005).

 
 
[¶38]  The appeal procedures applicable to 
medical necessity determinations set forth in the Group Plan, and of which 
Great-West advised Ms. Arnold in its denial letter, are clear and 
unambiguous.  Upon receipt of 
medical management's initial conclusion that insufficient documentation 
supported her claim, Ms. Arnold had the opportunity to submit additional 
information from which a determination of medical necessity could be made.  Ms. Arnold did not submit additional 
information.  Ms. Arnold also was 
required to complete two levels of appeal before bringing a civil action.  She did not complete either level.  She was not entitled to bring a civil 
action.  Reading the medical 
management appeal provisions together with the legal action provision upon which 
Ms. Arnold relies, it is clear that the former provisions imposed limitations on 
the latter.  That is, in the case of 
an adverse non-urgent medical management determination, the right to bring a 
legal action is limited by the express requirement that the insured complete the 
two levels of appeal.2  

 
 
[¶39]  Ms. Arnold asserts the Group Plan is 
ambiguous because, while the medical management provisions require an insured to 
appeal an adverse determination, the "Legal Actions" provision contains no such 
requirement and states instead that a legal action can be brought "no sooner 
than 60 days, and no later than 3 years, after the time written proof of loss is 
required."  She contends this 
provision should be read to mean an insured may bring legal action 60 days after 
submitting proof of loss.  At the 
very least, she maintains, the provision creates an ambiguity and should be 
construed in her favor.

 
 
[¶40] 
We interpret contracts as a whole, reading each provision in light of all the 
others to find the plain and ordinary meaning of the words.  Squillace v. Wyoming State Employees' and 
Officials' Group Ins. Bd. of Admin., 933 P.2d 488, 491 (Wyo. 1997).  We are reluctant to read parts of an 
insurance contract in isolation.  Id.  In isolation, the "Legal Actions" 
provision might be interpreted as Ms. Arnold suggests.  However, when read in light of the other 
provisions, it is clear that in the case of an adverse non-urgent medical 
management determination, the right to bring a legal action is limited by the 
express requirement that the insured complete the two levels of appeal.  To interpret the Group Plan otherwise 
would render meaningless the provision requiring appeals from adverse medical 
management determinations, an outcome this Court has consistently sought to 
avoid in interpreting contracts.  Stone v. Devon Energy Prod. Co., 2008 WY 
49, ¶ 18, 181 P.3d 936, 942 (Wyo. 2008).

 
 
[¶41]  Additionally, the "Legal Actions" 
provision allows a member to bring legal action no sooner than 60 days after the 
time written proof of loss is required to be given under the Plan.  The purpose of a proof of loss is to 
enable an insurer to investigate a claim and determine its rights and 
liabilities.  Hawkeye-Security Ins. Co. v. Apodaca, 
524 P.2d 874, 877 (Wyo. 1974).  
Medical management advised Ms. Arnold that it had insufficient 
documentation supporting a medical necessity determination and indicated 
additional medical records might be helpful.  Ms. Arnold did not submit additional 
information.  Under these 
circumstances, where the insurer expressly informs the insured that 
documentation is insufficient and the insured does not respond, we cannot 
conclude the proof of loss requirement for bringing a legal action was 
satisfied.

 
 
[¶42]  Within her argument that the Group Plan 
allowed her to bring a legal action, Ms. Arnold also contends that the State has 
given Great-West complete discretion to determine what is, and what is not, 
medically necessary for purposes of coverage.  She asserts that this violates public 
policy and the Group Insurance Act.  
We find nothing in the record to support these assertions.  To the contrary, the Group Plan 
expressly provides several levels for review of Great-West's determination, 
including:  an internal review by a 
board certified physician reviewer who was not involved in the initial adverse 
determination and is not a subordinate of the initial reviewer; an external 
review by an independent review entity not affiliated with Great-West; an 
administrative appeals process; and, upon completion of the two level Great-West 
appeals process, filing a legal action.  
The Group Plan does not give Great-West unbridled discretion to determine 
whether treatment is medically necessary.

 
 
[¶43]  Ms. Arnold contends the administrative 
appeals process is inadequate because the OAH has been unwilling to overturn 
Great-West's determinations as to whether services are medically necessary.  In support of this contention, Ms. 
Arnold submitted the affidavit of an attorney who has handled Group Plan claims 
before the OAH.  The attorney avers 
that in one such case before the OAH in 2006, the hearing examiner concluded he 
could not disregard the Group Plan language stating that medical necessity is 
"determined solely by Great-West."  
We do not find that language in the 2007 Group Plan and Ms. Arnold does 
not direct us to where it appears.  To the extent the OAH may have taken the 
position in other cases that medical necessity is determined solely by 
Great-West, that is contrary to law and clearly erroneous.  Beyond that comment, however, we decline 
to address in this case the adequacy of the Group Insurance Program 
administrative appeals process.  Ms. 
Arnold did not exhaust the Great-West appeals process before filing her 
grievance; therefore, the issue of whether a preponderance of the evidence 
supported Great-West's determination was never addressed and the OAH did not 
have the opportunity to disregard or accept Great-West's determination.  

 
 
CONCLUSION

 
 
[¶44]  The State Self-Insurance Program 
requires the risk manager to initiate and oversee the investigation, adjustment 
and settlement of claims brought against the state and its employees under the 
WGCA.  Under the circumstances of 
this case, however, where the claim involved the payment of medical benefits 
under the state employee's group insurance plan, the risk manager's duty was not 
so clear as to make issuance of a writ of mandamus appropriate.  

 
 
[¶45]  Ms. Arnold was entitled to a declaration 
of her rights under the Group Plan.  
Pursuant to the medical management provisions, she did not have the right 
to bring a legal action to recover under the Group Plan until she completed the 
required two level appeals process.  
We affirm the district court's order denying Ms. Arnold's petition for 
writ of mandamus and reverse the district court's order denying her complaint 
for declaratory judgment.3

 
 
FOOTNOTES

 
 

1Before describing the two levels, the Plan states:  

 
 
The appeal review will consider written comments, documents and any other 
information submitted by the Member, Authorized Representative or Doctor, 
regardless of whether the documentation was reviewed as part of the initial 
determination.

 
 
Given that the initial reviewer denied Ms. Arnold's request because 
insufficient documentation established that the treatment was medically 
necessary, this provision is significant.  
It gave Ms. Arnold the opportunity to present additional evidence at the 
appeal level to support her request.

 
 

2Our conclusion that an insured is required to complete the Group Plan 
appeals process before bringing a legal action necessarily means that the two 
year period for filing a notice of claim under the WGCA begins when that appeals 
process is completed, not when the initial determination is made whether the 
care was medically necessary.

 
 

3The 
declaratory judgment portion of this decision is limited to declaring that the 
Group Plan required Ms. Arnold to complete the two level appeals' process before 
filing a legal action. We have not decided the breach of contract claim.  In the event Ms. Arnold completes the 
Group Plan appeals process and still believes the Group Insurance 
Program, through Great-West, breached the contract, she will be entitled to 
bring legal action in accordance with the Group Plan and the 
WGCA.