Opinion ID: 1692653
Heading Depth: 1
Heading Rank: 3

Heading: Scope and Application of Wis. Stat. ch. 655 Preclusion

Text: [16, 17] ¶ 33. Having recognized that a cause of action for bad faith may be maintained against an HMO for out-of-network benefit decisions, we next address the issue whether Wis. Stat. ch. 655 precludes the plaintiffs' bad faith cause of action. When conducting statutory interpretation, our primary objective is to ascertain and effectuate the intent of the legislature. See Ball v. District No. 4, Area Bd., 117 Wis. 2d 529, 537-38, 345 N.W.2d 389 (1984). When determining legislative intent, we first examine the language of the statute and will resort to extrinsic aids only if the language is ambiguous. See id. at 538. ¶ 34. Wisconsin Stat. ch. 655, Health Care Liability and Patients Compensation, regulates claims made against individual health care provides and entities providing health care services through their employees. Section 655.002, Applicability, sets forth those medical actors covered by the chapter. This list includes physicians, nurse anesthetists, partnerships, and corporations organized to provide services through physicians and nurse anesthetists, hospitals, and cooperative sickness care associations like GHC. [7] ¶ 35. GHC would have us read ch. 655 as controlling all suits brought against HMOs, whether for medical mistake or for disputed coverage decisions. However, an examination of the language of chapter 655 reveals that the legislature did not intend to go beyond regulating claims for medical malpractice. Wis. Stat. § 655.007 provides: On and after July 24, 1975, any patient or the patient's representative having a claim or any spouse, parent or child of the patient having a derivative claim for injury or death on account of malpractice is subject to this chapter. (Emphasis added.) Wis. Stat. § 655.009 states: An action to recover damage on account of malpractice shall comply with the following. . . .(Emphasis added.) Wis. Stat. § 655.23 (5) specifies: [T]he health care provider. . [is] liable for malpractice. (Emphasis added.) Wis. Stat. § 655.27 states: There is created a patients compensation fund for the purpose of paying that portion of a medical malpractice claim which is in excess of the limits expressed in s. 655.23 (4). . . . (Emphasis added.) ¶ 36. Thus, the language of ch. 655 consistently expresses the legislative intent that the chapter applies only to medical malpractice claims. While malpractice is not defined within the statute, the term is traditionally defined as professional misconduct or unreasonable lack of skill, or [f]ailure of one rendering professional services to exercise that degree of skill and learning commonly applied under all the circumstances in the community by the average prudent reputable member of the profession. See Black's Law Dictionary 959 (6th ed. 1990). [18] ¶ 37. We conclude that ch. 655 applies only to negligent medical acts or decisions made in the course of rendering professional medical care. To hold otherwise would exceed the bounds of the chapter and would grant seeming immunity from non-ch. 655 suits to those with a medical degree. Thus, while certain HMOs may properly be sued for medical malpractice under ch. 655, claims not based on malpractice, such as a bad faith tort action, survive application of that chapter. [8] ¶ 38. The defendant contends that the McEvoys' allegations based on Lancer's decision to deny further coverage for Angela's treatment at UMH are really claims for medical malpractice. If this assertion is accurate ch. 655 controls this case and we need not proceed further in our analysis. Because the plaintiffs admittedly failed to comply with the mediation requirements of § 655.445, [9] a grant of summary judgment for the defendant would be appropriate. However, as discussed above, this opinion applies the bad faith cause of action to out-of-network coverage decisions by HMOs. Because such actions are based on a breach of duty imposed as a consequence of the relationship established by contract, and not on an improper medical action or decision resulting from negligence, the causes of action are distinct. Anderson, 85 Wis. 2d at 687. [19] ¶ 39. The McEvoys do not allege a malpractice action. Rather, they allege that GHC breached its contract and in bad faith denied and threatened to deny coverage for Angela's out-of-network treatment. Because we recognize that a bad faith cause of action is properly extended to HMOs making out-of-network benefit decisions and that Wis. Stat. ch. 655 does not preclude a bad faith cause of action against an HMO as an insurer, we conclude that the circuit court erred in granting summary judgment to GHC. The defendant is not entitled to judgment as a matter of law and issues of material fact remain. Accordingly, we affirm the decision of the court of appeals. By the Court. The decision of the Court of Appeals is affirmed.