Opinion ID: 149598
Heading Depth: 2
Heading Rank: 2

Heading: Wisconsin Statutory Limit on Exclusions for Preexisting Conditions

Text: We also agree that summary judgment was properly granted as to Kenseth's state-law claim. A Wisconsin statute precludes a group health insurer from excluding coverage for a preexisting condition for a period of longer than twelve months. Wis. Stat. ง 632.746(1)(b). Kenseth reasons that her gastric band constituted a preexisting condition and that, consequently, Dean could not exclude coverage for treatment related to the band for more than twelve months after she joined the Dean Plan in 1996. However, Wisconsin law also makes clear that the statutory limit on exclusions for preexisting conditions does not [p]revent a group health benefit plan from establishing limitations or restrictions on the amount, level, extent or nature of benefits or coverage for similarly situated individuals enrolled under the plan. Wis. Stat. ง 632.748(3). The exclusion that Dean relied on here is properly understood as a restriction on the nature of benefits provided rather than one based on a preexisting condition. See Wynn v. Washington Nat'l Ins. Co., 122 F.3d 266, 269 (5th Cir.1997) (Louisiana law) (exclusion for particular disease or injury is qualitatively different from exclusion for preexisting condition). Although it is true that Kenseth's VBG surgery took place before she joined the Dean plan, and her banded stomach thus could be understood as a preexisting condition, that was not the basis on which Dean denied coverage for conditions associated with the band. Dean instead relied on the exclusions in the policy for surgeries designed to deal with morbid obesity and for any conditions related to such non-covered services. As the district court pointed out, the timing of Kenseth's VBG procedure was irrelevant to Dean's decision; the exclusions would have applied regardless of whether Kenseth had had the gastric band inserted before or after she joined the Dean plan. 568 F.Supp.2d at 1019. We therefore agree with the district court that Dean's decision to deny coverage for the 2005 remediation surgery did not run afoul of the Wisconsin statute. See Wynn, 122 F.3d at 269 (reaching similar conclusion under Louisiana law); accord Aul v. Golden Rule Ins. Co., 304 Wis.2d 227, 737 N.W.2d 24, 31 (Ct.App.2007); Usick v. Am. Fam. Mut. Ins. Co., 131 P.3d 1195, 1201 (Colo.Ct.App.2006).