Court Opinion

ID: 9755346
Source: CourtListenerOpinion
Date Created: 2023-08-28 20:35:27.79702+00
Date Added: 2024-06-11T07:28:06.404719
License: Public Domain

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 co-payments 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 In-swramce Policies, 150 Roger Williams U.L.Rev. 98, 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 98. About our interpretation of statutes, we have said:
*715In interpreting statutes, our primary consideration is to determine the legislature's intent. All statutes must be construed in pari materice 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 accurate ly 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 mammo-plasty" 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 mammo-plasty as a covered service: Section 6, Part I (Covered Services-Deseription 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 mam-moplasty.
[¶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 *716identified 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 mam-moplasty" 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 statts: "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 mam-moplasty), 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 mammo-plasty are not covered by this contract. In Paragraph 85, mentioned above, the significance of the explicit wording of limitation "unless approved as Medically Necessary by the Plan" is that it demonstrates that Appel-lee 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 mammo-plasty" 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 mammoplasty 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 *717reduction 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 mammo-plasty, 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, 887 (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.