Court Opinion

ID: 6940337
Source: CourtListenerOpinion
Date Created: 2022-07-24 01:01:14.341612+00
Date Added: 2024-06-11T16:07:40.220665
License: Public Domain

DURHAM, J.,
specially concurring.
I agree with the majority that the parties’ disagreement about whether the treatment plan describes a service that must be covered pursuant to ORS 743.706(2) cannot be resolved by a summary judgment. However, the majority applies an interpretive gloss to the statute that changes its clear meaning and that will undermine its proper application on remand. I do not agree with that construction.
ORS 743.706 provides:
“(1) The Legislative Assembly declares that all group health insurance policies providing hospital, medical or surgical expense benefits include coverage for maxillofacial prosthetic services considered necessary for adjunctive treatment.
“(2) As used in this section, ‘maxillofacial prosthetic services considered necessary for adjunctive treatment’ means restoration and management of head and facial structures that cannot he replaced with living tissue and that are defective because of disease, trauma or birth and developmental deformities when such restoration and management are performed for the purpose of:
‘ ‘ (a) Controlling or ehminating infection;
“(b) Controlling or eliminating pain; or
‘ ‘ (c) Restoring facial configuration or functions such as speech, swallowing or chewing but not including cosmetic procedures rendered to improve on the normal range of conditions.
“(3) The coverage required by subsection (1) of this section may be made subject to provisions of the policy that apply to other benefits under the policy including, but not limited to, provisions relating to deductibles and coinsurance.
‘ ‘ (4) The services described in this section shall apply to individual health policies entered into or renewed on or after January 1, 1982.”
The majority concludes that the statute bars the exclusion from coverage of “medical,” as opposed to “dental,” services, including medical treatments that “may have dental attributes but which are treatments for medical problems and that are ‘adjunctive’ to medical treatments.” 117 Or App at 381.
*383As we attempt to discern the legislature’s intention, we cannot insert what has been omitted from the statute. ORS 174.010. We begin the examination with the words of the statute. Teeny v. Haertl Constructors, Inc., 314 Or 688, 694, 842 P2d 788 (1992). In subsection (2), the legislature has provided a comprehensive definition of the phrase “maxillofacial prosthetic services considered necessary for adjunctive treatment.” The legislature intended us to apply its definition of that term, not a definition that we might obtain from another source. What becomes obvious upon examining the definition in subsection (2) is that the majority’s distinction between medical and dental services is nowhere to be found. A covered service must satisfy three requirements. First, it must restore and manage head and facial structures; second, those structures must be incapable of replacement with living tissue and be defective because of disease, trauma or birth or developmental deformities; and, third, the service must be performed for one of the purposes in subsection (2)(a), (b) or (c). The requirements do not distinguish between services that might be labeled “medical” or “dental.” Furthermore, nothing in subsection (2) bars exclusion of a treatment only if it is “adjunctive” to another medical treatment. The majority recognizes distinctions in treatments that have no basis in the statutory definition. It has inserted into the statute that which it believes the legislature intended but omitted. That construction violates ORS 174.010.
The statutory definition is not ambiguous. However, even if it were, the legislative history supports plaintiff. The legislature enacted the present form of ORS 743.706 in 1981 in response to testimony from medical and dental professionals that insurers were delaying or refusing payment for services rendered by dentists, not physicians. See Allen v. Pacific Hospital Assoc., 91 Or App 356, 362 n 2, 757 P2d 428 (1988). The legislature eliminated any distinction between medical and dental services for the purpose of mandating coverage, notwithstanding that distinction. The majority nullifies that effort by reintroducing the distinction through its interpretive gloss on ORS 743.706(2). The legislature intended to require coverage for services described in the statute, even if it involved anchoring a prosthetic device to the teeth. That is the treatment contemplated here, according to plaintiffs experts.
*384Defendant’s argument that the trial court’s decision would require it to cover ordinary dental services under its medical insurance plan is unconvincing. It ignores the other elements of the statutory definition.
If the treatment for plaintiffs congenital condition is that described by plaintiffs experts, it meets the definition in subsection (2) and must be covered. We must liberally construe the Insurance Code “for the protection of the insurance-buying public.” ORS 731.008; ORS 731.016. The majority’s construction of ORS 743.706(2) disregards that rule.