Court Opinion

ID: 9608208
Source: CourtListenerOpinion
Date Created: 2023-08-22 03:07:36.36977+00
Date Added: 2024-06-11T18:02:44.361529
License: Public Domain

GOLDEN, Justice,
dissenting.
I respectfully dissent. There is little question that an insurer is not required to pay for medical treatment simply because a treating physician has recommended the treatment. It is equally certain, however, that an insurer does not have sole discretion to decide that medical treatment obtained upon advice of a physician is not medically necessary. Upon the request of either the insurer or the insured, courts may review insurance payment decisions and the assessment procedures utilized by the insurers in making its decision. In conducting that review, courts must not add terms to a contract in order to find that substantial evidence supports the conclusions of law of a review board. In my opinion, the majority has permitted the Wyoming Employees’ and Officials’ Group Insurance Board (Board) to rewrite this contract. Although the entire contract is not before us, given the parties’ agreement that the terms at issue are in the record, the effect of the Board’s interpretation should be reviewed as explained below.
A court that decides whether or not an insurer properly denied payment for a physician-recommended course of treatment as not “medically necessary” is required to construe the term “medically necessary” in accord with the rules of contract law which apply. Many courts have attempted to define this term, some quite liberally in favor of the insured and others more restrictively. See Kinzie v. Physician’s Liability Ins. Co., 750 P.2d 1140, 1141-42 (Okla.App.1987) (collecting cases). In this case, the Board had the policy’s definition and criteria before it and determined that one criterion used in the policy’s definition of this term was not met. The second criterion listed for determining whether a procedure is “medically necessary” is whether it is “required for the treatment or management of a medical symptom or condition.” In essence, the Board determined that this criterion permitted it to add the requirements that the patient show her “bodily functions were impaired to the degree that surgery was needed” and have “established that she was at risk to adverse *494medical problems in the future if the surgery was not performed.” This interpretation of the second criterion listed in the policy essentially defines “required” as meaning that surgery must be the only alternative or it is barred from coverage. Such an interpretation is simply an exercise in adding terms to a contract which of course is prohibited under the traditional contract law our court applies.
We have found no case law that has interpreted “required” as meaning that the insured must show medical symptoms or conditions exist to a certain degree or that the recommended treatment chosen was the only alternative. An insurer must expressly provide for these limitations in order to avoid a finding that a procedure was medically necessary. It is common knowledge that many medical conditions can be tolerated without surgery, but the question is whether a patient’s choice to undergo surgery which will cure the impaired function and pain is medically necessary. In this case, the patient complained of pain and an impaired ability to perform normal exercise and normal lifting of her children. Her first treating physician diagnosed a ventral hernia. The patient wisely received a second opinion and received a more serious diagnosis of the cause for her impairment and pain. The majority opinion acknowledges that the treating physicians established that the medical condition and symptoms existed and were the result of two cesarean section surgeries and these serious afflictions could be cured by another surgery. Following the surgery, the patient was found to have suffered another kind of hernia which was repaired and apparently the surgery has successfully alleviated her medical condition. Under these facts, I believe that the terms of the insurance contract require that review be limited to the questions of whether the medical symptoms and condition existed at all and whether the chosen treatment is an accepted or established method of treatment or management. If this limitation is not applied, this particular criterion is so elastic as to be meaningless. Additionally, it leads to the result reached by the majority, viz., rewriting the contract to support Ms. Reynolds’ testimony although the patient and her doctors had established that surgery would treat her medical condition. It should be noted that under my recommended analysis, Appellant was not required to rebut Ms. Reynolds’ testimony. The evidence of the treating physicians and Appellant’s own testimony were reasonably sufficient for the Board to properly apply this policy’s criteria and determine medical necessity. There is no need to have insureds do more than what is reasonable or we risk permitting administrative review to frustrate the reasonable expectations of the insurer and the insured.
I am not suggesting that consideration of degree of impairment and future risk to adverse medical problems would never be appropriate. In fact, the third criterion, whether surgery was the most efficient and economical service which can safely be provided, would seem to require such consideration. However, the Board did not reject the claim on this basis and did not have evidence to make a comparison between the efficiency and economy of surgery as opposed to continued medical treatment. Instead, it improperly added terms to the definition of “medically necessary” under the guise of defining “required” and, as a matter of law, the Board’s interpretation of the second criterion should be rejected by this Court.
Additionally, I find that the plain language of the policy permits this surgery as a covered cosmetic surgery. The Board concluded that coverage included cosmetic surgery to correct deformities that result from illness. The Board then concluded that the insured’s medical condition was a deformity caused by pregnancy, which the policy defines as an illness. Although the insured had obviously met the requirements to obtain coverage, the Board went further and determined that the deformity was normal because it resulted from pregnancy. Nothing in the policy or definition of “normal” permits a denial of coverage because the deformity which has resulted from the illness is a normal occurrence. Again, this simply rewrites the contract to add an additional term and frustrates the reasonable expectations of the insurer and insured. I would reverse the Board’s decision to deny payment of benefits.