Summary 2011 WY 131

Summary of Decision September 20, 2011


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Case Name: Shaffer v. WINhealth Partners

Citation: 2011 WY 131

Docket Number: S-11-0005

URL: http://wyomcases.courts.state.wy.us/applications/oscn/DeliverDocument.asp?CiteID=464399

Appeal from the District Court of Laramie County, Honorable Thomas T.C. Campbell, Judge

Representing Appellant (Plaintiff): Blair J. Trautwein of Wick & Trautwein, Fort Collins, CO.

Representing Appellee (Defendant): Michael Rosenthal and Lucas Buckley of Hathaway & Kunz, Cheyenne, WY.

Date of Decision: September 20, 2011

Facts: Appellant challenges an order of the district court granting summary judgment in favor of the Appellee. Appellant contends that there are ambiguities in the insurance contract which the district court interpreted incorrectly as a matter of law, and that there are genuine issues of material fact with respect to terminology used in the insurance contract that governs in this case.

Issues: Whether the Exclusions and Limitations provision of the insurance contract is ambiguous as to whether it applies only to cosmetic breast reduction surgeries or all breast reduction surgeries. Whether the term “reduction mammoplasty” has a single plain meaning or two plain meanings. Whether the trial court erred in considering parol evidence in determining the meaning of the contract. Whether the trial court erred in finding the parol evidence affidavit was not disputed by competent evidence. Whether the trial court erred in failing to consider other parts of the contract when determining that reduction mammoplasty was an exclusion applying to all breast reduction surgeries rather than a limitation applying only to cosmetic surgeries. Whether the trial court erred in finding the Exclusions and Limitations provision dealing with complications of operations excluded by the policy applies and denies coverage for Appellant’s penicillin-resistant infection. Whether the court erred in failing to consider the differences in language between two other subparts of the contract when interpreting a third subpart. Whether the contract provided a basis to deny a medically necessary surgery.

Holdings: It is undisputed that Appellant’s breast reduction surgery was medically necessary and was not performed for cosmetic purposes. It is likewise clear that the infection was a complication of her breast reduction surgery. The contract excludes from coverage complications and side effects resulting from surgeries not covered by the policy. The parties disagree as to whether Appellant’s non-cosmetic breast reduction surgery falls within the definition of reduction mammoplasty referred to in the contract.

Reduction mammaplasty is occasionally performed for purely cosmetic purposes. More often, women seek surgical relief from the discomfort caused by massive, heavy, pendulous breasts. The female breast can become large enough to restrict physical activity, interfere with breathing, prevent sleep, and cause constant pain. Operations to relieve such distress are certainly not purely cosmetic surgery. This description of reduction mammoplasty confirms that the term is synonymous with breast reduction surgery and applies whether the procedure is performed for cosmetic or non-cosmetic purposes. Thus, applying the ordinary and common meaning of the words used in the insurance contract Appellant’s breast reduction surgery fell within the definition of “reduction mammoplasty.” Consequently, if the contract simply stated that mammoplasty reduction was “excluded,” all breast reductions are excluded from coverage under the policy. However, the contractual language states that reduction mammoplasty is either “not covered or subject to limitations,” without specifying which of those alternatives applies. The district court did not consider the effect of the “subject to limitations” language. Rules of contract interpretation require effect be given to each word if possible because each provision is presumed to have a purpose. Thus, the contractual language that states that coverage for reduction mammoplasty may be subject to limitations, as opposed to excluded altogether. The only interpretation which gives effect all the various provisions of the contract is that coverage for reduction mammoplasty is not wholly excluded but, rather, coverage is limited to non-cosmetic breast reduction surgeries.

The district court erred in granting summary judgment to Appellee. Appellant is entitled to summary judgment on her claims for the treatment of her infection. This ruling is dispositive and the parties’ other arguments need not be addressed.

The district court’s summary judgment order is reversed, and the district court is directed to enter summary judgment in favor of Appellant on her claims for treatment of her infection. In addition, the matter is remanded to the district court for further proceedings to dispose of all other remaining issues/claims.

J. Hill delivered the opinion for the court.

J. Golden, joined by J. Voigt dissented. In the provision detailing covered services the contract states that all benefits are subject to plan limitations and exclusions and that services that are not specifically identified are not a covered benefit. Thus, medical services for complications arising from medically necessary reduction mammoplasty must be specifically identified in order to be a covered service. One does not find “medical services for complications arising from medically necessary reduction mammoplasty” in the identified covered services. Accordingly, the decision of the district court should be affirmed.

J. Voigt joined by J. Golden dissented. The majority attempts to create insurance coverage for the appellant where none exists. 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. Furthermore, one party’s subjective intent or interpretation of a contract is not controlling; instead the objective intent of the language used must be examined. The policy in this case is not ambiguous. The exclusions are not ambiguous. There is nothing to construe or interpret. The action should be affirmed.