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Kimberly Shaffer v. Winhealth Partners

September 20, 2011

KIMBERLY SHAFFER, APPELLANT (PLAINTIFF),
v.
WINHEALTH PARTNERS, APPELLEE (DEFENDANT).



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

The opinion of the court was delivered by: Hill, Justice.

Before KITE, C.J., and GOLDEN, HILL, VOIGT, and BURKE, JJ.

HILL, J., delivers the opinion of the Court; GOLDEN, J. files a dissenting opinion in which VOIGT., J. joins; and VOIGT, J., files a dissenting opinion, in which GOLDEN, J., joins.

NOTICE: This opinion is subject to formal revision before publication in Pacific Reporter Third. Readers are requested to notify the Clerk of the Supreme Court, Supreme Court Building, Cheyenne, Wyoming 82002, of any typographical or other formal errors so that correction may be made before final publication in the permanent volume.

[¶1] Appellant, Kimberly Shaffer (Shaffer), challenges an order of the district court granting summary judgment in favor of the Appellee, WINhealth Partners (WIN). Shaffer 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. We will reverse the district court's order granting summary judgment in favor of WIN, direct the entry of a partial summary judgment in favor of Shaffer on her claims for benefits, and remand this matter to the district court for further proceedings so as to address Shaffer's other claims, including "bad faith" and attorney's fees.

ISSUES

[¶2] Shaffer raises these issues:

A. Did the trial court improperly grant summary judgment on all issues in favor of [WIN]?

1. Is Article VI, Part II, (Exclusions and Limitations) subpart 45 ambiguous as to whether it applies only to cosmetic breast reduction surgeries or all breast reduction surgeries?

2. Does the term "reduction mammoplasty" have a single plain meaning or two plain meanings?

3. Did the trial court err in considering the affidavit of Dr. Wyatt as it is parol evidence in determining the meaning of subpart 45?

4. Did the trial court err in finding Dr. Wyatt's affidavit was not disputed by competent evidence?

5. Did the trial court err in failing to consider other parts of the WINhealth contract when determining that subpart 45 (reduction mammoplasty) was an exclusion applying to all breast reduction surgeries rather than a limitation applying only to cosmetic surgeries?

B. Did the trial court err in failing to grant partial summary judgment on the contract issues in favor of Shaffer?

1. Did the trial court err in finding Article VI, Part II (Exclusions and Limitations) subpart 28 dealing with complications of operations excluded by the WINhealth policy applies and denies coverage for Shaffer's penicillin-resistant MRSA infection?

2. Did the court err in failing to consider the differences in language between subparts 8 and 28 in interpreting subpart 28?

3. Does subpart 8 provide a basis to deny a medically necessary surgery?

WIN restates the issues as follows:

1. The district court's grant of summary judgment was appropriate as no material issue of fact exists as to the definition of a "reduction mammoplasty" and a judgment was appropriate as a matter of law.

2. [Shaffer] was not entitled to a summary judgment.

FACTS AND PROCEEDINGS

[¶3] In her complaint, Shaffer alleged that on August 17, 2005, her primary care physician, James G. Haller, M.D. (Dr. Haller), examined her regarding ongoing shoulder pain and back pain, as well as a recurring interiginous rash beneath her breasts. Dr. Haller referred Shaffer to William J. Wyatt, M.D. (Dr. Wyatt) for further treatment. Shaffer then consulted with Dr. Wyatt on September 8, 2005, and he advised her that her "symptoms could be improved upon greatly by a Bilateral Breast Reduction Mammoplasty." On October 18, 2005, Shaffer consulted with Jeffery K. Chapman, M.D., (Dr. Chapman) regarding her symptoms. He observed bruising on Shaffer's shoulders from her bra straps and a rash beneath her breasts. Shaffer also advised Dr. Chapman of her ongoing low back pain. Dr. Chapman advised her that breast reduction surgery is very much medically indicated to control the symptoms described above.

[¶4] Shaffer had health care coverage through her husband's employment with the City of Cheyenne. Shaffer provided her medical records to that health care insurer, Great West Healthcare, and breast reduction surgery was authorized upon its determination that the surgery was medically necessary. The surgery was accomplished in late December of 2005.

[¶5] At the turn of the year 2006 (i.e., January 1, 2006), the health care insurer for the City of Cheyenne changed from Great West to WIN. On or about January 2, 2006, Shaffer noticed redness and swelling around the areas affected by the surgery, and she immediately sought medical attention. She was hospitalized for an MRSA (Methicillin-resistant Staphylococcus aureus) infection and was treated aggressively as that condition is life threatening. MRSA is frequently contracted during surgery and in hospitals and is then described more accurately as health-care associated MRSA (see http://www.mayoclinic.com/health/mrsa/DS00735).

[¶6] Shaffer presented the bills for the treatment she received in early 2006 to WIN and her claims were denied, in part on the basis that the treatment she received for her MRSA infection arose from treatment to improve appearance. Shaffer went through three levels of appeal with WIN but was not successful in getting WIN to change its original decision.

[¶7] On January 2, 2009, Shaffer filed a complaint alleging that because of WIN's actions/omissions, she suffered economic damages, pain, suffering, and emotional damages. She alleged breach of contract, bad faith breach of contract, and she asked for attorney's fees and prejudgment interest. The parties filed cross motions for summary judgment regarding the interpretation of the insurance contract. They submitted sections of the insurance contract, which is entitled "Medical Benefit Plan Information and Evidence of Coverage" (EOC), as part of the summary judgment materials.

[¶8] The district court reviewed the insurance contract and concluded that the language clearly and unambiguously excluded coverage for Shaffer's breast reduction surgery. Because the contract also excluded coverage for treatment of complications arising from non-covered services, the district court concluded that Shaffer was not entitled to benefits for treatment of her MRSA infection. Consequently, it granted summary judgment in favor of WIN. Shaffer appealed.

STANDARD OF REVIEW

[ΒΆ9] We will affirm a summary judgment provided there is no genuine issue of material fact and the law clearly entitles the moving party to prevail. An insurance policy constitutes a contract between insurer and insureds. When the parties have stipulated to all material facts, summary judgment is proper if such an insurance contract is found to be unambiguous. Aaron v. State Farm ...


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