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COURT OF APPEALS DECISION DATED AND RELEASED FEBRUARY 18, 1997 |
NOTICE |
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A party may file with the
Supreme Court a petition to review an adverse decision by the Court of
Appeals. See § 808.10 and
Rule 809.62(1), Stats. |
This opinion is subject to
further editing. If published, the
official version will appear in the bound volume of the Official Reports. |
No. 96-2463-FT
STATE
OF WISCONSIN IN COURT OF
APPEALS
DISTRICT III
JAMES E. PAGEL,
Plaintiff-Appellant,
v.
SECURITY HEALTH PLAN,
Defendant-Respondent.
APPEAL from an order of
the circuit court for Marathon County:
RAYMOND F. THUMS, Judge. Affirmed.
Before Cane, P.J.,
LaRocque and Myse, JJ.
CANE, P.J. James Pagel appeals an order granting
summary judgment to Security Health Plan because its health insurance contract
with Pagel did not provide coverage for the medical treatment he received in
Canada.[1] Pagel argues that summary judgment was
inappropriate because material facts were in dispute as to whether his medical
condition constituted a covered "emergency" under the terms of
Security's policy language. In the
alternative, Pagel asserts that summary judgment should have been granted to
him rather than Security.
Security asserts that
summary judgment was appropriate because the undisputed facts demonstrate that
the medical treatment at issue was not covered under the contract. We agree with Security and affirm the order.
Pagel obtained group
health insurance through Security Health Plan in 1991, under the terms of
Security's "master contract" and "member handbook." On October 14, 1994, Pagel went to see Dr.
Mark Szmanda, a Wausau neurologist, for a severe headache and stroke-like
syndrome. Szmanda was a plan provider
for Security. He diagnosed Pagel with a
basilar tip aneurysm on November 2, 1994.
Szmanda referred Pagel to University Hospital in Ontario, Canada, for
treatment because he believed that University Hospital was experienced with this
type of surgery, and that treatment there would be less expensive than
treatment locally.
Pagel sought and
subsequently received treatment for the aneurysm at the University Hospital,
which was not a plan provider for Security.
When it learned on November 3, 1994, of Pagel's decision to be treated
in Canada, Security informed him that their policy would not cover the services
rendered in Canada, and made an appointment for Pagel with plan provider Dr.
Arturo Camacho, a neurosurgeon at the Marshfield Clinic.
However, on November 4,
1994, Pagel flew to Ontario without seeing Camacho and without written approval
from Security for treatment in Canada.
Pagel was admitted to the hospital in Ontario on November 4, discharged
and readmitted on November 7, at which time surgery was performed.
Security sent a letter
dated November 8 to Pagel, notifying him that it was denying coverage for his
treatment at University Hospital.
Although Pagel asserts that he first learned of Security's denial of
coverage when he received the letter upon his return from Canada, Security
asserts that it notified Pagel on November 3 that it would not cover his
expenses at University Hospital.
Pagel sued Security to
recover $16,280.65 in surgical and related medical expenses from University
Hospital. The court granted Security's
motion for summary judgment, deciding that Pagel's treatment was not covered
for the following reasons: Pagel did
not follow the prerequisite procedures to receiving treatment from a non-plan
physician; Security was denied the
opportunity to treat Pagel through its member physicians; Pagel's condition was not an
"emergency" as defined in the contract; and, even if it were an
"emergency," there would be no coverage for his nonprovider treatment
because his medical condition arose within the service area. Pagel now appeals the summary judgment
order.
We review summary
judgments de novo, and will affirm if the record shows that there is no genuine
issue as to any material fact and that the moving party is entitled to judgment
as a matter of law. See St.
John's Home v. Continental Cas. Co., 147 Wis.2d 764, 781-82, 434 N.W.2d
112, 119 (Ct. App. 1988). The
construction of an insurance policy presents a question of law, which we review
independently of the trial court. American
States Ins. Co. v. Skrobis Painting & Decor., Inc., 182 Wis.2d 445,
450, 513 N.W.2d 695, 697 (Ct. App. 1994).
Insurance policies are
reviewed pursuant to the rules of contract construction. School Dist. v. Wausau Ins. Cos.,
170 Wis.2d 347, 367, 488 N.W.2d 82, 88-89 (1992). We must construe the words of the policy provisions to give
effect to the parties' intentions, and we must interpret the policy terms as
would a reasonable person in the position of the insured. See id. "However, when the terms of the policy
are unambiguous and plain on their face, the policy should not be rewritten to
include insurance coverage not agreed to by the parties and for which it was
not paid." Id. at
367, 488 N.W.2d at 89.
The relevant contract
provisions are the following:
1. Regular Services. ... In order for hospital and other benefits to be covered, a Plan
Physician must manage the care of the Enrollee, unless prior written approval
is received from the Medical Director of Plan....
2. Emergency Services in Plan Service Area.
....
If
Enrollee's condition is of sufficient severity that traveling to a Plan
Hospital or the office of a Plan Physician would endanger his or her health, he
or she should go to the nearest medical facility.
3. Emergency Services Outside Plan Service
Area. Care received in Emergency
Conditions outside the Plan Service Area is covered. Enrollee should go to the nearest physician or hospital for care if
Emergency Conditions arise while he or she is outside the Plan Service Area. Enrollee is then required to (a) notify Plan
of the condition and treatment as soon as possible, (b) receive only that
treatment which is reasonably necessary under the conditions, and (c) return to
the Plan Service Area for follow-up treatment.
(Emphasis added).
It is
undisputed that Pagel did not obtain the requisite authorized referral from
Security for his treatment in Canada, and University Hospital is a non-plan
provider located outside Security's service area. We therefore conclude that the first and second contract
provisions above do not apply.
Pagel argues that
material issues of fact exist as to whether his medical condition constituted a
covered "emergency" under the terms of Security's policy.[2] Even if we assume, without deciding, that
Pagel's condition was an emergency under the terms of the contract, we conclude
that the policy did not cover his medical expenses because his medical
condition did not arise outside Security's service area.[3]
The plain meaning of
Security's policy effectively denies coverage for costs associated with
emergency medical conditions arising within the plan's service area but treated
outside the plan's service area.
Pagel's condition was first treated and diagnosed by Szmanda in Wausau. It was after this diagnosis that Pagel
elected to travel to University Hospital in Canada for further treatment and
surgery. Therefore his condition did
not arise outside the service area, and is not covered under Security's policy.[4]
We conclude that there
were no disputed issues of material fact as to whether Security's policy
covered Pagel's medical expenses.
Therefore, the court properly granted summary judgment to Security.
By the Court.—Order
affirmed.
Not recommended for
publication in the official reports.
[2]
"Emergency Conditions" are defined as follows:
Conditions under which medical services are
required as a result of the sudden onset of illness or accidental bodily injury
and cannot reasonably be obtained from a Plan Provider because of medical
necessity and not because of the convenience of the Enrollee. Medical necessity shall not be considered to
exist unless 1) the Enrollee's life or health would have been jeopardized if
the Enrollee had obtained required services from a Plan Provider, or 2) the
decision to obtain required services from other than a Plan Provider was not
made by an adult family member who was capable of rational, independent
judgment concerning the source of medical services.
Security also issued a handbook to its insureds,
describing its emergency policies as follows:
Medical emergencies
Emergency care is covered by Greater Marshfield Health Plan,
anywhere, anytime.
An emergency is defined as the sudden onset of a condition which
requires medical care immediately. It
is important to note that you and your emergency provider must follow Greater
Marshfield Health Plan guidelines in order to qualify for coverage of emergency
costs....
Life-threatening emergencies
If a life-threatening emergency occurs, go directly to the
nearest hospital emergency room for care....
Out-of-area emergency
If you are away from home when an emergency arises, seek care at the nearest medical center....