Thiemann v. Columbia Public School District
2011 Mo. App. LEXIS 384
| Mo. Ct. App. | 2011Background
- Thiemann, CPSD employee, contested whether a self-funded medical plan must cover a dental surgical procedure performed in a hospital under anesthesia.
- FMH Benefits Services administers the Plan for CPSD and denied coverage after referral by Thiemann’s dentist.
- Dr. Coyle recommended maxilla bone graft and related implants; FMH advised these procedures were not covered.
- Dr. Gossett performed the described maxillary procedures in July 2009; coverage denial followed, citing Plan limitations on dental/oral surgery.
- Thiemann appealed; the Denial Letter relied on Article III.D.10 and Article III.C.4 to exclude the procedures from coverage.
- The trial court granted CPSD summary judgment; Thiemann cross-moved for summary judgment; this appeal followed with a request to establish coverage as a matter of law.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Does the Plan provide coverage for Thiemann’s surgical procedures? | Thiemann argues the Plan covers the procedures under Section B. | CPSD argues Section A excludes and Section B does not independently restore coverage | Yes; plan provides coverage. |
| Is the Plan ambiguous or an adhesion contract requiring construction against the insurer? | Plan is ambiguous and should be construed in Thiemann’s favor. | No ambiguity; terms unambiguous; Plan controlled by its express exclusions. | Not addressed on remand; Court emphasizes de novo interpretation and grants coverage. |
Key Cases Cited
- Burns v. Smith, 303 S.W.3d 505 (Mo. banc 2010) (interpretation of insurance policies is a question of law; de novo review)
- Mo. Employers Mut. Ins. Co. v. Nichols, 149 S.W.3d 617 (Mo. App. W.D. 2004) (contract interpretation principles for insurance policies)
- C-H Bldg. Assocs., LLC v. Duffey, 309 S.W.3d 897 (Mo. App. W.D. 2010) (summary judgment standard and reviewing record favoring non-movant)
- ITT Commercial Fin. v. Mid-Am. Marine Supply Corp., 854 S.W.2d 371 (Mo. banc 1993) (summary judgment standard and deference to factual inferences)
- Derousse v. State Farm Mut. Auto. Ins. Co., 298 S.W.3d 891 (Mo. banc 2009) (plain meaning and interpretation of terms in contracts)
- State ex rel. Jackson v. City of Joplin, 300 S.W.3d 531 (Mo. App. S.D. 2009) (administrative determinations and de novo review of legal issues)