WAKE v. STATE ex rel. OMES EMPLOYEES GROUP INSUR. DIVISION
2019 OK CIV APP 47
Okla. Civ. App.2019Background
- Plaintiff Denise Wake had a 1984 vertical banded gastroplasty (VBG) that later failed and caused symptoms (pain, GERD, nausea/vomiting, staple erosion) and weight regain; she seeks conversion to a Roux-en-Y (RNY) gastric bypass (revision) in 2017.
- Wake is covered under the HealthChoice Health and Dental Plan (OMES/EGID) since 2012; bariatric benefits were added effective January 1, 2017 and require pre-certification.
- Wake’s physician requested pre-certification on January 6, 2017; HealthChoice denied on January 17, 2017, stating the original gastric surgery occurred before 1/1/2017 and thus was not a covered benefit.
- The OMES EGID Grievance Panel upheld denial, concluding the requested revision was a complication of a non-covered procedure; the district court affirmed that final agency order.
- On appeal, the Court of Civil Appeals reviewed contract interpretation de novo and considered whether the Plan covered revision/conversion surgery and whether exclusions for complications from non-covered procedures applied.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether revision/conversion bariatric surgery is a covered service under the Plan | Wake: Revision/conversion is expressly listed as a covered service in the policy | OMES: Revision should be treated as addressing complications and only covered if prior bariatric surgery was performed under HealthChoice on/after 1/1/2017 | Held: Revision/conversion is expressly covered; policy language is unambiguous and includes revision/conversion independent of whether prior surgery was under HealthChoice |
| Whether exclusion for "complications from any non-covered treatments" bars coverage | Wake: Exclusion does not apply to revision/conversion because those procedures are separately listed as covered services | OMES: The revision corrects complications from a non-covered 1984 surgery and thus falls within the exclusion | Held: Exclusion applies to complications generally but does not override the specific covered listing for revision/conversion; OMES cannot read an unwritten exclusion into the policy |
| Whether extrinsic evidence of agency intent may control interpretation | Wake: Policy text governs; plain meaning controls | OMES: Agency testimony supports interpreting revisions as tied to prior HealthChoice coverage | Held: Because contract language is unambiguous, extrinsic evidence of intent (agency testimony) is inadmissible to contradict the written policy |
| Remedy after finding coverage | Wake: Grant certification for the requested RNY revision | OMES: Deny based on exclusion/interpretation | Held: Final agency order reversed; case remanded with instructions to grant certification |
Key Cases Cited
- Flitton v. Equity Fire & Cas. Co., 1992 OK 2, 824 P.2d 1132 (court must give contract language its plain, ordinary meaning)
- Wiley v. Travelers Ins. Co., 1974 OK 147, 534 P.2d 1293 (policy construction should be natural, reasonable, and avoid absurd results)
- May v. Mid-Century Ins. Co., 2006 OK 100, 151 P.3d 132 (insurance contracts reviewed under rules of construction; legal questions reviewed de novo)
- Am. Econ. Ins. Co. v. Bogdahn, 2004 OK 9, 89 P.3d 1051 (ambiguity in contract is a question of law)
- First Nat. Bank & Trust Co. of Vinita v. Kissee, 1993 OK 96, 859 P.2d 502 (parol evidence inadmissible to vary clear, unambiguous written contract)
- Mercury Inv. Co. v. F.W. Woolworth Co., 1985 OK 38, 706 P.2d 523 (intent of parties determined from the four corners of the contract)