Mercycare Insurance v. Wisconsin Commissioner of Insurance

2010 WI 87, 786 N.W.2d 785, 328 Wis. 2d 110, 2010 Wisc. LEXIS 113
CourtWisconsin Supreme Court
DecidedJuly 16, 2010
Docket2008AP2937
StatusPublished
Cited by23 cases

This text of 2010 WI 87 (Mercycare Insurance v. Wisconsin Commissioner of Insurance) is published on Counsel Stack Legal Research, covering Wisconsin Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mercycare Insurance v. Wisconsin Commissioner of Insurance, 2010 WI 87, 786 N.W.2d 785, 328 Wis. 2d 110, 2010 Wisc. LEXIS 113 (Wis. 2010).

Opinions

ANN WALSH BRADLEY, J.

¶ 1. This case is before the court on certification from the court of appeals, pursuant to Wis. Stat. § (Rule) 809.61.1 The certification states: "We certify this appeal to the Wisconsin Supreme Court to determine whether Wis. Stat. § 632.895(7) permits an insurer to exclude maternity coverage for an insured acting as a surrogate mother. The answer to this question is determined, in part, by what level of deference, if any, should be accorded the Commissioner's decision."

[117]*117¶ 2. The Commissioner concluded that Wis. Stat. § 632.895(7) does not permit an insurer to exclude generally covered maternity services for surrogate mothers. Thus, the Commissioner determined that MercyCare's 2002 Contract was ambiguous, and MercyCare's attempt to exclude generally covered maternity services for surrogate mothers under its 2002 Contract contravened the requirements of Wis. Stat. § 632.895(7). For the same reason, he determined that the 2005 Contract contravened Wis. Stat. § 632.895(7). Finally, the Commissioner also disapproved the 2005 Contract under Wis. Stat. § 631.20(2)(a)l., determining that it is misleading because the benefits are too restricted to serve the purposes for which the policy is sold. On review, the circuit court accorded no deference to the Commissioner's interpretation of Wis. Stat. § 632.895(7) and reversed the Commissioner's legal conclusions.2

¶ 3. Applying due weight deference, we conclude that an insurer may not make routine maternity services that are generally covered under the policy unavailable to a specific subgroup of insureds, surrogate mothers, based solely on the insured's reasons for becoming pregnant or the method used to achieve pregnancy. Accordingly, we determine that MercyCare's application of the 2002 Contract to exclude from coverage all maternity services for surrogate mothers contravenes Wis. Stat. § 632.895(7).

¶ 4. We also conclude that the Commissioner appropriately disapproved the surrogacy provision in MercyCare's 2005 Contract because it is contrary to Wis. Stat. § 632.895(7). In addition, the definition of [118]*118"surrogate mother" set forth in the 2005 Contract is misleading because the benefits are too restricted to serve the purposes for which the policy is sold. Accordingly, we reverse the decision of the circuit court.

I

¶ 5. MercyCare Insurance Company and Mercy-Care HMO, Inc. (collectively "MercyCare") are insurance companies authorized to do business in Wisconsin and subject to the jurisdiction and control of the Wisconsin Commissioner of Insurance. In 2002, MercyCare offered a group disability insurance policy that provided maternity coverage for eligible persons covered under the policies.

¶ 6. J.M. and C.S. were eligible persons insured by MercyCare under MercyCare's 2002 Certificate of Coverage ("the 2002 Contract").3 C.S. was insured as a dependent, and J.M. was insured as an employee.

¶ 7. While insured under the 2002 Contract, J.M. and C.S. each agreed to act as a gestational carrier by carrying a child for other parents. The children carried by J.M. and C.S. are not genetically related to J.M. or C.S. respectively.

¶ 8. Both women received health care services in connection with their pregnancies. J.M. received medical care including laboratory tests, ultrasounds, maternity care, physician visits, inpatient hospital care, anesthesia and delivery. The total costs incurred amounted to $16,774.63. C.S. received comparable pre- and post-partum medical services, with costs totaling $18,510.84.

¶ 9. During the course of their pregnancies, MercyCare denied coverage for the maternity services re[119]*119ceived by both J.M. and C.S. It notified J.M. that benefits for lab work were being denied because the contract did not cover "surrogate mother services."4 Subsequently, MercyCare informed J.M. by letter:

MercyCare is unable to authorize coverage for all services related to this pregnancy. Services provided from 5-10-04 through 1-7-05 are not eligible for reproductive services benefits or pregnancy benefits. Any benefits paid for the services will be recouped.

C.S. was similarly denied coverage based on the 2002 Contract's identification of "surrogate mother services" as a "non-covered service" under the Contract's "Pregnancy Benefits coverage."5

¶ 10. The 2002 Contract provides that "surrogate mother services" are a "non-covered service" in two separate places — under the section titled "Pregnancy Benefits" and under the section titled "Reproductive Services." However, the term "surrogate mother services" is not defined anywhere within the 2002 Contract.6

[120]*120¶ 11. The "Pregnancy Benefits" section provides as follows:

Covered Services:
Treatment of pregnancy is covered for an employee, an employee's covered dependent spouse, or an employee's covered dependent child.
Pregnancy benefits include coverage for inpatient hospital care and pre- and post-natal care received from a participating provider.
Non-Covered Services:
• Surrogate mother services.
• Elective abortions.
• Maternity services received out of the service area in the last 30 days of pregnancy without prior authorization from the Plan except in an emergency. Prior authorization is based on medical necessity.
• Amniocentesis or chorionic villi sampling (CVS) solely for sex determination.

In addition, the "Reproductive Services" section of the 2002 Contract lists various covered services and provides that "surrogate mother services" are a "non-covered service."7

[121]*121¶ 12. After denying coverage for J.M. and C.S.'s pregnancies, MercyCare sought to recoup the money it had already paid for claims related to the pregnancies. Ultimately, the services provided to both women were paid in full by third parties.

¶ 13. C.S. filed a complaint with the Office of the Commissioner of Insurance. Her complaint triggered the agency's review of MercyCare's denial of coverage to the two women. During this review, MercyCare filed its newest group disability policy insurance form ("the 2005 Contract")8 with OCI for approval.9

¶ 14.

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Bluebook (online)
2010 WI 87, 786 N.W.2d 785, 328 Wis. 2d 110, 2010 Wisc. LEXIS 113, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mercycare-insurance-v-wisconsin-commissioner-of-insurance-wis-2010.