Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Short v. Blue Cross and Blue Shield of Kansas, Inc.

Court of Appeals of Kansas

April 12, 2019

Zachary Short, Appellant,
v.
Blue Cross and Blue Shield of Kansas, Inc., Appellee.

         SYLLABUS BY THE COURT

         1. Whether a written instrument is ambiguous is a question of law subject to de novo review.

         2. The cardinal rule of contract interpretation is to ascertain the parties' intent. If the contract is unambiguous, we determine the parties' intent by the language of the contract alone. But if a contract has ambiguous language, we may consider extrinsic evidence to construe it.

         3. When determining whether a provision in an insurance policy is ambiguous, courts consider what a reasonably prudent insured would understand the language to mean, not what the insurer intends the language to mean.

         4. The applicability of an insurance exclusionary clause is a question of fact. The insurer bears the burden of proving facts which would bring a case within the specified exception.

         5. When opposing a motion for summary judgment, an adverse party must come forward with evidence to establish a dispute as to a material fact.

          Appeal from Saline District Court; Paul J. Hickman, judge. Affirmed.

          Matthew L. Bretz, of Bretz & Young, L.L.C., of Hutchinson, for appellant.

          David S. Wooding and Anna C. Ritchie, of Martin, Pringle, Oliver, Wallace & Bauer, L.L.P., of Wichita, for appellee.

          Before Arnold-Burger, C.J., Atcheson, J., and Burgess, S.J.

          Arnold-Burger, C.J.

         The cardinal rule of contract interpretation is to ascertain the parties' intent. If the contract is unambiguous, we determine the parties' intent by the language of the contract alone. But if a contract has ambiguous language, we may consider extrinsic evidence to construe it.

         Zachary Short sued Blue Cross and Blue Shield of Kansas (BCBS) for breach of contract after BCBS refused to cover the full cost of a prosthetic leg called the Ottobock X3. The insurance policy provided that BCBS would cover the cost of a basic (standard) device and that it would not cover charges for deluxe or electrically operated devices beyond the extent allowed for a basic (standard) device. BCBS provided evidence that the X3 was electrically operated and thus subject to the limitations in the insurance policy. The district court agreed and granted BCBS's motion for summary judgment.

         Short appeals, arguing that the contract is ambiguous and should be construed in a way that would require BCBS to cover the full cost of the X3. He also asserts that he should have been permitted to conduct more extensive discovery and that he should have been allowed to present expert testimony. However, the language in the contract is not ambiguous and electrically operated prosthetics are clearly subject to the limitations. Because the contract was unambiguous, the district court did not err in refusing to allow Short to seek additional evidence through discovery or introduce extrinsic evidence in the form of expert testimony. The decision of the district court is affirmed.

         Factual and Procedural History

         Short was involved in a catastrophic farming accident in October 2014 which left him severely injured. Short's injuries required him to undergo a bilateral knee amputation, with his left leg amputated above the knee and his right leg below the knee.

         At the time of the accident, Short was insured by Blue Cross Blue Shield of Kansas (BCBS). Short sent a pre-service request to BCBS requesting coverage for multiple prosthetics. One of the prosthetics was an Ottobock X3 Microprocessor leg and knee. The X3 costs about $145, 000. BCBS declined to cover the full cost of the X3 based on its insurance contract. The relevant portion of the contract provided:

"Except as limited, the services listed below are covered:
b. Orthopedic and prosthetic devices, appliances and items when medically needed and not otherwise excluded herein. This includes items such as orthopedic braces, artificial limbs, artificial eyes, and auditory osseointegrated devices.
Limitations:
(3) Benefits are limited to the amount normally available for a basic (standard) appliance which allows necessary function. Basic (standard) medical devices or appliances are those that provide the essential function required for the treatment or amelioration of the medical condition at a Medically Necessary level.
(4) Charges for deluxe or electrically operated orthotic or prosthetic appliances, devices or items are not covered, beyond the extent allowed for basic (standard) appliances. Deluxe describes medical devices or appliances that have enhancements that allow for additional convenience or use beyond that provided by a basic (standard) device or appliance."

         The contract defines "medically necessary" as:

"a service required to diagnose or to treat an illness or injury. To be Medically Necessary, the service must: be performed or prescribed by a Doctor; be consistent with the diagnosis and treatment of Your condition; be in accordance with standards of good medical practice; not be for the convenience of the patient or his Doctor; and is provided in the most appropriate setting."

         BCBS believed that a prosthetic device was medically necessary and thus covered by the insurance contract. However, BCBS considered the X3 to be a deluxe or electrically operated prosthetic appliance subject to the limitations provision in the contract. BCBS determined that a basic (standard) knee would cost $2, 925.32. It informed Short that it would pay him that amount, and that Short would be responsible for the balance of the cost of the X3. Short disagreed, and he sued BCBS for breach of contract.

         During discovery, Short made several inquiries that are now at issue on appeal. In Interrogatory Number 2, Short asked BCBS to "[s]tate all facts and identify all documents you contend support [BCBS]'s refusal to pay the cost of the Ottobock X3 prosthetic knees . . . ." Short also made several requests for documents, including:

"1. All insurance claims and underwriting files pertaining to the subject matter of this lawsuit. . . . .
"5. Copies of all correspondence to and from others concerning Plaintiff. "
6. Original or true and correct copies of any recorded statement taken of Plaintiff. . . . . "
8. Original or true and correct copies of all medical records and reports pertaining in any way to Plaintiff. . . .
"10. Any utilization or medical reviews dealing with Plaintiff. "
11. All documents you intend to introduce as evidence at the time of trial."

         BCBS objected to these requests based on their relevance and scope. BCBS argued that the issue in the case was whether the full cost of the X3 fell within the provisions of Short's insurance, and that the issue could "be determined by the contract language as a matter of law by the Court."

         Short filed a motion to compel discovery responses. Short asserted that he was "entitled to know what facts and documents [BCBS] contends supports their denial." He asked the district court to require BCBS to "produce any facts or documents besides the contract upon which [BCBS] relies in denying to provide [Short] the Ottobock X3, if any exists besides the contract." BCBS objected to Short's motion to compel discovery responses. It maintained its argument that this ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.