Opinion
No. C7-95-2610.
Filed May 14, 1996.
Appeal from the District Court, Dakota County, File No. C39415420.
James A. Heuer, Jr., (for Respondent)
Andrew J. Voss, (for Appellant)
Considered and decided by Norton, Presiding Judge, Peterson, Judge, and Amundson, Judge.
This opinion will be unpublished and may not be cited except as provided by Minn. Stat. § 480A.08, subd. 3 (1994).
Unpublished Opinion
Appellant Minnesota Comprehensive Health Association (the MCHA) challenges the district court's grant of summary judgment. The MCHA argues that the removal of four healthy bicuspids (for the purpose of putting braces on) and putting braces on respondent's son were not covered by the insurance policy because: (1) they did not constitute "reconstructive surgery" within the meaning of the policy, and (2) the policy excludes from coverage "[c]harges for physicians' services or X-ray examinations involving any of the teeth * * *." We reverse.
Facts
Respondent Michael Charles Deziel is the father and guardian of Michael William Deziel. On February 15, 1988, respondent's son was riding in a car with his grandmother when her car collided with another car. He sustained serious facial and head injuries and was taken to a hospital for treatment (including surgery). In 1989, the MCHA issued an insurance policy to respondent.
In January 1993, an orthodontist, Dr. James May, examined respondent's son. Dr. May suggested that, as a result of the accident, respondent's son needed braces. Before putting the braces on, Dr. May suggested removing four healthy bicuspids because the son's jaw was crowded and removing the teeth would allow the teeth to shift into realignment. An oral surgeon, Dr. Bruce Templeton, removed the four bicuspids (Dr. Templeton operated on respondent's son shortly after the accident to treat the numerous fractures to the bones of the son's face). Dr. May put the braces on. The total bill was $3,066 ($366 for extracting the teeth and $2,700 for putting the braces on and an orthodontic therapy plan that included follow-up visits to monitor progress). The MCHA refused to pay these expenses, claiming that they were not "covered expenses" under the insurance policy. Respondent brought a conciliation court action, but the court determined that the costs were not covered under the MCHA policy. Respondent removed the case to district court. The district court denied the MCHA's motion for summary judgment and granted summary judgment in favor of respondent. The court concluded that the treatments provided by Dr. Templeton and Dr. May were "the type of reconstructive procedure[s] described in the insurance contract." This appeal followed.
Decision
The MCHA argues that the district court erred in determining that the removal of the four bicuspids and the orthodontic services were covered by the policy. Insurance coverage is a question of law that this court reviews de novo. See State Farm Ins. Cos. v. Seefeld, 481 N.W.2d 62, 64 (Minn. 1992).
"Reconstructive surgery"
The district court concluded that the removal of the bicuspids and putting on the braces constituted "reconstructive surgery" and thus were covered under the policy.
The policy lists as a covered expense:
17. Services and articles for reconstructive surgery:
a. When such service is incidental to or follows surgery resulting from any injury, illness, or disease of the involved part; or
b. To correct a functional defect resulting from a congenital illness, injury, or malformation or premature birth; or
c. To correct congenital cleft palate and cleft lip for person up to age
18. * * *
Payment for dental or orthodontic treatment not related to cleft palate and cleft lip is not covered by this provision.
The MCHA argues that Dr. Templeton's and Dr. May's services were not "reconstructive surgery" because the policy excludes "dental or orthodontic treatment not related to cleft palate and cleft lip" from its definition of "reconstructive surgery." We agree. The services rendered in this case were clearly dental or orthodontic — the removal of teeth and putting on braces. The treatment was not related to a cleft palate or cleft lip. Thus, the services were not "reconstructive surgery" within the meaning of the policy.
"Services * * * involving any of the teeth"
The MCHA argues that there is no coverage for Dr. May's and Dr. Templeton's services because the policy does not cover services involving any of the teeth.
Among the "Charges Not Covered" are
f. Charges for physicians' services or X-ray examinations involving any of the teeth, their surrounding tissue or structure or the alveolar process of the gingival tissue, unless the charges are:
(1) in connection with the treatment or removal of malignant tumors,
(2) for services provided under item 7 of Section B, Article II [oral surgery], or
The policy covers oral surgery "to remove or expose partially or completely unerupted impacted teeth, to remove a tooth root without extraction of the entire tooth including root canal, apicoectomy, apical curettage and removal of residual roots, or repair the gums and tissue of the mouth when not performed in connection with the extraction or repair of teeth."
(3) for services provided under item 13c of Section B, Article II [cleft palate or cleft lip].
The services provided in this case, removal of the four bicuspids and putting on braces and other orthodontic services were clearly "services * * * involving any of the teeth." They do not come under any of the provision's three exceptions. Thus, they are excluded from coverage under this provision also.