In re Marriage of Zandi

This case asks if out-of-network health care costs qualify as

"'[u]ninsured medical expenses"' under RCW 26.18.170(18)(d). Victor and Deanna

Zandi's dependent daughter, T.Z., incurred approximately $13,000 in medical bills

when she had a kidney stone removed while traveling outside the Kaiser Permanente

network. The superior court ordered Victor Zandi to pay 7 5 percent of the cost and

Deanna Zandi to pay the remaining 25 percent. The Court of Appeals reversed,

finding that the superior court abused its discretion by modifying the parties' 2009

In reMarriage ofZandi, 92296-9

order of child support, which required Victor Zandi to pay 100 percent of "uninsured

medical expenses." In reMarriage of Zandi, 190 Wn. App. 51, 52, 357 P.3d 65

(2015).

We affirm the Court of Appeals. The legislature defines '" [ u ]ninsured

medical expenses"' as costs "not covered" by insurance. RCW 26.18.170(18)(d).

WAC 388-14A-1020 clarifies that this includes costs "not paid" by insurance, even

if those costs would be covered under other circumstances. Because the health care

expenses in this case are unambiguously within the scope ofRCW 26.18.170(18)(d),

financial responsibility is allocated by the 2009 order and may not be modified

absent evidence of changed circumstances or other evidence consistent with the

requirements ofRCW 26.09.170(6)-(7).

FACTS AND PROCEDURAL HISTORY

T.Z. is the daughter ofDeanna and Victor Zandi.1 In June 2011, T.Z. developed

a four millimeter stone in her left kidney. The following month, while visiting her

maternal aunt in Ohio, T.Z. 's condition worsened. T.Z. was admitted to a hospital in

the Cincinnati area, where doctors installed a temporary stent. T .Z. 's surgeon referred

her to the Urology Group in Cincinnati to have the kidney stone removed via lithotripsy.

1 Because the parties share the last name Zandi, we use their first names for clarity,

with no disrespect intended.

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Lithotripsy uses ultrasound shock waves to break up a stone, allowing it to be passed

from the body.

T.Z. has medical insurance through her father's plan with Kaiser. Kaiser is not

available in the Cincinnati area. T.Z.'s aunt lives in Goshen, a suburb of Cincinnati in

southwestern Ohio; the closest Kaiser facility is near Cleveland, 186 miles to the

northeast. When Deanna contacted Victor to advise him ofT.Z. 's situation, Victor told

her that T.Z. 's aunt should either drive T.Z. to Cleveland or wait to see if Kaiser would

authorize an out-of-network provider. Deanna disagreed, believing T.Z. needed

immediate surgery. T.Z. 's aunt took her to the Urology Group in Cincinnati on July 7,

2011, where doctors used lithotripsy to successfully treat T.Z. 's kidney stone. Medical

expenses for T.Z.'s time in Ohio totaled approximately $13,000. Concluding that

T.Z. 's treatment was both nonemergent and out of network, Kaiser ultimately declined

to cover these costs.

Under the terms of the Zandis' 2009 order of child support, Victor is responsible

for providing T.Z. with medical insurance and paying any uninsured medical expenses.

Paragraph 3.19 states, "The father shall pay 1 00% of uninsured medical expenses and

the mother shall pay 0% of uninsured medical expenses .... " Clerk's Papers (CP) at

7. Deanna sought enforcement of this provision under RCW 26.18.170. See Resp't's

Suppl. Br. at 10-13. Victor argued that he should be excused from the terms of the child

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support order because Deanna did not "go through the appropriate channels" (i.e.,

obtain preauthorization before sending T.Z. to a non-Kaiser facility). CP at 207. The

trial court found that Deanna's status as primary residential parent put her in a "better

position to secure coverage for the kidney stone treatment by Kaiser Permanente" and

ordered Deanna to pay 25 percent of the medical costs. I d. at 24 7.

A divided Court of Appeals reversed, finding that because T.Z. 's medical costs

were "'[u]ninsured medical expenses'" under RCW 26.18.170(18)(d), paragraph 3.19

of the 2009 order controlled the allocation of financial responsibility. Zandi, 190 Wn.

App. at 54-55. The majority acknowledged the dissent's concern that a parent with

control over a child's health care could unfairly subject the financially responsible

parent to unnecessary out-of-network expenses. Id. at 56-57. Noting that nothing in

the record before the superior court suggested Deanna acted in bad faith or

unreasonably, the majority held that the lower court abused its discretion by effectively

modifying the 2009 order of child support without adequate cause. We granted Victor's

petition for review. In reMarriage ofZandi, 185 Wn.2d 1002, 366 P.3d 1244 (2016).

ANALYSIS

Victor argues that the health care costs in this case were not "uninsured medical

expenses" within the scope of the 2009 order of child support because the health care

T.Z. received would have been covered by Kaiser under different circumstances. Pet.

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for Review at 7. We disagree, and affirm the Court of Appeals. Reading RCW

26.18.170(18)( d) and its interpretive regulation in the context of chapter 26.18 RCW,

"uninsured medical expenses" unambiguously includes the costs Kaiser declined to

cover in this case. See WAC 388-14A-1020. By contrast, the narrow interpretation of

"uninsured medical expenses" advanced by Victor and the dissenting Court of Appeals

judge reads RCW 26.18.170(18)( d) out of context and runs contrary to the core purpose

of chapter 26.18 RCW.

Chapter 26.18 RCW governs the enforcement of child support orders. Under

that chapter, one parent's financial responsibility for a dependent child's medical

expenses can be enforced by the other parent. See RCW 26.18.170. Specifically, RCW

26.18.170(17) states:

If a parent required to provide medical support fails to pay his or her portion ...

of any premium, deductible, copay, or uninsured medical expense ... the parent

seeking reimbursement of medical expenses may enforce collection of the

obligated parent's portion.

(Emphasis added.) The legislature, recognizing the importance of ensuring that child

support obligations are met, instructed courts to "liberally construe[]" chapter 26.18

RCW in order to "assure that all dependent children are adequately supported." RCW

26.18.030(3). Here, the 2009 order of child support states that Victor is financially

responsible for 100 percent of his daughter's uninsured medical expenses. CP at 7.

Because the superior court reduced Victor's financial burden to 75 percent, this case

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turns on whether the medical bills T .Z. incurred while in Ohio qualify as "uninsured

medical expenses" under RCW 26.18.170.

Statutory interpretation involves a question of law, subject to de novo review.

See, e.g., Clallam County v. Dry Creek Coal., 161 Wn. App. 366, 385, 255 P.3d 709

(20 11 ). The purpose of our inquiry is to identify and give effect to the legislative intent

behind the statute. Jametsky v. Olsen, 179 Wn.2d 756,762,317 P.3d 1003 (2014). If

the plain meaning of a statute is unambiguous, our inquiry ends. I d. When attempting

to ascertain a statute's plain meaning, we consider the "context of the entire act" as well

as related statutes. !d. (citing Dep 't of Ecology v. Campbell & Gwinn, LLC, 146 Wn.2d

1, 11, 43 P.3d 4 (2002)).

A. The Medical Costs in This Case Are Unambiguously "Uninsured Medical

Expenses" under RCW 26.18.170

This case presents a straightforward question of statutory interpretation. The

Court of Appeals majority correctly recognized that "uninsured medical expenses"

under RCW 26.18.170 unambiguously include costs "'not covered by insurance.'"

Zandi, 190 Wn. App. at 54-55. Because "Kaiser is not covering the disputed medical

expenses," these health care costs are "uninsured medical expenses" that the 2009 order

obliges Victor to pay. Id.

The legislature promulgated chapter 26.18 RCW to meet "an urgent need for

vigorous enforcement of child support and maintenance obligations." RCW 26.18.01 0.

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The provision at issue here, RCW 26.18.170(17), furthers this goal in the context of

medical expenses. If a financially responsible parent fails to meet his or her obligations,

RCW 26.18.170(17) allows either the State or the other parent to enforce the child

support order. This applies specifically to the "obligated parent's portion of the

premium, deductible, copay, or uninsured medical expense incurred on behalf of the

child." Id. The legislature defined "'[u]ninsured medical expenses"' as "premiums,

copays, deductibles, along with other health care costs not covered by insurance."

RCW 26.18.170(18)(d) (emphasis added).

The meaning of the phrase "along with other health care costs not covered by

insurance" is clear and unambiguous: it means costs the insurer declines to cover. Since

Kaiser declined to pay T .Z. 's medical expenses, thos·e expenses were "costs 'not

covered by insurance."' Zandi, 190 Wn. App. at 55. Any potential ambiguity is

resolved by reading RCW 26.18.170(17) and (18)( d) in their statutory context.

The interpretation advanced by Victor and the Court of Appeals dissent requires

distinguishing medical costs that are "not covered" from those that are merely unpaid.

See Pet. for Review at 7; Zandi, 190 Wn. App. at 56-57. According to the dissent,

"'premiums, copays, [and] deductibles"' are specific costs Kaiser "never promised to

pay," and thus the general phrase "'other health care costs not covered by insurance"'

should apply only to other health care costs Kaiser did not promise to pay. 190 Wn.

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App. at 56-57 (quoting RCW 26.18.170(18)(d)). Such a narrow construction ofRCW

26.18.170(18)(d) runs contrary to the legislature's directive that chapter 26.18 RCW

must be "liberally construed." RCW 26.18.030(3). The motivating principle in chapter

26.18 RCW is to ensure that dependents are "adequately supported," id., which means

that children actually receive the health care they need. To achieve this purpose, the

scope ofRCW 26.18.170(17)'s enforcement power must be at least as broad as Victor's

medical support obligations. By removing out-of-network provider charges from the

scope ofRCW 26.18.170, Victor's interpretation would undermine the statute's ability

to guarantee that children receive health care regardless of the circumstances.

The narrow analysis advanced by Victor and the Court of Appeals dissent also

ignores the regulatory definition of"'uninsured medical expenses."' WAC 388-14A-

1 020 (boldface omitted). The regulation clarifies that medical costs "not paid" by

insurance qualify as "'uninsured medical expenses."' I d. (boldface omitted). The

expenses in this case were indisputably not paid by Kaiser. Thus, reading RCW

26.18.170(18)(d) alongside the applicable regulation clarifies that medical expenses

"not paid" by insurance and costs "not covered" by insurance qualify as ''uninsured

medical expense[s]" under RCW 26.18.170(17). WAC 388-14A-1020. Because the

medical expenses in this case were neither "covered" nor "paid," they are

unambiguously "uninsured medical expense[ s ]" in the context ofRCW 26.18.170(17).

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B. Consideration of the Parties' Relative Fault Is Inappropriate in Enforcing

Child Support Orders

In accepting Victor's narrow interpretation of"uninsured medical expenses," the

Court of Appeals dissent expressed a concern for "[b ]asic fairness." Zandi, 190 Wn.

App. at 57. The dissenting judge criticized the majority for requiring Victor to "pay

1 00 percent of this large medical bill, even though ... Victor was not responsible for

violating [Kaiser's] in-network limitation." Id. This analysis incorrectly introduces

concepts of marital fault into the enforcement of a child support order.

In general, marital fault is irrelevant in proceedings relating to divorce. See, e.g.,

RCW 26.09.090(1) (excluding spousal "misconduct" from the calculation of

maintenance orders); In reMarriage of Steadman, 63 Wn. App. 523,528, 821 P.2d 59

(1991) (noting that "immoral" conduct may not be considered in dividing property).

Generally, absent a showing of changed circumstances to justify modification, a child

support order must be enforced according to its terms. See RCW 26.09.170(5)-(7). We

certainly acknowledge the possibility that "a parent with control over his or her child's

medical care could boundlessly violate the insurance plan's in-network limitation with

knowledge that the other parent would be forced to absorb the resulting costs." Zandi,

190 Wn. App. at 57. But there is no evidence ofbad faith or unreasonable conduct by

either parent in this case. The superior court made no findings as to fault. See CP at

246-47. Indeed, the record shows that before incurring the out-of-network expenses,

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Deanna asked Victor's permission, contacted Kaiser to request coverage, and was

assured by the Urology Group doctor that Kaiser would pay for the procedure.2 Id. at

43-44.

Underlying the "basic fairness" argument seems to be the belief that the parent

paying for a child's health care should be able to insist on the most cost-effective care,

as the nonpaying parent has little incentive to avoid unnecessary expenses. See Zandi,

190 Wn. App. at 57. This argument overlooks the premise that parenting authority is a

fundamental right and is not based on financial responsibility. See, e.g., Troxel v ..

Granville, 530 U.S. 57, 120 S. Ct. 2054, 147 L. Ed. 2d 49 (2000) (plurality opinion)

(recognizing that the due process clause of the Fourteenth Amendment to the federal

constitution protects the fundamental parenting rights of each spouse). By assigning

financial responsibility for T.Z. 's health care to Victor, the 2009 order of child support

did not in any way limit Deanna's right to make parenting decisions as the primary

residential parent. From Victor's perspective, the outcome may seem "unfair," but it is

not difficult to imagine the complications that would arise if courts recognized the

"right" of a paying parent to interfere with the other parent's authorized

2 Because there was no finding of bad faith in this case, CP at 246-47, our holding

in no way limits a trial court's discretion to fashion a result that comports with fundamental

fairness. A trial court presented with evidence of bad faith could, for example, reasonably

conclude that a party acting in bad faith constitutes changed circumstances. See

RCW 26.09.170(5), (6), (7).

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decision-making. Moreover, concerns of fault or unfairness to the paying parent cannot

influence the proper interpretation of"uninsured medical expenses" within the meaning

ofRCW 26.18.170. Out-of-network costs-even those that could have been avoidedremain

"uninsured medical expenses," and the parties' child support order allocates 1 00

percent of these expenses to Victor.

The Court of Appeals correctly determined that unpaid, out-of-network health

care costs are "uninsured medical expenses" under RCW 26.18.170. When read in light

of chapter 26.18 RCW's purpose and alongside WAC 388-14A-1020, the legislature's

definition in RCW 26.18.170(18)(d) unambiguously encompasses the out-of-network

expenses that Kaiser declined to cover. Because the medical expenses in this case fall

within the scope of "uninsured medical expenses," Victor is obligated to pay 100

percent of the costs by the terms of the 2009 order of child support. By modifying the

terms of this order without evidence of changed circumstances, see RCW 26.09.170(5),

or other evidence justifying modification, see RCW 26.09 .170( 6)-(7), the superior court

abused its discretion. We affirm the Court of Appeals.