Find Legal Information

No. 2--01--0698

IN THE

APPELLATE COURT OF ILLINOIS

SECOND DISTRICT

JUSTICE BOWMAN delivered the opinion of the court:

The marriage of petitioner, Virginia Turrell, and respondent,Graham Turrell, was dissolved in 1995. Virginia subsequently filed petitions against Graham, seeking payment of extraordinary medicalexpenses for the parties' son, Sam, and an increase in childsupport. Graham filed a petition to modify the marriage settlementagreement, seeking to reduce his child support obligation andterminate his maintenance obligation. Graham filed an additionalpetition in which he asked the court to order Virginia to providehim with notice prior to incurring new or ongoing extraordinarymedical expenses for Sam. Following a hearing, the trial courtdirected a finding in Graham's favor on the issue of the payment ofcertain medical expenses. The court denied Virginia's request forincreased child support, decreased Virginia's maintenance by 60%,and ordered that her maintenance would end after two years. Additionally, the trial court ruled that Virginia had to notifyGraham before incurring any extraordinary medical expense for Samand that Graham had the right to investigate and object to any suchexpense. Virginia appeals, arguing that (1) the directed findingin Graham's favor on the issue of the payment of certain medicalexpenses was improper; (2) the trial court abused its discretionwhen it denied her request for more child support; (3) the trialcourt abused its discretion when it reduced her maintenance andlimited it to two years; and (4) the trial court erred in allowingGraham the opportunity to investigate and object to Sam'sextraordinary medical expenses.

BACKGROUND

Under the marital settlement agreement (agreement), Virginiais Sam's sole custodian. The agreement acknowledges that bothVirginia and Sam are afflicted with Lyme disease. With respect toSam's medical expenses, the agreement provides that Virginia isresponsible for Sam's "ordinary medical expenses" not covered byinsurance, which are defined as those less than $25 per occurrence. Graham bears responsibility for all "extraordinary medicalexpenses" not covered by insurance. The agreement does not define"extraordinary medical expenses."

The agreement required Graham to pay child support of $850 permonth. It was later modified to require Graham to pay $894 permonth. In 1997, the parties entered an agreed order increasingchild support to $620 biweekly.

The agreement further provided that Graham was to pay Virginia$1,250 per month in maintenance for a period of five years. At theend of five years, the issue of maintenance was reviewable. Theagreement noted that Virginia received Social Security disabilitypayments and provided that whether Virginia would be entitled toadditional maintenance at the end of the five-year period "shall bedependent upon [her] employability, health, and needs at thattime." In 1999 Virginia filed a rule to show cause, alleging thatGraham owed $5,197.68 in back child support and $18,395.81 forSam's extraordinary medical expenses. Graham filed petitions tomodify the judgment of dissolution in which he sought, inter alia,to decrease his child support obligation, terminate his maintenanceobligation, and require Virginia to notify him before incurringextraordinary medical expenses for Sam.

At the hearings on the parties' petitions, Virginia related Sam's medical history. He was diagnosed with Lyme disease soonafter his birth in 1991. From 1991 to 1997, he was a patient ofDr. Dorothy Petruca. Dr. Petruca's office was in New Jersey, andSam saw her there every six months. As a result of the Lymedisease, Sam had cognitive deficits, attention problems, and painin his joints. Dr. Petruca treated Sam with oral antibiotics. In1997, Dr. Petruca referred Sam to Dr. Cancillieri. Dr. Cancillieripractices in New York and will treat only patients who reside inNew York. Consequently, Sam and Virginia moved to New York fromMay 1996 through September 1998. Dr. Cancillieri treated Sam withoral antibiotics and sleeping medications until Sam began havinghallucinations and his condition deteriorated significantly. Dr.Cancillieri then placed Sam on daily intravenous antibiotics. InAugust 1999, Sam was doing poorly and Dr. Cancillieri told Virginiathere was nothing more he could do for Sam. Consequently, Dr.Cancillieri referred Sam to Dr. Charles Jones, a physician inConnecticut. Dr. Jones treats patients with Lyme disease whoreside out of state. Virginia paid for the travel and relocationexpenses associated with their trips to the East Coast to visitSam's physicians as well as a trip to California where she and Samreceived hyperbaric oxygen treatment.

Virginia testified that her daily food and clothing expensesfor Sam have increased since the time of the dissolution. Hergrocery expenses increased from $350 to $600 per month becauseSam's appetite greatly increased. She stated that she has to buySam new jeans and shoes every three months because of his growth. In addition, Sam participates in soccer, basketball, baseball, andgolf. These activities require Virginia to buy uniforms,equipment, and shoes.

Virginia testified that she is a registered nurse. She lastworked full time in 1990. She worked part time until 1991. Sheresigned from her nursing job because her short-term memory losscaused by the Lyme disease interfered with her ability to performher job duties. At the time of her divorce from Graham, her Lymedisease-related symptoms included fatigue, chronic joint and neckpain, and cognitive difficulties. As of 2000, she still haddifficulty performing daily activities because of fatigue,arthritis, and pain in her hips and knees. She also continued toexperience short-term memory loss.

Virginia further testified that she provides home schooling toSam because he did not function well in public school. Because ofSam's learning disabilities, Virginia must assist him with reading,writing, and math. Virginia stated that she teaches Sam from zeroto three hours per day, depending on how Sam is feeling.

Dr. Jones testified by videotaped deposition. He specializesin pediatric adolescent medicine. His practice primarily consistsof treating children and adolescents with Lyme disease. Dr. Jonesexplained that the symptoms of Lyme disease usually are fatigue,headache, muscle soreness, joint pain and swelling, andoccasionally a rash. Lyme disease affects the brain and peripheralnervous system, causing various cognitive deficits.

Dr. Jones first saw Sam in December 1999. He noted that Samwas very fatigued, extremely sensitive to light, and had impairedbalance, double vision and intermittent blurred vision, and skinsensitivity. He also had a sinus and throat infection andgeneralized arthritis. In Dr. Jones's opinion, Sam suffered fromboth gestational and acquired Lyme disease, meaning that he hadcontracted Lyme disease from Virginia while in utero and that hehad also been bitten by Lyme disease-infested ticks. Dr. Jonestestified that Sam has severe disabilities, including learningdisabilities, as a result of Lyme disease.

Dr. Jones prescribed oral antibiotics for Sam, and hiscondition improved. However, based on conversations with Virginiaand an evaluation of Sam on March 1, 2000, Dr. Jones determinedthat Sam was not responding adequately to the oral antibioticsalone. Dr. Jones then placed Sam on intravenous antibiotics whilecontinuing the oral antibiotics. Sam had to have a port for theintravenous antibiotics surgically placed in his chest. Dr. Jonesalso recommended hyperbaric oxygen treatments in conjunction withthe antibiotics. The antibiotics Sam takes can cause gallbladderproblems. Consequently, he must have monthly ultrasounds to makesure he does not develop gallbladder damage.

Dr. Jones testified that Sam's condition is improving. He didnot have any arthritis as of his last office visit. However, sincehis hyperbaric oxygen therapy he has experienced increased jointpain and swelling. His balance is normal, and he has no doublevision. His light sensitivity has improved. His ability toconcentrate and his short-term memory are still impaired. In Dr.Jones' opinion, if Sam were to stop receiving continuousantibiotics he would relapse and his Lyme disease would not becured. Dr. Jones anticipates that Sam will have to receive two tothree years of continuous antibiotic therapy.

On cross-examination, Dr. Jones acknowledged that mostphysicians treat Lyme disease with a two- to six-week course ofantibiotics. That is the treatment taught in medical school. TheNew York licensing board believes that four to six weeks ofantibiotic therapy is proper. Dr. Jones stated that he is the onlydoctor in the United States who treats children with Lyme diseasewith prolonged antibiotics. Such treatment can cause liver andgallbladder damage and can cause the patient to develop an allergicreaction to the antibiotics. Dr. Jones testified that mosthyperbaric treatment facilities will not treat patients with Lymedisease. Dr. Jones is not aware of such a facility in Illinoisthat will treat Lyme disease patients.

Dr. Jones also testified that he reviewed Virginia's medicalrecords and, based on those records and his conversations withVirginia, she suffers from persisting Lyme disease and, as aresult, cannot work. He never treated Virginia. In Dr. Jones'experience, most adults with Lyme disease are employed.

Graham testified that he is currently employed as the chiefexecutive officer of Empirical Solutions. He earned $146,877 in1996, $86,000 in 1997, $125,000 in 1998 and $90,720 in 1999.

The trial court directed a finding for Graham on the issue ofhis responsibility for certain of Sam's extraordinary medicalexpenses. The court ruled that Graham is responsible for payingonly those medical expenses that are "for a method of treatmentthat is recognized by the medical community for a recognizedmedical need." The court found that Dr. Jones's treatment did notfall into this category because it was not provided by any otherphysician and was found to be "suspect" by the New York medicalboard. The court further found that Virginia failed to presentevidence regarding Dr. Cancillieri's diagnosis and treatment of Samand whether his treatment was recognized by the medical community. Accordingly, the court ruled that Graham had no duty to pay anyexpenses related to Sam's treatment by Dr. Jones or Dr.Cancillieri, including any transportation and lodging expenses.

As to Graham's child support, the court ordered Graham to pay the child support arrearage but declined to increase child support. The court further found that there was no evidence establishingthat Virginia could not work. However, the court determined thatshe should receive some maintenance until Sam reached 12 years ofage because until that time Sam would require care before and afterschool. Therefore, the court reduced Virginia's maintenance by60%, to $513.60 per month, and ordered that the maintenance wouldend after a two-year period.

The court subsequently entered an order modifying the portionof the settlement agreement pertaining to the payment of Sam'smedical expenses. The court's order provides in relevant part:

"Paragraph 10 of the parties' Settlement Agreementincorporated in their Judgment for Dissolution of Marriageentered on March 7, 1995, is modified as follows:

GRAHAM shall be responsible to pay the extraordinarymedical expenses for the parties' minor son to the extent theyare not covered by insurance upon the following conditions:

If VIRGINIA believes an extraordinary medical expense isnecessary for SAMUEL, she shall notify GRAHAM in writing ofthe medical procedure, treatment, test, evaluation or otherservice to be provided, the name, address, telephone number ofthe intended provider and the estimated cost for the service. GRAHAM shall then have fourteen (14) days in which toinvestigate the extraordinary expense proposed by VIRGINIA. Not later than fourteen (14) days following VIRGINIA's noticeto GRAHAM, he shall respond to her in writing and inform herif he agrees to the expense or disagrees. If GRAHAM disagreesas to the need for the service, the proposed provider ofservice or the cost of service, GRAHAM shall have the right tofile a petition and shall not be obligated to pay the proposedextraordinary expense unless ordered to do so by a court ofcompetent jurisdiction. For purposes of this paragraphextraordinary medical expenses shall be defined as allmedical, dental, optical, psychological, surgical andorthodontia, consultation, examination and treatment, allmedications, eyeglasses, contact lens, braces and other dentalappliances for which the cost for an individual occurrence orseries of occurrences is greater than $200.00. VIRGINIA shallbe responsible to pay all ordinary and routine medical anddental expenses for SAMUEL. For purposes of this paragraph,ordinary expense shall be defined as those which are less than$50.00 per occurrence."

Virginia filed a timely notice of appeal challenging the trialcourt's orders.

ANALYSIS

We note initially that Graham filed a motion to dismiss theappeal on the ground that jurisdiction is lacking. We deniedGraham's motion and need not revisit the issue.

The first issue Virginia raises is whether the trial courterred when it granted Graham's motion for a directed finding on herpetition for the payment of extraordinary medical expenses. Virginia contends that the trial court improperly added a conditionto the dissolution decree by ruling that Graham is responsible forpaying only those extraordinary medical expenses "for a method oftreatment which is recognized by the medical community for arecognized medical need."

When a trial court has directed a finding in a bench trial, wereview that decision under the manifest weight of the evidencestandard. Zannini v. Reliance Insurance Co. of Illinois, Inc., 147Ill. 2d 437, 448-49 (1992). The court must first determine whetherthe petitioner presented a prima facie case. Zannini, 147 Ill. 2dat 449. If the petitioner has failed to do so, then the courtshould direct a finding for the respondent. Zannini, 147 Ill. 2dat 449. If the petitioner has made a prima facie case, then thecourt weighs the evidence, taking into account the credibility ofthe witnesses and the weight and quality of the evidence. Zannini,147 Ill. 2d at 448-49. We will not reverse the trial court'sdetermination unless it is contrary to the manifest weight of theevidence. Zannini, 147 Ill. 2d at 449.

In the case before us, the basis of the trial court's decisionlay in its definition of the term "medical expense" as used inparagraph 10 of the settlement agreement. A marital settlementagreement that is incorporated into a dissolution decree isinterpreted in the same manner as other contracts. In re Marriageof Mulry, 314 Ill. App. 3d 756, 758 (2000). The construction of acontract is a question of law, which we review de novo. Mulry, 314Ill. App. 3d 758. Accordingly, we must determine whether the trialcourt correctly construed the agreement before we reach the issueof whether the decision to direct a finding in Graham's favor wasagainst the manifest weight of the evidence.

A court construes the settlement provisions within adissolution judgment so as to give effect to the parties'intention. Mulry, 314 Ill. App. 3d at 759. When the terms areunambiguous, the court determines the parties' intent solely fromthe language of the instrument. Mulry, 314 Ill. App. 3d at 759. We consider the instrument as a whole and presume that the partiesincluded each provision deliberately and for a purpose. Mulry, 314Ill. App. 3d at 759. We will not construe the terms and provisionsin a manner that is contrary to or different from the language'splain and obvious meaning. Mulry, 314 Ill. App. 3d at 760.

We determine the language of the settlement agreement to beplain and unambiguous with respect to Graham's obligation to paySam's extraordinary medical expenses. Graham's duty to pay extendsonly to those expenses that are reasonable and necessary.

Petitioner contends that under the agreement the onlycriterion for determining whether respondent must pay a particularmedical bill is whether the expense exceeded $25. We believe thisinterpretation oversimplifies the definition of "medical expense." In our view, the plain and unambiguous meaning of the term"medical expense" as used in the parties' agreement encompassesonly those expenses that are reasonable and necessary. Perhapsthere might be a situation in which a party to a dissolution wouldagree to pay for treatment that is not considered reasonable ornecessary by the medical community. Such a situation would be theexception, however, rather than the rule and should be specified inthe settlement agreement. In the case before us, the language ofthe agreement does not indicate that the parties agreed that Grahamwould pay for such treatment.

Our research has not revealed any Illinois authority thatsquarely addresses this issue. Our holding finds support, though,in Goldberg v. Goldberg, 30 Ill. App. 3d 769 (1975). In that case,the court considered whether the husband was responsible for the payment of certain medical bills incurred by the wife. Theparties' dissolution decree stated in relevant part that thehusband agreed to pay the wife's extraordinary medical expensesexceeding $50, except for psychiatric or psychologic expenses. Thecourt held that the husband was obligated to pay the expenses atissue because "[a]ll of the bills received into evidence were foramounts above $50 and there is no indication in the record thatsuch expenses were unreasonable or unnecessary." (Emphasis added.)Goldberg, 30 Ill. App. 3d at 773. Virginia cites the same sentencefrom Goldberg and argues that it supports her position because allof Sam's expenses were reasonable and necessary. Apparently,Virginia believes that requiring her to show that Sam's expenseswere "for a method of treatment which is recognized by the medicalcommunity for a recognized medical need" is different from requiring her to show that the expenses were reasonable andnecessary. We disagree.

The court's requirement, while more specific than the term"reasonable and necessary," does not insert a new condition intothe agreement. The question of whether an expense was fortreatment recognized by the medical community goes to thereasonableness of the expense. Similarly, requiring Virginia toshow that the expense was for a "recognized medical need" is simplyanother way of saying that she must show that the expense wasnecessary. Consequently, we hold that the trial court did not errin requiring Virginia to demonstrate that the expenses she incurredfor Sam's treatment were "for a method of treatment which isrecognized by the medical community for a recognized medical need." That being said, we consider next whether the trial court properlydirected a finding in Graham's favor as to his obligation to payDr. Jones's and Dr. Cancillieri's expenses.

The only medical testimony the trial court heard on the issueof Sam's treatment was that of Dr. Jones. Even though Virginia isa registered nurse, there was no showing that she is an expert inLyme disease. Thus, the trial court properly declined to rely onher testimony regarding Sam's condition and treatment. Based onDr. Jones's testimony, the court determined that the course oftreatment he prescribed for Sam was not followed by any otherphysician in the United States and was found to be suspect by theNew York medical board.

Virginia contends that the trial court erred by disregardingDr. Jones's uncontradicted testimony that the continuousintravenous antibiotics and hyperbaric oxygen treatments werehelping Sam. She cites Bazydlo v. Volant, 164 Ill. 2d 207, 215(1995), for the proposition that the finder of fact may notarbitrarily or capriciously reject testimony where the testimony isneither contradicted, either by positive testimony or bycircumstances, nor inherently improbable and the witness has notbeen impeached.

We note initially that the trial court did not find that Dr.Jones's treatment was not helping Sam. That is not the issue. Anynumber of treatment methods that are not recognized by the medicalcommunity might help Sam feel better, but that does not mean thatSam should receive such treatment or that Graham should pay for it. Rather, the relevant question, which the court addressed, iswhether Dr. Jones's methods of treatment are recognized by themedical community. Dr. Jones's own testimony established that theyare not. He testified that he is the only physician in the countrywho treats children with Lyme disease with continuous antibiotictherapy. He admitted that the medical community generally treatsLyme disease with four to six weeks of antibiotics. Dr. Jones alsoprescribed hyperbaric oxygen treatment for Sam. Virginia and Samhad to travel to California to obtain this treatment because veryfew hyperbaric treatment centers across the country will treat Lymedisease patients. Thus, Dr. Jones's testimony provided sufficientevidence that his treatment of Sam was not recognized by themedical community and that the expenses for such treatment were notreasonable.

The court also directed a finding in Graham's favor as to Dr.Cancillieri's expenses. Virginia does not address those expensesin her brief and, therefore, has waived any challenge to thecourt's order in this regard. See Stewart v. Jones, 318 Ill. App.3d 552, 559 (2001). Consequently, we affirm the trial court'sdecision as to Dr. Cancillieri's expenses as well.

Virginia's next contention is that the trial court abused itsdiscretion when it denied her petition to increase Graham's childsupport obligation. The court may modify a child support awardonly on proof of a substantial change in circumstances pursuant tosection 510(a)(1) of the Illinois Marriage and Dissolution ofMarriage Act (Act) (750 ILCS 5/510(a)(1) (West 2000)). In reMarriage of Hughes, 322 Ill. App. 3d 815, 818 (2001). Thepetitioning party must show both an increase in the child's needsand the supporting spouse's ability to pay. In re Marriage ofMorrisroe, 155 Ill. App. 3d 765, 771 (1987). The court mustdetermine the threshold issue of whether a substantial change incircumstances has occurred before determining the amount of theincrease in child support. Hughes, 322 Ill. App. 3d at 818. Thedetermination that there has been a substantial change incircumstances sufficient to warrant the modification of childsupport lies within the trial court's discretion and will not bedisturbed absent an abuse of discretion. Villanueva v. O'Gara, 282Ill. App. 3d 147, 149 (1996). An abuse of discretion occurs whenno reasonable person would agree with the decision. In re Marriageof Mitteer, 241 Ill. App. 3d 217, 224 (1993).

According to Virginia, both Graham's ability to pay and theexpenses related to caring for Sam have increased. Virginia arguesthat Graham's yearly income has increased from $68,000 at the timeof the judgment of dissolution to $146,000 in 2000. She contendsthat Sam's needs have increased, as evidenced by her increasedgrocery and clothing expenses and her expenses for Sam's sportsactivities. The court determined that, looking at Graham's averageincome over the years, his biweekly obligation of $620 was theproper amount.

On the issue of Virginia's increased expenses for Sam, theorder of May 24, 2001, states that "[t]here was no evidence fromany qualified educator that the parties' son, SAMUEL, has to behome-schooled or that he is being properly home-schooled and,accordingly, no basis for deviating from the statutory supportguidelines."

The court erred as a matter of law in defining the issue aswhether a basis existed for deviating from the statutoryguidelines. The guidelines set the minimum amount of support, notthe maximum amount. See 750 ILCS 5/505(a) (West 2000). Thus,whether the court deviates from the guidelines is not materialunless it sets support below the statutory minimum. The courtshould have determined whether a substantial change incircumstances occurred. We vacate the trial court's denial ofVirginia's petition to increase child support and remand the matterfor the court to reconsider its decision, applying the correctstandard. We further note that Virginia testified to the increasedexpenses she has incurred, such as grocery and clothing expenses,that are unrelated to whether Sam is home-schooled. The court didnot address this evidence but, instead, for reasons we could notdiscern from the record, focused on whether Sam has to be home-schooled. Upon remand the court should consider all relevantevidence of Sam's increased needs. We do not express an opinion,however, as to whether Virginia met her burden of demonstrating asubstantial change in circumstances.

Next, Virginia contends the trial court abused its discretionwhen it reduced her maintenance and limited it to a two-yearduration. The decision to modify or terminate maintenance lieswithin the sound discretion of the trial court, and we will notdisturb the trial court's decision absent an abuse of discretion. In re Marriage of Cantrell, 314 Ill. App. 3d 623, 629 (2000). Based on our review of the record, we hold that the trial courtabused its discretion when it reduced Graham's maintenanceobligation and ordered the termination of maintenance after twoyears.

Section 510(a) of the Act provides that maintenance may bemodified only where the moving party can demonstrate a "substantialchange in circumstances." 750 ILCS 5/510(a) (West 2000). Cantrell, 314 Ill. App. 3d at 629. When deciding whether to modifyor terminate maintenance, the trial court should consider the samefactors it considered when it made the initial maintenance award. In re Marriage of Kocher, 282 Ill. App. 3d 655, 661 (1996). Thosefactors include the following: (1) the standard of livingestablished during the marriage; (2) the financial resources of theparty seeking maintenance; (3) the other spouse's ability to pay;(4) the needs of both parties; (5) the age and physical and mentalcondition of both parties; and (6) the contributions by the partyseeking maintenance to the other spouse's education, training,career, or career potential. Kocher, 282 Ill. App. 3d at 661. Thetrial court must consider all of the relevant statutory factors butneed not make specific findings as to the reasons for its decision. Kocher, 282 Ill. App. 3d at 661.

Here, the deciding factor was Virginia's health. The maritalsettlement agreement incorporated into the dissolution judgmentacknowledged that she is afflicted with Lyme disease and wasreceiving Social Security disability payments. The agreementprovided that the issue of maintenance was reviewable after fiveyears and that "[t]he payment of additional maintenance *** shallbe dependent upon the Wife's employability, health, and needs atthat time." At the hearing, Virginia testified that she continuesto receive disability and is unable to work as a nurse because sheexperiences short-term memory loss and fatigue. Dr. Jones alsotestified that Virginia is unable to work because of her symptoms. Dr. Jones acknowledged, however, that he is not Virginia's treatingphysician. Virginia further testified that she home-schools Samdue to his cognitive deficits and other symptoms caused by the Lymedisease.

After hearing the evidence, the trial court found there was nomedical evidence to support Virginia's claim that she is unable towork. In so doing, the court improperly placed the burden of proofon Virginia and erred as a matter of law. Graham petitioned thecourt to terminate his maintenance obligation. As the partyseeking the modification, he had the burden of demonstrating asubstantial change in circumstances. In re Marriage of Neuman, 295Ill. App. 3d 212, 214 (1998). Thus, he was required to show asubstantial change in circumstances that would justify reducing hismaintenance obligation. Contrary to the trial court's ruling,Virginia did not have the burden of proving that she remainedphysically unable to work.

Based on our review of the record, Graham did not meet hisburden. He did not establish a substantial change in Virginia'shealth that would enable her to return to work, nor did heestablish a substantial change in his own financial circumstancesthat would support reducing his maintenance obligation. We hold,therefore, that the reduction in maintenance was an abuse ofdiscretion. Likewise, the two-year limit on Graham's maintenanceobligation cannot stand. There is no guarantee that Virginia'scondition will have improved by end of the two-year period. Certainly a review of the maintenance issue would be appropriate. Upon remand the court may in its discretion determine if and whensuch a review should take place.

Virginia's last contention is that the trial court erred whenit ordered her to notify Graham regarding proposed extraordinarymedical expenses and allowed Graham the opportunity to investigateand object to the proposed expenses. Virginia claims that Grahamhas failed to demonstrate a substantial change in circumstancesthat would justify this modification to the parties' agreement. Graham responds that the change is one of procedure rather thansubstance and, therefore, he is not required to show a substantialchange in circumstances. Alternatively, he contends that he hasestablished a substantial change in circumstances by showing thatSam has been receiving nonstandard medical care from the physiciansVirginia has selected.

We agree with Virginia that a showing of a substantial changein circumstances was required in order for the court to modify thesettlement agreement as it did. Sam's medical expenses are in thenature of child support, and, thus, modifications to provisions ofthe agreement pertaining to the payment of such expenses aregoverned by section 510(a) of the Act (750 ILCS 5/510(a) (West2000)). That section provides in relevant part that the provisionsof any judgment respecting maintenance or support may be modifiedonly upon a showing of a substantial change in circumstances. 750ILCS 5/510(a) (West 2000). The statute does not distinguishbetween "procedural" and "substantive" changes, and Graham does notcite any authority for his contention that "procedural" changes areexempt from the requirements of section 510(a). Moreover, asVirginia points out, the court's order not only implements the"procedural" changes but also increases the "ordinary expenses" forwhich she is responsible from $25 to $50. For these reasons, weconclude that Graham had to show a substantial change incircumstances to be entitled to the relief he requested.

We agree with Graham that there was evidence of a substantialchange in circumstances sufficient to support the notificationrequirement and the opportunity for him to object to the expenseshe believes to be unreasonable or unnecessary. The trial courtfound that the treatment Sam has been receiving from Dr. Jones wasnot followed by any other physician who treats children with Lymedisease and was considered suspect by the New York medical board. This constitutes a substantial change in circumstances from thetime of the entry of the judgment of dissolution, when Dr. Joneswas not treating Sam and Sam was not receiving the same type oftreatment that Dr. Jones prescribed.

Virginia also contends that the trial court's orderimpermissibly intrudes upon her interests as Sam's sole custodianin making decisions about his medical treatment. Technically,Virginia retains the authority to obtain whatever treatment shefeels is best for Sam. Practically speaking, it may be financiallyimpossible for Sam to receive the treatment Virginia chooses if thecourt determines that Graham is not responsible for the expense ofsuch treatment. We believe the court's solution strikes anappropriate compromise between Virginia's interests as Sam's solecustodian and Graham's interests in preventing unreasonable andunnecessary expenses. We hope the parties will keep Sam's bestinterests in mind and try to resolve any differences that may arisewithout resorting to further litigation.

That being said, the order setting forth the modifications tothe agreement is problematic in several respects. First, the orderrequires Virginia to notify Graham of any proposed extraordinarymedical expense over $200. Graham then has 14 days to investigatethe proposed expense and to inform Virginia in writing of whetherhe agrees to the expense. The court's order next provides thatGraham has the right to file a petition if he disagrees with theneed for the proposed treatment, the proposed provider, or the costof the treatment. The order does not provide a time limit withinwhich Graham must file his petition. Because the petition involvesSam's medical treatment, we believe the court should set a specifictime limit for Graham to file a petition so that the necessarydecisions related to Sam's treatment may be made as expeditiouslyas possible.

The court's order is also unclear as to the parties'respective responsibilities for Sam's medical expenses. In theinitial agreement, Virginia was responsible for paying ordinarymedical expenses, defined as those expenses less than $25. Grahambore the responsibility for expenses greater than $25. The order ofMay 30, 2001, states that it modifies paragraph 10 of theagreement. It goes on to say that Virginia is responsible for allordinary expenses, defined as those expenses less than $50 peroccurrence. The order provides that Graham is responsible for allextraordinary expenses not covered by insurance and defines"extraordinary expense" as those expenses for which the cost of anindividual occurrence or series of occurrences is greater than$200. The order fails to account for those expenses between $50and $200. Graham contends that the modification only determinesthe level at which Virginia must notify Graham of proposedtreatment. The order does not say that, however, nor does it statewhether the modification was intended to supplant the originalparagraph 10 in its entirety or whether portions of the originalparagraph 10 remain in effect. Accordingly, we direct the courtupon remand to clarify its order as to the parties'responsibilities under paragraph 10 of the agreement, as modified.

Virginia also argues that the court erred in increasing herobligation toward Sam's medical expenses from $25 to $50. We mightbe inclined to agree with Virginia had she provided some argument and citations to the record to support her contention. Because shedid not, this argument is waived for purposes of appeal. City ofHighwood v. Obenberger, 238 Ill. App. 3d 1066, 1073-74 (1992) (barecontentions, in the absence of argument or citation of authority,do not merit consideration on appeal and are deemed waived).

Accordingly, for the reasons stated, we affirm the trialcourt's order directing a finding in favor of Graham on the issueof his responsibility for the extraordinary medical expensesrelated to treatment by Dr. Jones and Dr. Cancillieri. We vacatethe denial of Virginia's petition to increase child support andremand the cause for further proceedings in accordance with thisopinion. We reverse the reduction and limitation of Virginia'smaintenance. We affirm the trial court's decision to implementprocedures that give Graham the opportunity to investigate andobject to proposed extraordinary medical expenses but remand thecause for clarification of those procedures and the parties'financial responsibilities under paragraph 10 of the agreement.

Affirmed in part, vacated in part, and reversed in part; causeremanded.

McLAREN and GROMETER, JJ., concur.