STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

JOHN H. ADAMS, )

)

Petitioner, )

)

vs. ) CASE NO. 83-1327

) STATE OF FLORIDA, DEPARTMENT ) OF ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

This cause came on for hearing on July 18, 1983, in Naples, Florida, before the Division of Administrative Hearings and its duly appointed Hearing Officer,

1. T. Carpenter. The parties were represented by:

   
   

   APPEARANCES

   
   

   For Petitioner: Mr. John H. Adams

   2596 Linwood Avenue

   Naples, Florida 33962

   
   

   For Respondent: Daniel C. Brown, Esquire

   Department of Administration

   435 Carlton Building Tallahassee, Florida 32301

   
   

   This case arose on Respondent's failure to give Petitioner notice that a portion of his state employee's health insurance coverage would lapse at age 65, and that he would need to obtain replacement coverage under Medicare. The parties submitted proposed findings of fact and conclusions of law. Those findings not incorporated herein are found to be either subordinate, cumulative, immaterial, unnecessary or not supported by the evidence.

   
   

   FINDINGS OF FACT

   
   

   1. Petitioner was employed with the Collier County Health Department, Department of Health and Rehabilitative Services, on March 9, 1973.

      
      

   2. Petitioner's date of birth is November 26, 1916.

      
      

   3. On October 1, 1980, Petitioner's medical insurance coverage was entered into the payroll system under the Spouse Program, State of Florida plan.

      
      

   4. The proper amount of premiums under the Spouse Program were paid to Blue Cross Blue Shield from October 1, 1980, up to and including June, 1983.

      
      

   5. On November 26, 1981, Petitioner reached the age of 65.

   6. Under the State plan, coverage at age 65 is automatically reduced and changed to Medicare Supplement Coverage. In order to have remained fully covered, Petitioner would have had to apply for the Medicare insurance prior to reaching age 65, which he did not do.

      
      

   7. Due to both spouses being covered, there was no change in policy premium deductions even after Petitioner reached age 65 and his State coverage was reduced.

      
      

   8. The Blue Cross Blue Shield (State program) paid several claims of Petitioner subsequent to his 65th birthday and through December, 1982.

      
      

   9. On March 8, 1983, Petitioner was admitted to the hospital and on March 11, 1983, heart bypass surgery was performed.

      
      

   10. Respondent normally notifies the employee and employing agency of the coverage change prior to the employee's 65th birthday, as required by Rule 22K- 1.16, F.A.C. In this case, Respondent did not do so due to a failure in its computer program.

       
       

   11. Petitioner could have determined that he was required to apply for Medicare coverage had he read in detail a copy of the plan's benefit booklet furnished to all State employees in 1978.

       
       

       CONCLUSIONS OF LAW

       
       

   12. Rule 22K-1.16(4), F.A.C., provides in part:

       
       

       Within two months prior to an employee. attaining age sixty-five (65), the Department of Administration shall notify the employee and the employing agency of the employee,

       of an automatic change of coverage at age sixty-five (65) to Medicare Supplement Coverage.

       
       

   13. Respondent failed to provide specific notice which is required under the above provision, and which it would have provided but for a failure in its computer program. The absence of any premium change and the continued payment of claims after age 65 were indications to petitioner that his health insurance coverage was undisturbed.

       
       

   14. Respondent did not issue the benefit booklet as a substitute for the notice required under the above-cited rule. Petitioner's failure to read, or recall, a provision of this booklet is therefore not relevant.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Respondent direct its insurer to pay Petitioner's claims

arising from his March, 1983, hospitalization.

DONE and ENTERED this 2nd day of September, 1983, in Tallahassee, Florida.

R. T. CARPENTER, Hearing Officer Division of Administrative Hearings The Oakland Building

2009 Apalachee Parkway

Tallahassee, Florida 32301

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 2nd day of September, 1983.

COPIES FURNISHED:

Mr. John H. Adams 2596 Linwood Avenue

Naples, Florida 33962

Daniel C. Brown, Esquire Department of Administration

435 Carlton Building Tallahassee, Florida 32301

Nevin G. Smith, Secretary Department of Administration Carlton Building Tallahassee, Florida 32301

Docket for Case No: 83-001327

Orders for Case No: 83-001327