STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

THOMAS J. APPLEYARD, III, )

)

Petitioner, )

)

vs. ) CASE NO. 84-2047

) DEPARTMENT OF ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

A hearing was held in the above-captioned matter, after due notice, at Tallahassee, Florida, on August 28, 1984, before Thomas C. Oldham, Hearing Officer.

APPEARANCES

For Petitioner: Thomas J. Appleyard, III

Post Office Box 4147 Tallahassee, Florida 32315

For Respondent: Daniel C. Brown, Esquire

Department of Administration

435 Carlton Building Tallahassee, Florida 32301

ISSUE PRESENTED

Whether Petitioner's claim for medical expenses from August 6, 1982 through February 27, 1983 should be approved, pursuant to the State of Florida Employees Group Health Self Insurance Plan.

Petitioner appeared at the hearing accompanied by legal counsel. The Hearing Officer thereupon explained his rights and procedures to be followed in the administrative hearing. Petitioner acknowledged that he understood his rights and elected to represent himself.

Petitioner testified in his own behalf at the hearing and the parties stipulated to the introduction of Respondent's Exhibits 1 and 2. A late filed exhibit, Respondent's Exhibit 3, was also admitted in evidence. Respondent presented the testimony of one witness, William R. Seaton, Benefit Analyst for the Respondent's Bureau of Insurance.

FINDINGS OF FACT

1. Petitioner Thomas J. Appleyard, III, is a former state employee who retired with disability in 1976 as a result of cardiac disease. At the time Petitioner retired, he maintained coverage in the state Employees Group Health Self Insurance Plan under which the Blue Cross/Blue Shield of Florida, Inc.

   serves as the administrator of the plan for the state. Petitioner also receives disability benefits under the Medicare program for medical expenses. (Testimony of Petitioner)

   
   

2. The State Group Health Self Insurance Plan provides in Section X, COORDINATION OF BENEFITS, that if an insured has coverage under Medicare, the benefits payable under the state plan will be coordinated with similar benefits paid under the other coverage to the extent that the combination of benefits will not exceed 100 percent of the costs of services and supplies to the insured. Paragraph D of Section X provides that the state plan will be the secondary coverage in such situations and will pay benefits only to the extent that an insured's existing insurance coverage does not entitle him to receive benefits equal to 100 percent of the allowable covered expenses. This provision applies when the claim is on any insured person covered by Medicare. (Testimony of Seaton, Respondent's Exhibit 3)

   
   

3. Petitioner was hospitalized at the Tallahassee Memorial Regional Medical Center on three occasions in 1982-33. His Medicare coverage paid all but $261.75 of the hospital expenses. In February 1983, Petitioner also incurred medical expenses to his cardiologist, Dr. J. Galt Allee, in the amount of $248.33. Petitioner was originally denied his remaining hospital expenses by the administrator of the state plan under the erroneous belief that he was receiving regular Medicare benefits for persons over the age of 65. In addition, Dr. Allee's bill was only partially paid by Medicare, subject to the receipt of additional information from the physician. Payment under the state plan was limited to an amount sufficient to reimburse petitioner 100 percent of the amount originally allowed by Medicare. (Testimony of Seaton, petitioner, Respondent's Exhibit 1, 3)

   
   

4. Respondent does not receive information on claims filed under the state plan until contacted by an employee. In February 1984, Petitioner requested assistance from William R. Seaton, Benefit Analyst, of Respondent's Bureau of Insurance, regarding his difficulties in receiving proper claims payments. Seaton investigated the matter with the Insurance administrator for the state, Blue Cross/Blue Shield of Florida, and discovered that the latter had not coordinated the hospital expense balance with Medicare. They thereafter did so and as of the date of hearing, there was no longer a balance due to Tallahassee Memorial Regional Medical Center. Seaton also gave written instructions to Blue Cross to review all of Petitioner's claims and make sure that they were paid properly, and to install controls on his and his wife's records. (Testimony of Petitioner, Seaton, Respondent's Exhibit 1-2)

   
   

5. The full claim of Dr. Allee had not been paid by Medicare since it had been awaiting requested additional in formation from the physician. Such information was provided after a personal visit had been made to Dr. Allee by Seaton and Medicare then recognized additional eligible expenses. However, a balance of $36.00 is still owed to the physician due to the fact that Blue Cross/Blue Shield had not received the necessary payment information from Medicare as of the day before the hearing. (Testimony of Seaton, Respondent's Exhibit 1)

   
   

6. Section XVII of the state's Group Health Self Insurance Plan benefit document provides that an employee who wishes to contest decisions of the state administrator considering the employee's coverage under the plan may submit a petition for a hearing for consideration by the Secretary of Administration. (Respondent's Exhibit 3)

   CONCLUSIONS OF LAW

   
   

7. Petitioner originally sought payment for medical expenses in the total amount of $510.08 under the Employees Group Health Self Insurance Plan. By the date of hearing, however, all sums except $36.00 due the physician had been paid. This proceeding arises under the provisions of Section 110.123(5), Florida Statutes, which provides that the Secretary of Administration shall be responsible for administration of the state group insurance program. In this capacity, Respondent determines the benefits to be provided under the program and contracts on a competitive proposal basis with an insurance carrier or professional administrator to administer the program. Pursuant to this authority, Respondent has contracted with Blue Cross/Blue Shield of Florida, Inc.

   
   

8. The facts disclose that there is no dispute as to the liability of Respondent to Petitioner in the remaining amount of $36.00. It is thus incumbent upon Respondent to see that its administrator makes the appropriate payment. However, it is also acknowledged by the parties that the failure of the state's administrator to honor the remaining balance is due to the lack of receipt of payment information from Medicare over which Respondent has no control. It would therefore appear to be necessary for Petitioner to ensure that the necessary information is provided to the state administrator by Medicare.

In view of the foregoing, it is RECOMMENDED that Respondent pay the balance due Petitioner upon receipt of necessary payment information from the agency having primary coverage responsibility.

DONE and ENTERED this 25th day of September, 1984, in Tallahassee, Florida.

THOMAS C. OLDHAM

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 25th day of September, 1984.

COPIES FURNISHED:

Thomas J. Appleyard, III Post Office Box 4147 Tallahassee, Florida 32315

Daniel C. Brown, Esquire Department of Administration

435 Carlton Building Tallahassee, Florida 32301

Honorable Nevin G. Smith

Secretary, Department of Administration

435 Carlton Building Tallahassee, Florida 32301

Docket for Case No: 84-002047

Orders for Case No: 84-002047