Judges: LARRY J. SARTIN
Agency: Department of Management Services
Latest Update: Jul. 15, 1988
Summary: The issues in this case, as stipulated to, by the parties in their Prehearing Stipulations, are as follows: Whether the surgery performed on Susan Cobb on 11/11/85 was covered by State Employees Group Health Self- Insurance Plan; Whether Respondent is estopped from denying coverage?Petitioner not entitled to payment by state health insurance plan for wife's surgery after he elected to switch to HMO coverage. Not prove estoppel.
86-4109.PDFSTATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
DANIEL O. COBB, )
)
Petitioner, )
)
vs. ) CASE NO.: 86-4109
) DEPARTMENT OF ADMINISTRATION, )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to written notice a formal hearing was held in this case before Larry J. Sartin, a duly designated Hearing Officer of the Division of Administrative Hearings, on June 7, 1988 in Jacksonville, Florida.
APPEARANCES
For Petitioner: O. C. Beakes, Esquire
Lindner Smith, Jr., Esquire 836 Riverside Avenue
Jacksonville, Florida 32205
For Respondent: Andrea R. Bateman, Esquire
Department of Administration Room 438 Carlton Building Tallahassee, Florida 32399-1550
INTRODUCTION
The Petitioner, Daniel O. Cobb, submitted claims to the Respondent, the Depatment of Administration (hereinafter referred to as the "Department"), for surgery performed on Mr. Cobb's spouse. In a letter dated August 27, 1986, the Department denied payment of the claims. Mr. Cobb filed a Petition for Formal Hearing contesting the denial of the payment of the claims. On October 22, 1986, the Department filed a Notice of Election to Request Appointment of Hearing Officer with the Division of Administrative Hearings. The request was assigned case number 86-4109 and was initially assigned to William B. Thomas.
The case was subsequently transferred to Diane K. Kiesling, then to P. Michael Ruff and, on June 3, 1988, to the undersigned.
Prior to the commencement of the formal hearing, the parties filed a Prehearing Stipulation, by which the parties limited the issues, exhibits and witnesses to be presented at the formal hearing. The Prehearing Stipulation also contained stipulated facts. These stipulated facts have been incorporated into this Recommended Order.
At the formal hearing the Mr. Cobb testified on his own behalf and presented the testimony of Susan Catherine Cobb. Mr. Cobb also offered five exhibits which had been previously marked as Petitioner's exhibits 2 through 6. These exhibits were accepted into evidence. Petitioner's exhibits 3 and 4 constitute hearsay.
The Department presented the testimony of Hazel Rosser and Joseph Wellman.
The Department also offered four exhibits which were marked as "DOA" exhibits and accepted into evidence.
Subsequent to the formal hearing, Mr. Cobb filed a Notice indicating that the Petitioner did not intend to file a transcript of the formal hearing nor a proposed recommended order.
The Department has filed a proposed recommended order containing proposed findings of fact. A ruling on each proposed finding of fact has been made either directly or indirectly in this Recommended Order or the proposed finding of fact has been accepted or rejected in the Appendix which is attached hereto.
ISSUE
The issues in this case, as stipulated to, by the parties in their Prehearing Stipulations, are as follows:
Whether the surgery performed on Susan Cobb on 11/11/85 was covered by State Employees Group Health Self- Insurance Plan;
Whether Respondent is estopped from denying coverage?
FINDINGS OF FACT
Daniel O. Cobb was an employee of the Florida Department of Transportation during 1985.
Mr. Cobb and his spouse, Susan Cobb, had family coverage under the State of Florida Employees Group Health Self Insurance Plan (hereinafter referred to as the "State Plan"), until November 1, 1985.
The State Plan is administered by Blue Cross/Blue Shield. Pursuant to the agreement between the State of Florida and Blue Cross/Blue Shield benefits which are payable under the State Plan are governed by a "Benefit Document."
Each year, State employees are given an opportunity change the form of health insurance coverage they wish to have. During this "open enrollment period" an employee covered by the State Plan can elect to participate in a Health Maintenance Organization and an employee covered by a Health Maintenance Organization can elect to participate in the State Plan.
During 1985, there was an open enrollment period between September 9, 1985, and September 20, 1985.
During the 1985 open enrollment period State employees, including Mr. Cobb, were provided a Notice to Employees in which they were advised to carefully review information contained in a Benefit Comparison Brochure, a Rate Comparison Chart and a Health Care Plan Selection Form. These documents were
provided to all State employees. The Selection Form instructed employees to "Please read the employee notice about HMO service areas and effective date of coverage before completing this section." State employees were also advised that any change in coverage would be effective November 1, 1985.
On September 19, 1985, Mr. Cobb signed a State of Florida Employes Group Health Self Insurance Plan, Change of Information Form. Pursuant to this Change of Information Form, Mr. Cobb elected to terminate his health insurance coverage with the State Plan. On the Change of Information Form it was indicated that Mr. Cobb's election to terminate his coverage under the State Plan was to be effective November 1, 1985. Therefore, Mr. Cobb was informed and should have known that he was no longer eligible for medical cost payment for himself or his family pursuant to the State Plan after October 31, 1985.
Mr. Cobb also signed a Member Enrollment (Group) and Physician Selection Form on September 19, 1985. Pursuant to this Form, Mr. Cobb enrolled himself, his Spouse and their children, in Health Options, Inc., a health maintenance organization.
Mr. Cobb's participation in Health Options, Inc., began November 1, 1985.
On September 19, 1985, Mr. Cobb was provided a list of Health Options, Inc., approved physicians which were available for use by Mr. Cobb and his family. Mr. Cobb designated Gerald A. Giurato, M.D., as his primary care physician on the Physician Enrollment Form which he signed on September 19, 1985.
On October 28, 1985, Mr. Cobb was mailed a copy of the Health Options Member Handbook which, among other things, describes the grievance procedure to be followed when medical expenses were not paid by Health Options Inc., and the manner in which physicians were to be used in order to be entitled to payment, of their charges. The Handbook informed Mr. Cobb that all care had to be arranged through a primary care physician and that only services provided or approved by the primary care physician were covered. The Handbook also indicated that treatment by physicians who were not approved by the primary care physician would be the responsibility of the patient.
During 1985 Mrs. Cobb was under the care of Alexander Rosin, M.D. Dr. Rosin performed surgery for the removal of a cyst on Mrs. Cobb, on November 11, 1985. Dr. Rosin was not a physician approved by Health Options, Inc., or Mr. Cobb's primary care physician. Nor was the surgery approved.
Claims attributable to the November 11, 1985, surgery were submitted to the State Plan. Claims, for the charges of Dr. Rosin, Scott Blonder, M.D., and a Pathologist were submitted.
The expenses for the November 11, 1985, surgery were incurred after coverage of Mr. and Mrs. Cobb under the State Plan ended.
The type of surgery performed on Mrs. Cobb was also not authorized by the Benefit Document.
No claims were submitted to Health Options, Inc., for medical expenses incurred for Mrs. Cobb's operation on November 11, 1985.
None of the medical expense attributable to Mrs. Cobb's November 11, 1985, surgery were incurred with physicians or facilities approved by Health Options, Inc.
By letter dated August 27, 1986, the Department denied the claims submitted to the State Plan attributable to Mrs. Cobb's November 11, 1985, surgery. Mr. Cobb filed a request for an administrative hearing to contest the Department's proposed denial.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction of the parties to and the subject matter of this proceeding. Section 120.57(1), Florida Statutes (1987).
The burden of proof in this case is on Mr. Cobb. See Balino v. Department of Health an Rehabilitative Services, 348 So.2d 349 (Fla. 1st DCA 1977).
The Secretary of Administration is responsible for administering the State's group health insurance program. Section 110.123(5), Florida Statutes. Pursuant to Section 110.123(3), Florida Statutes. State employees are eligible to participate in the State Plan or, in lieu thereof, a State employee may elect to participate in a health maintenance organization.
Pursuant to Section 110.123(5), Florida Statutes, the Department is authorized to determine the benefits to be provided under the State Plan.
The evidence in this case proved that Mr. Cobb elected to end his participation in the State Plan and to begin participation in Health Options, Inc., a health maintenance organization, effective November 1, 1985. Prior to November 1, 1985, Mr. Cobb was provided information concerning the procedures which he would be required to follow in order to be eligible for medical reimbursement from the health maintenance organization.
Mr. Cobb knew or should have known that he was no longer eligible for medical payments under the State Plan after October 31, 1985. Mr. Cobb also knew or should have known that he had to comply with the procedures for receiving medical reimbursement established by Health Options, Inc., after October 31, 1985. Despite these facts, Mr. Cobb submitted claims to the State Plan for the medical expenses attributable to his spouse's surgery which was performed after his coverage by the State Plan ended. In light of the fact that the surgery was performed and the expenses at issue in this case were incurred after coverage under the State Plan ended, the claims at issue in this proceeding should be denied.
Additionally, the type of surgery performed on Mrs. Cobb was not eligible for payment under the State Plan because it was not covered pursuant to the Benefits Document. Although Mr. Cobb submitted what purports to be letter from Blue Cross/Blue Shield (see Petitioner's exhibit 6) indicating that the "location of the services" is appropriate, this document does not indicate that the surgery is otherwise covered. More importantly, the letter is hearsay which does not supplement or explain any other evidence which was admissible in the proceeding.
Finally, the claimed expenses should be denied because no evidence was presented to prove what the amount of the unpaid expenses was. The burden of proving the amount at issue in this case was on Mr. Cobb. He failed to meet that burden.
Whether the claimed expenses are properly payable by Health Options, Inc., is not an issue properly before the undersigned. The Department does not administer the payment of expenses payable by Health Options, Inc. Additionally the evidence in this case proved that Mr. Cobb has not claimed payment of the expenses attributable to Mrs. Cobb's surgery to Health Options, Inc.
Although no proposed recommended order has been submitted by Mr. Cobb, it was argued at the formal hearing that the Department should be estopped from denying payment of the claims at issue in this proceeding. In order for the doctrine of equitable estoppel to apply it must be proved that there has been:
a representation as to a material fact that is contrary to a later asserted position;
reliance on that representation; and
a change in position detrimental to the party claiming estoppel, caused by the representation and reliance thereon. State Department of Revenue v. Anderson, 403 So.2d 397, 400 (Fla. 1981)(citation omitted)
Kuge v. Department of Administration, 449 So.2d 389, 391 (Fla. 3d DCA 1984).
Mr. Cobb has failed to prove that any of the elements of the doctrine of equitable estoppel apply in this case. The only evidence offered relating to Mr. Cobb's argument concerning equitable estoppel was Petitioner's exhibit 6.
As indicated, that document is hearsay evidence and no findings of fact can be made based upon the document. No other competent substantial evidence was presented to support a conclusion that the doctrine of equitable estoppel applies in this case.
RECOMMENDATION
Based upon the foregoing Findings of Fact and Conclusions of Law it is RECOMMEDED that a final order be issued by the Department denying payment
of claimed expenses attributable to Mrs. Cobb's surgery of November 11, 1985.
DONE and ENTERED this 15th day of July, 1988, in Tallahassee, Florida.
LARRY J. SARTIN
Hearing Officer
Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 15th day of July, 1988.
APPENDIX TO RECOMMENDED ORDER, CASE NO. 864109
The Department has submitted proposed findings of fact. It has been noted below which proposed findings of fact have been generally accepted and the paragraph number(s) in the Recommended Order where they have been accepted, if any. Those proposed findings of fact which have been rejected and the reason for their rejection have also been noted.
The Department's Proposed Findings of Fact
Proposed Finding Paragraph Number in Recommended Order of Fact Number, of Acceptance or Reason for Rejection
1 18. The letter denying payment was dated August 27, 1986, and not September 4, 1986. See DOA exhibit 1.
2 7.
3 Hereby accepted.
4 7.
5 3.
6 4 and 5.
7-9 6.
10-12 11.
Summary of testimony and irrelevant.
Summary of testimony argument. Concerning the weight to be given evidence and cumulative.
15 7.
16 Hearsay.
17-18 Conclusion of law.
19-20 16.
21 Not supported by the weight of the evidence.
22 15.
COPIES FURNISHED:
O. C. Beakes, Esquire Lindner Smith, Jr., Esquire 836 Riverside Avenue Jacksonville, Florida 32205
Andrea R. Bateman, Esquire Department of Administration Room 438, Carlton Building Tallahassee, Florida 32399-1550
Adis Vila, Secretary
435 Carlton Building Tallahassee, Florida 32399-1550
Augustus D. Aikens, Jr. General Counsel
435 Carlton Building Tallahassee, Florida 32399-1550
=================================================================
AGENCY FINAL ORDER
=================================================================
STATE OF FLORIDA DEPARTMENT OF ADMINISTRATION
DANIEL O. COBB,
Petitioner
v. DOA CASE NO. A-86-13
DOAH CASE NO. 86-4109
STATE OF FLORIDA,
DEPARTMENT OF ADMINISTRATION, OFFICE OF STATE EMPLOYEES' INSURANCE,
Respondent.
/
FINAL ORDER
This matter is before the Department of Administration for entry of a Final Order.
A Recommended Order was entered by Larry J. Sartin, an Officer of the Division of Administrative Hearings, on July 15, 1988. An administrative hearing was held on June 7, 1988, in Jacksonville, Florida.
APPEARANCES
For the Petitioner: O. C. Beakes, Esquire
Lindner Smith, Jr., Esquire 836 Riverside Avenue
Jacksonville, Florida 32205
For the Respondent: Andrea R. Bateman, Esquire
Department of Administration Room 438, Carlton Building Tallahassee, Florida 32399-1550
ISSUES AND INTRODUCTION
The issues are whether Petitioner, Daniel O. Cobb, is entitled to payment of claims for surgery performed on Ms. Cobb, Susan Catherine Cobb, his spouse, on November 11, 1985, and whether Respondent, the State, is estopped from denying coverage.
A prehearing stipulation was filed limiting the facts, issues, exhibits and witnesses. The stipulated facts were incorporated into the Recommended Order and are in the Final Order as well. Petitioner presented the testimony of himself and his spouse. Petitioner's exhibits 2 through 6 were accepted into evidence. Exhibits 3 and 4 constituted hearsay. The Department presented the testimony of Hazel Rosser and Joseph F. Wellman. Four exhibits by the Department were offered into evidence and were accepted. Neither party ordered a transcript. Only the Department filed a proposed recommended order and findings of fact.
The Findings of Fact and the Conclusions of Law in the Recommended Order are hereby adopted, except in Findings of Fact Nos. 16, 17, and 18, Mrs. Scott is changed to Mrs. Cobb and in Findings of Fact No. 18, Mr. Scott is changed to Mr. Cobb.
FINDINGS OF FACT
Daniel O. Cobb was an employee of the Florida Department of Transportation during 1985.
Mr. Cobb and his spouse, Susan Cobb, had family coverage under the State of Florida Employees Group Health Self Insurance Plan (hereinafter referred to as the "State Plan"), until November 1, 1985.
The State Plan is administered by Blue Cross/Blue Shield. Pursuant to the agreement between the State of Florida and Blue Cross/Blue Shield benefits which are payable under the State Plan are governed by a "Benefit Document."
Each year, State employees are given an opportunity to change the form of health insurance coverage they wish to have. During this "open enrollment period" an employee covered by the State Plan can elect to participate in a Health Maintenance Organization and an employee covered by a Health Maintenance Organization can elect to participate in the State Plan.
During 1985, there was an open enrollment period between September 9, 1985, and September 20, 1985.
During the 1985 open enrollment period State employees, including Mr. Cobb, were provided a Notice to Employees in which they were advised to carefully review information contained in a Benefit Comparison Brochure, a Rate Comparison Chart and a Health Care Plan Selection Form. These documents were provided to all State employees. The Selection Form instructed employees to "Please read the employee notice about HMO service areas and effective date of coverage before completing this section." State employees were also advised that any change in coverage would be effective November 1, 1985.
On September 19, 1985, Mr. Cobb signed a State of Florida Employees Group Health Self Insurance Plan, Change of Information Form. Pursuant to this Change of Information Form, Mr. Cobb elected to terminate his health insurance coverage with the State Plan. On the Change of Information Form it was
indicated that Mr. Cobb's election to terminate his coverage under the State Plan was to be effective November 1, 1985. Therefore, Mr. Cobb was informed and should have known that he was no longer eligible for medical cost payment for himself or his family pursuant to the State Plan after October 31, 1985.
Mr. Cobb also signed a Member Enrollment (Group) and Physician Selection Form on September 19, 1985. Pursuant to this Form, Mr. Cobb enrolled himself, his spouse and their children, in Health Options, Inc., a health maintenance organization.
Mr. Cobb's participation in Health Options, Inc., began November 1, 1985.
On September 19, 1985, Mr. Cobb was provided a list of Health Options, Inc., approved physicians which were available for use by Mr. Cobb and his family. Mr. Cobb designated Gerald A. Giurato, M.D., as his primary care physician on the Physician Enrollment Form which he signed on September 19, 1985.
On October 28, 1985, Mr. Cobb was mailed a copy of the Health Options Member Handbook which, among other things, describes the grievance procedure to be followed when medical expenses were not paid by Health Options, Inc., and the manner in which physicians were to be used in order to be entitled to payment of their charges. The Handbook informed Mr. Cobb that all care had to be arranged through a primary care physician and that only services provided or approved by the primary care physician were covered. The Handbook also indicated that treatment by physicians who were not approved by the primary care physician would be the responsibility of the patient.
During 1985, Mrs. Cobb was under the care of Alexander Rosin, M.D. Dr. Rosin performed surgery for the removal of a cyst on Mrs. Cobb on November 11, 1985. Dr. Rosin was not a physician approved by Health Options, Inc., or Mr. Cobb's primary care physician. Nor was the surgery approved.
Claims attributable to the November 11, 1985, surgery were submitted to the State Plan. Claims for the charges of Dr. Rosin, Scott Blonder, M.D., and a pathologist were submitted.
The expenses for the November 11, 1985, surgery were incurred after coverage of Mr. and Mrs. Cobb under the State Plan ended.
The type of surgery performed on Mrs. Cobb was also not authorized by the Benefit Document.
No claims were submitted to Health Options, Inc., for medical expenses incurred for Mrs. Cobb's operation on November 11, 1985.
None of the medical expenses attributable to Mrs. Cobb's November 11, 1985, surgery were incurred with physicians or facilities approved by Health Options, Inc.
By letter dated August 27, 1986, the Department denied the claims submitted to the State Plan attributable to Mrs. Cobb's November 11, 1985, surgery. Mr. Cobb filed a request for an administrative hearing to contest the Department's proposed denial.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction of the parties to and the subject matter of the proceeding. Section 120.57(1), Florida Statutes (1987).
The burden of proof in this cafe is on Mr. Cobb. See Balino v. Department of Health and Rehabilitative Services, 348 So.2d 349 (Fla. 1st DCA 1977).
The Secretary of Administration is responsible for administering the State's group health insurance program. Section 110.123(5), Florida Statutes. Pursuant to Section 110.123(3), Florida Statutes, State employees are eligible to participate in the State Plan or, in lieu thereof, a State employee may elect to participate in a health maintenance organization.
Pursuant to Section 110.123(5), Florida Statutes, the Department is authorized to determine the benefits to be provided under the State Plan.
The evidence in this case proved that Mr. Cobb elected to end his participation in the State Plan and to begin participation in Health Options, Inc., a health maintenance organization, effective November 1, 1985. Prior to November 1, 1985, Mr. Cobb was provided information concerning the procedures which he would be required to follow in order to be eligible for medical reimbursement from the health maintenance organization.
Mr. Cobb knew or should have known that he was no longer eligible for medical payments under the State Plan after October 31, 1985. Mr. Cobb also knew or should have known that he had to comply with the procedures for receiving medical reimbursement established by Health Options, Inc., after October 31, 1985. Despite these facts, Mr. Cobb submitted claims to the State Plan for the medical expenses attributable to his spouse's surgery which was performed after his coverage by the State Plan ended. In light of the fact that the surgery was performed and the expenses at issue in this case were incurred after coverage under the State Plan ended, the claims at issue in this proceeding should be denied.
Additionally, the type of surgery performed on Mrs. Cobb was not eligible for payment under the State Plan because it was not covered pursuant to the Benefits Document. Although Mr. Cobb submitted what purports to be a letter from Blue Cross/Blue Shield (see Petitioner's exhibit 6) indicating that the "location of services" is appropriate, this document does not indicate that the surgery is otherwise covered. More importantly, the letter is hearsay which does not supplement or explain any other evidence which was admissible in the proceeding.
Finally, the claimed expenses should be denied because no evidence was presented to prove what the amount of the unpaid expenses were. The burden of proving the amount at issue in this case was on Mr. Cobb. He failed to meet that burden.
Whether the claimed expenses are properly payable by Health Options, Inc., is not an issue properly before the undersigned. The Department does not administer the payment of expenses payable by Health Options, Inc. Additionally, the evidence in this case proved that Mr. Cobb has not claimed payment to the expenses attributable to Mrs. Cobb's surgery to Health Options, Inc.
Although no proposed recommended order has been submitted by Mr. Cobb, it was argued at the formal hearing that the Department should be estopped from denying payment of the claims at issue in this proceeding. In order for the doctrine of equitable estoppel to apply it must be proved that there has been:
a representation as to a material fact that is contrary to a later-asserted position;
reliance on that representation; and
a change in position detrimental to the party claiming estoppel , caused by the representation and reliance thereon. State Department of Revenue v. Anderson, 403 So.2d 397, 400 (Fla. 1981)(citation omitted)
Kuge v. Department of Administration, 449 So.2d 389, 391 (Fla. 3d DCA 1984).
Mr. Cobb has failed to prove that any of the elements of the doctrine of equitable estoppel apply in this case. The only evidence offered relating to Mr. Cobb's argument concerning equitable estoppel was Petitioner's exhibit 6.
As indicated, supra, that document is hearsay evidence and no findings of fact can be made based upon the document. No other competent substantial evidence was presented to support a conclusion that the doctrine of equitable estoppel applies in this case.
Accordingly, it is ordered that Petitioner is not entitled to any reimbursement for the claims or benefits for services attributed to Ms. Cobb's surgery of November 11, 1985.
This Order constitutes final agency action. Judicial review of this proceeding may be instituted by filing a Notice of Appeal in the First District Court of Appeal pursuant to Section 120.68, Florida Statutes. Such notice must be filed with the District Court of Appeal within thirty (30) calendar days of the date this Order is filed in the official records of the Department of Administration, as indicated in the Certificate of Clerk below, or further review of this action will be barred.
SO ORDERED in Tallahassee, Florida, this 14th day of October, 1988.
ADIS M. VILA, SECRETARY
Department of Administration
435 Carlton Building Tallahassee, Florida 32399-1550 (904) 488-4116
Certificate of Clerk
Filed with the Department of Administration this 14th day of October, 1988.
Clerk
Docket for Case No: 86-004109
Orders for Case No: 86-004109
| Issue Date |
Document |
Summary |
|
Oct. 14, 1988 |
Agency Final Order
|
|
|
Jul. 15, 1988 |
Recommended Order
|
Petitioner not entitled to payment by state health insurance plan for wife's surgery after he elected to switch to HMO coverage. Not prove estoppel.
|
