WILLIAM F. LENNAN, )
vs. ) CASE NO. 89-5485
Respondent. )
By agreement of the parties, the above-styled case was presented by Stipulation filed March 2, 1990, to Robert E. Meale, Hearing Officer of the Division of Administrative Hearings.
For Petitioner: William F. Lennan, pro se
740 Hunan St., N.E. Palm Bay, Florida 32907
For Respondent: Augustus D. Aikens, Jr.
The issue in the case is whether the State of Florida Employees Group Health Self Insurance Plan Benefit Document provides coverage for a maxillary subperiosteal implant surgical procedure under the circumstances described below.
By letter dated August 9, 1989, Respondent informed Petitioner that the State of Florida Group Health Self Insurance Plan Benefit Document did not provide coverage for the maxillary subperiosteal implant procedure that Petitioner proposed to undergo. As grounds, Respondent explained that the procedure, which was to prepare Petitioner's mouth for dentures, was considered a dental procedure.
By letter dated September 5, 1989, Petitioner requested a formal hearing.
Instead of a hearing, the parties agreed to present the case by Stipulation filed March 2, 1990. The only document not referenced in the Stipulation but included in the record is the
State of Florida Employees Group Health Self Insurance Plan Benefit Document, effective July 1, 1988. Respondent filed the document on March 14, 1990, and it is hereby accepted into evidence.
Petitioner filed a memorandum, and Respondent filed a proposed recommended order. All of Respondent's proposed findings are adopted or adopted in substance.
At all material times, Petitioner has been insured under the State of Florida Employees Group Health Self Insurance Plan Benefit Document, effective July 1, 1988 (the "Plan").
Dr. Clark F. Brown, Jr. is a dentist licensed to practice in the State of Florida. His specialty is dental implantology.
The subperiosteal implant, which is the subject of this case, is a framework that rests on top of the bone
underneath the tissue. Following the insertion of the framework, the tissue reattaches to the jawbone, thereby securing the framework to the bone.
The implant procedure takes two days, but can be performed in Dr. Clark's office. On the first day, a direct bone impression is taken. In the process, the gum tissue is cut along the entire remaining ridge and lifted back almost to the base of the eye, floor of the nose, and palate. After the impression is taken, the incision is closed with sutures. On the next day, the stitches are removed, the implant is installed, and the incision again closed with sutures.
On July 31, 1987, Petitioner visited Dr. Clark and complained of difficulties wearing his upper denture. Upon examination, Dr. Clark discovered that Petitioner lacked adequate bone to retain an upper denture. Lacking about 90% of the bone in the vicinity of the upper arch, Petitioner's upper denture was highly unstable.
By letter dated August 8, 1987, Dr. Clark informed
the Plan administrator of Petitioner's condition and proposed a full maxillary subperiosteal procedure for the installation of an orthopedic augmentation appliance.
By letter dated December 11, 1987, the Plan administrator informed Dr. Clark that the proposed procedure was not covered under the Plan. The letter explains that dental services are a specific exclusion unless performed "as the result of an accident where a natural tooth has been damaged and the treatment is rendered within 120 days from the date of the accident."
On December 17, 1987, Dr. Clark relined the denture that fit Petitioner the best. As he had warned Petitioner in advance, the procedure was unsuccessful.
On June 26, 1988, Dr. Clark prepared a new upper denture in preparation for the installation of mucosal implants, which utilize the gum for support. Dr. Clark and Petitioner
pursued this treatment largely because it was less expensive that the subperiosteal implant for which the Plan administrator had refused coverage. Dr. Clark later installed these implants, but they were unsuccessful due to the lack of bone. They were removed in November, 1988. At this point, the subperiosteal implant remained the only available treatment for Petitioner.
On February 2, 1989, Dr. Thomas Priest, a
physician licensed to practice in the State of Florida, examined Petitioner and found that his gums were severely receded, his alveolar ridge was absent, and his lower teeth were in poor shape. Considering the complaints of Petitioner concerning digestive disorders and weight loss, Dr. Priest determined that Petitioner would be a good candidate for, and might benefit from, the maxillary subperiosteal implant. Dr. Priest reached this conclusion based in part on the experience of other patients who had undergone similar procedures.
Dr. Clark and the Plan administrator exchanged correspondence through the first half of 1989, at which time the administrator, in response to a threat of litigation, stated that
"the preparation of the mouth for dentures is considered to be a dental procedure and non-covered." She then referred Dr. Clark
to Respondent.
The loss of bone was probably caused by Petitioner wearing loose upper dentures for an extended period of time. However, severe periodontal disease, which cannot be ruled out as a possible cause, could also result in the loss of bone.
Another potential cause of the loss of bone is
trauma from accidental injuries, such as those typically suffered in an automobile accident. However, this potential cause can be ruled out in Petitioner's case. No accident has necessitated the subject implant procedure, nor has any accident preceded the proposed procedure by 120 days.
The Plan contains three coverage sections. Section II describes "Covered Hospital and Other Facility Services." Section III describes "Covered Medical--Surgical Benefits." Section IV describes "Other Covered Services."
Section II deals with hospitals primarily and is not applicable to the present case.
Subsections III.A. and D. provide coverage for "medically necessary inpatient/outpatient services provided to an insured by a . . . physician for the treatment of the insured as a result of a covered accident or illness."
Section IV provides coverage for "medically
necessary services when ordered by a physician for the treatment of an insured as a result of a covered accident or illness,"
including, at Subsection IV.D., "other medical supplies and prostheses . . . determined by the Administrator to be medically
necessary for the treatment of an insured's condition."
The phrase, "covered accident or illness," which
is not defined in the Plan, apparently refers to accidents or illnesses that are not elsewhere excluded, such as in Section VII on Exclusions and Section VIII on Limitations.
Section VII.A. excludes "services for cosmetic surgery or treatment unless the result of a covered accident as provided in Subsection VIII.A."
However, Subsection VII.A. adds that cosmetic surgery is covered if it is:
a medically necessary procedure in the correction of an abnormal bodily function; [or)
for reconstruction to an area of the body which has been altered by the treatment of a disease, provided such alteration occurred while the insured was covered under the Plan.
Subsection VII.G excludes:
Services and supplies in connection with dental work, dental treatment, or dental examinations unless the result of a covered accident as provided in Subsection VIII.B., except that in no case shall orthodontia be covered.
Subsection VIII.A. provides the following limitation upon coverage:
Cosmetic surgery or treatment necessary for the repair or alleviation of damage to an insured covered by the Plan if such surgery or treatment is the result of an accident sustained while the insured is covered under the Plan and actually performed while the Plan is in force . .
Subsection VIII.B. provides the following limitation upon coverage:
Any dental work, dental treatment or dental examinations medically necessary for the repair or alleviation of damage to an insured is covered by the Plan only if such work, treatment or examination is (1) the result of an accident sustained while the insured is covered under this Plan and (2) rendered within . . . 120 days of the accident. .
Subsection I.AX. defines a physician to include:
a licensed dentist who performs specific surgical or non-dental procedures covered by the Plan, or who renders services due to injuries resulting from accidents, provided such procedures or services are within the scope of the dentist's professional license.
Subsection I.AM(b). defines "medically necessary" to mean that: in the opinion of the Administrator the
service received is required to identify or treat the illness or injury which a physician has diagnosed or reasonably suspects. The service must (1) be consistent with the diagnosis and treatment of the patient's condition (2) be in accordance with standards of good medical practice, and (3) be required for reasons other than convenience of the patient or his/her physician. The fact that a service is prescribed by a physician does not necessarily mean that such service is medically necessary.
Subsection I.AE. defines "illness" as:
physical sickness or disease, . . . bodily injury, [or] congenital anomaly . .
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and the subject matter. Section 120.57(1), Florida Statutes.
Respondent is responsible for the determination of benefits under the Plan. Section 110.123(5), Florida Statutes.
The three main prerequisites for coverage under Sections III and IV of the Plan are that the services of a "physician" are "medically necessary" for the treatment of a "covered accident or illness." A dentist may qualify as a "physician," as long as the condition is otherwise covered. Because no accident is involved in this case, the coverage question may be reduced to whether the proposed implant procedure is "medically necessary" for the treatment of a "covered illness."
The necessity is not in doubt. The proposed procedure is the last option available to Petitioner; less expensive treatments have already been tried without success. The procedure is obviously consistent with the diagnosis and treatment of Petitioner's condition and is required for reasons other than the convenience of Dr. Clark. The procedure is also in accordance with standards of good medical practice. Dr.
Priest, who is a physician, so testified. Given the fact that a
dentist may provide covered services under certain conditions, the relevant standards in such a case would be dental standards. The conditions for medical necessity have therefore been satisfied.
The Plan defines an "illness" as a "physical sickness or disease." Words in an insurance policy should be given their natural meaning. See, e.g., Celtic Life Insurance
Company v. Fox, 544 So.2d 245, 248 (Fla. 2d DCA 1989). "Disease" means "an abnormal condition of an organism or a part,
especially as a consequence of infection, inherent weakness, or environmental stress, that impairs normal physiological functioning." The American Heritage Dictionary of the English Language. The most likely source of Petitioner's condition is the environmental stress caused by loose-fitting dentures. He therefore has satisfied the requirement of an "illness."
To determine whether the illness is covered requires consideration of the dental exclusion and dental limitation. The dental exclusion removes from coverage all nonaccident-related, "physician-supplied "dental work [or] dental treatment." The dental limitation reinforces this exclusion.
The Plan does not define "dental work or dental treatment." "Dental" means "of, pertaining to, or for the teeth." See, e.g., The American Heritage Dictionary of the English Language.
In Blue Shield of Florida, Inc. v. Woodlief, 359 So.2d 883, 885 (Fla. 1st DCA 1978), the court, noting the well- established principle that ambiguities in a policy are
interpreted in favor of the insured, stated that an exclusion for "dental services," which was undefined, means "health care services performed directly on teeth." In that case, the court
held that coverage existed for, among other services performed by a dentist, removal of palatal tissue necessitated by ill-fitting
dentures, relining of a denture, and removal or treatment of diseased bone, but not for a tooth extraction.
In Celtic Life Insurance v. Fox, 544 So.2d 245
(Fla. 1989), the court interpreted a "dental care" exclusion in a health policy in connection with services to correct a temporomandibular joint syndrome (TMJ). The exclusion covered teeth and "any surrounding tissues." Finding "surrounding" susceptible to more than one meaning, the court construed the word in the manner most favorable to the insured and approved the trial court's characterization of TMJ as "an upper jawbone problem far removed from the teeth."
The Celtic Life court distinguished Pilot Life Insurance Company v. Rycek, 498 So.2d 458 (Fla. 3d DCA 1986).
In Pilot Life, the insured suffered from a nondental condition
that led to dental problems, including common tooth decay. Finding that the dental work did not treat the underlying
problem, the court held that the coverage was excluded by the "dental care" exclusion. The Celtic Life court noted that the
insured in Pilot Life sought coverage for treatment of tooth decay that failed to address the underlying medical condition.
Under the above-discussed authority, the dental exclusion and limitation would not preclude coverage in this case. These cases construe strictly dental exclusions and limit them to the teeth. Surrounding tissue and bone do not fall
within the exclusion. The Blue Shield decision expressly provided coverage for relining dentures. The exclusion of the
removal of natural teeth in Blue Shield and treatment of tooth decay in Pilot Life are weak authority for denying coverage for the proposed treatment to Petitioner's jawbone.
A second basis for coverage exists in the cosmetic surgery exclusion. "Cosmetic" surgery is to "correct physical defects." The American Heritage Dictionary of the English Language. The exclusion for cosmetic surgery provides coverage if the surgery is medically necessary to correct an abnormal bodily function or reconstructs an area of the body altered by the treatment of a disease, provided the alteration occurred while the insured was covered by the Plan.
There is no evidence that Petitioner's bone loss occurred while he was covered by the Plan.
However, Petitioner's condition qualifies as an abnormal bodily function. It is unnecessary to consider whether the loss of natural teeth itself satisfies this criterion. In this case, the abnormal bodily function involves more than the loss of natural teeth or even receding gums; it involves the loss of the alveolar ridge.
For the reasons set forth above, the procedure is "medically necessary." The definition of "medically necessary" refers only to "illness," not "covered illness," so the dental exclusion from coverage, although inapplicable in any event, would be completely inapplicable.
The coverage for cosmetic surgery requires consideration of Subsection VIII.A., which limits the coverage
for "cosmetic surgery" to "surgery" that "is the result of an accident sustained while the insured is covered under the Plan
The coverage provided by the cosmetic surgery exclusion and the cosmetic surgery limitation are in conflict. The limitation would appear to limit coverage to surgery necessitated by an accident. The coverage provided by the exclusion is broader, extending to congenital defects and treatment of disease, for example. Under the above-discussed authority, this conflict is resolved against the insurer. The proposed procedure is also covered as medically necessary to correct an abnormal bodily function.
RECOMMENDED that the Administration Commission enter a Final Order determining that the proposed procedure, under the facts of this case, is covered by the Plan.
ROBERT E. MEALE
Augustus D. Aikens, Jr. General Counsel
William F. Lennan 740 Hunan St., N.E. Palm Bay, FL 32907
