STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

HONORABLE HARRY LEE COE, III, )

)

Petitioner, )

)

vs. ) CASE NO. 83-1980

) STATE OF FLORIDA, DEPARTMENT ) OF ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

A hearing was held in the above-captioned matter, after due notice, at Tampa, Florida, on October 20, 1983, before Thomas C. Oldham, Hearing Officer.

APPEARANCES

For Petitioner: Alex B. Vecchio, Esquire

620 East Twiggs Street Tampa, Florida 33602

For Respondent: Daniel Brown, Esquire

Department of Administration

435 Carlton Building Tallahassee, Florida 32301

ISSUE PRESENTED

Whether Petitioner is entitled to coverage under the State of Florida Group Health Self Insurance Plan for dental treatment, as set forth in the Petition.

This proceeding arose after denial of a supplemental claim by Petitioner for dental expenses under the State of Florida Group Health Self Insurance Plan.

At the hearing, Petitioner presented the testimony of one witness and testified in his own behalf. Petitioner submitted five exhibits in evidence. Respondent presented no witnesses and submitted two exhibits in evidence.

Respondent's Proposed Findings of Fact and Conclusions of Law have been fully considered and those portions thereof not adopted herein are considered to be either unnecessary, irrelevant, or unsupported in law or fact, and are specifically rejected.

FINDINGS OF FACT

1. Petitioner Judge Harry Lee Coe, III, of Tampa, Florida, was insured by the Florida Group Health Self Insurance Plan during 1981 and continues to be so insured. (Stipulation)

2. During the month of June 1981, Petitioner had an accident in his home which caused a fracture to his left upper incisor and lower incisor, teeth numbers 9 and 25, respectively. He was treated by Dr. F. A. Priede, D.D.S., in June 1981, for the damage to his teeth. The treatment consisted of crowning the two chipped teeth. The accident also damaged the lateral incisor, tooth number 10, necessitating a root canal procedure by another dentist. Petitioner filed a claim with the Administrator of the State of Florida Employee Group Health Self Insurance Plan, Blue Cross and Blue Shield of Florida, Inc., and received payment in the amount of $321.88. (Testimony of Priede, Coe, Petitioner's Exhibits 1, 3-4)

   
   

3. In February 1982, Petitioner fractured tooth number 9 to the extent that it required extraction. Dr. Priede replaced the tooth with a temporary bridge. A permanent bridge was placed in June 1982 replacing tooth number 9 and swinging to tooth number 10 which had been crowned. Although the cause of the fractured tooth number 9 was not established, Dr. Priede testified that it is common for such a weak small tooth to fracture later as a result of the initial damage and treatment to the tooth. (Testimony of Priede, Petitioner's Exhibits 1, 3)

   
   

4. The cost of the supplementary dental treatment was in the amount of

   $400 and a claim was submitted to Blue Cross and Blue Shield of Florida, Inc. for that amount. The claim was denied on the basis that the dental services did not result from accidental injury. Petitioner's counsel requested reconsideration of the denial and enclosed a letter from Dr. Priede to him, dated May 10, 1983, explaining the course of dental treatment. By letter, dated June 3, 1983, he was advised by Blue Cross and Blue Shield of Florida, Inc. that the claim was not timely under the State of Florida Employees Group Health Self Insurance Plan because dental services must be provided within 120 days of the accident unless explanation from the dentist is submitted within that period stating the extenuating circumstances requiring the treatment to be performed over a longer period of time. Petitioner then requested an administrative hearing under Chapter 120, Florida Statutes. (Testimony of Priede, Petitioner's Exhibits 1-5)

   
   

5. The contractual provisions of the State of Florida Employees Group Health Self Insurance Plan are set forth in summarized form in a booklet issued by the Department of Administration. Paragraph 23B of the booklet, effective May 1, 1978, provided as follows:

   
   

   23. LIMITATIONS

   The following limitations shall apply under the plan.

   * * *

   B. Any dental work, dental treatment or dental examinations necessary for the repair or alleviation of damage to an Insured

   caused by an Accident shall be rendered within one hundred and twenty (120) days of the accident unless a written explanation from the dentist or Physician is submitted stating the extenuating circumstances which would require treatment to be performed over a longer period of time. Such extension must be approved by the Administrator. However, in no instance shall any services be covered unless such services are rendered within one hundred and

   twenty (120) days of the termination of the Insured's coverage.

   
   

   However, this provision was subsequently changed, as set forth in the booklet, effective July 1, 1982, to require that the dentist's written explanation regarding extended treatment must also he submitted within the 120-day period. (Respondent's Exhibits 1-2)

   
   

   CONCLUSIONS OF LAW

   
   

6. The State Group Health Self Insurance Plan is administered by Petitioner pursuant to the provisions of Section 110.123, Florida Statutes.

   
   

7. Petitioner seeks payment of a dental claim submitted under the Self Insurance Plan which was denied by Blue Cross and Blue Shield of Florida, Inc., as administrator for the plan. The Petitioner contends that the denial of his claim under the plan's contractual provisions is unwarranted because the claim was based on dental treatment required as a result of the original accident that he sustained in 1981, and that the subsequent treatment was part of a continuing event precipitated by that accident. Petitioner does not claim that the fracture of his tooth in 1982 constituted a second accident for which reimbursement for dental treatment might be appropriate and payable. Respondent contends that the claim should be denied because the services were not rendered within 120 days of the accident and that no explanation of the need for extension of the time for treatment was filed within that period, and approved.

   
   

8. The 1982 contractual provision under which the claim was denied in 1983 provides that any dental treatment required as the result of an accident must be rendered within 120 days of the accident unless a written explanation from the dentist is submitted within the same period stating extenuating circumstances which would require treatment to be performed over a longer period of time. Any required extension of time for treatment must be approved by the Administrator of the plan. Inasmuch as Petitioner's subsequent treatment was not rendered within 120 days of the 1981 accident, and a dentist's explanation of the need for an extension of time for treatment was not submitted within that time period, payment of the claim is precluded under the terms of the existing contract. Although the 1978 version of the pertinent contractual provision did not specify a time period for submitting the dentist's explanation, a fair reading of the provision leads to the conclusion that extension of the 120-day treatment period could be based only on a continuing need for treatment for a specific additional length of time which was known and requested prior to the termination of the initial 120-day period.

RECOMMENDATION

That a final order be entered denying Petitioner's claim.

DONE AND ORDERED this 16th day of November, 1983, in Tallahassee, Florida.

THOMAS C. OLDHAM

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 16th day of November, 1983.

COPIES FURNISHED:

Honorable Nevin G. Smith Secretary, Department of

Administration Carlton Building

Tallahassee, Florida 32301

Alex B. Vecchio, Esquire 620 Twiggs Street

Tampa, Florida 32602

Daniel Brown, Esquire Department of Administration

435 Carlton Building Tallahassee, Florida 32301

Docket for Case No: 83-001980

Orders for Case No: 83-001980