STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

WILLIAM R. LEDDEN, )

)

Petitioner, )

)

vs. ) CASE NO. 84-0269

) DEPARTMENT OF ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice the Division of Administrative Hearings by its duly designated Hearing Officer, K. N. Ayers, held a hearing in the above-styled case on May 9, 1984, at Tampa, Florida.

APPEARANCES

For Petitioner: William Ledden, pro se

Post Office Box 1882 Seffner, Florida 33584

For Respondent: Daniel C. Brown, Esquire,

Department of Administration

435 Carlton Building Tallahassee, Florida 32301

By Petition dated October 24, 1983, William R. Ledden, Petitioner, contests the alleged underpayment in insurance premiums assessed against him for the period December, 1982 through August, 1983 in the amount of $436.14.

At the hearing Petitioner and his wife testified, Petitioner's response to Request for Admissions was accepted into evidence and one composite exhibit was submitted into evidence. The ultimate facts are not in dispute.

FINDINGS OF FACT

1. Petitioner became employed by the Department of Transportation, Bureau of Weights, on November 5, 1982. Upon being accepted for employment Petitioner completed and submitted to proper authorities the forms necessary to be covered by the State's group health insurance program and authorized the appropriate deductions from his salary to cover the premiums.

   
   

2. On several occasions, he and his wife inquired through the Department of Transportation regarding their failure to receive an insurance card. Each time they were told the insurance card would be forthcoming and only administrative delays in processing the application were causing the delay.

   
   

3. During this time no deductions were being taken from Petitioner's pay.

4. In June, 1983 Petitioner incurred two doctor bills for his wife and son (Exhibit 1) in the total amount of $50, of which he paid $10 with the remainder forwarded to Blue Cross and Blue Shield who administers the state's health insurance plan. Blue Cross and Blue Shield had no record of Petitioner's insurance and the claim was denied. Petitioner paid the additional $40 charges.

   
   

5. Although evidence was not submitted to show why Petitioner's application was not properly processed or what finally got this application back on track, the proper steps were finally taken and Petitioner was credited with having been covered with health insurance in accordance with his application from December 1982 and billed for premiums due from that date. This resulted in the assessment by the state of $436.14 for back premiums. Since he was not on the Blue Cross register in June 1983, Petitioner contests the assessment as a condition to remaining a participating member in the state health insurance program.

   
   

   CONCLUSIONS OF LAW

   
   

6. The Division of Administrative Hearings has jurisdiction over the parties to, and the subject matter of, these proceedings.

   
   

7. The sole issue for determination is the effective date of Petitioner's coverage. Rule 22K-1.17 provides:

   
   

   1. The effective date of coverage or enrollment or changes in coverage in the Plan shall always be the first day of the month subject to the following:

      1. The effective date shall be no later than the first day of the month for which a full month's premium may be deducted using single deduction(s) based on the employee's signature date on the New Enrollee or Change of Information form.

      2. The effective date shall be no earlier the first day of the month following the employee's signature date on the New Enrollee or Change of Information form.

      3. If the properly completed New Enrollee or Change of Information form is received by the

         Department of Administration any time prior to the effective date shown on the form, provided the proper premium is paid in accordance with Section 22K-1.l9 or Section 22K-1.20.

      4. If the proper full month's premium is received by the Department of Administration in the month prior to the effective date shown on the

         New Enrollee or Change of Information form, the effective date of coverage shall be the date shown

         on the form, even though the form may not be received until after such date.

      5. If the proper full month's premium is received by the Department of Administration more than one month prior to the effective date shown on the New Enrollee or Change of Information form, the effective date of coverage shall be the first

         day of the month subsequent to the date the premium was received, even though the form may not be

         received until after such date.

      6. If both the proper full month's premium and the properly completed New Enrollee or Change of Information form are received by the Department of Administration after the effective date shown on

         the form the effective date of coverage shall be the first day of the month subsequent to the date both the premium and form are received.

         
         

   2. In those cases under paragraph (1) above where one, but not both, the premium and the properly completed New Enrollee or Change of Information form have not been received by the Department of Administration prior to the effective date which was determined as described in paragraph (1) above the effective date of coverage shall be the same as that which is determined above; however, the administrator shall not be notified of the employee's coverage until

      after the receipt of both the premiums and the properly completed form.

      * * *

      (6) The effective date of coverage as provided in paragraph (1) above is contingent upon receipt of both the premium payments and the properly completed prescribed forms by the Department of Administration.

      
      

8. In overseeing the state employee's health program, the Department of Administration must follow its own rules in establishing the effective date of coverage. Gadsden State Bank v. Lewis, 348 So.2d 343 (Fla. 1st DCA 1977).

   
   

9. Rule 22K-1.17(1)(a) above quoted is the rule most in accord with Respondent's position that Petitioner owes premiums from what should have been the effective date of his coverage, December 1, 1982. However, that rule provides the effective date shall be no later than the first day of the month for which a full month's premium may be deducted using single deduction(s). Obviously a full month's premium cannot now be deducted from Petitioner's pay due in December 1982.

   
   

10. Although no evidence was presented by Respondent to show whether Petitioner's New Enrollee form was mishandled in the Department of Transportation or the Department of Administration the rules require receipt by the Department of Administration, before an enrollee's insurance can be effective. Furthermore, if neither the form nor the payment is received by the Department of Administration, Subsection (2) above quoted precludes any insurance coverage. Assuming the New Enrollee form was timely received by the Department of Administration, Subparagraph (1)(c) requires the proper premium be paid before the effective date of coverage. Specifically, that rule provides that if the form is received by the Department of Administration prior to the effective date shown on the form, the effective date shall be the date shown on the form, provided the proper premium is paid in accordance with Section 22K-

    1.19 or Section 22K-1.20. If these underlined words have any meaning it is that payment is a condition precedent to coverage under the health insurance program. Section 22K-1.19 provides for payment of premiums by payroll deduction. Section 22K-1.20 covers underpayment of premiums and was amended December 13, 1982. Prior to the amendment this rule provided:

    
    

    When it has been determined there has been none

    or some, but not all, of the required premium payment the employee or surviving spouse will be notified of such underpayment in writing.... (Emphasis supplied)

    
    

    After amendment the rule provided:

    
    

    When it has been determined that a premium has been underpaid, the Department of Administration shall notify the employee or surviving spouse of the underpayment by certified letter....

    
    

11. Considering this language with that used in Rule 22K-1.19 PAYMENT OF PREMIUMS the overall intent, that coverage starts only after premiums are paid, is reinforced. 22K-1.19(3) provides in pertinent part:

    
    

    Payroll deductions for insurance coverage should always be made in such a manner that a full month's premium has been deducted prior to the effective date of coverage shown on the employee's New Enrollee form.

    
    

12. Other provisions of Chapter 22K-1 support this interpretation. Section 22K1.16(3) involves changes in coverage and requires an employee who desires immediate coverage of a dependent expected during the month to make application in time for a complete month's premium to be deducted prior to the first day of the month during which the dependent will be acquired. Otherwise, coverage cannot be effective on the actual date the dependent is required.

    
    

13. Respondent apparently contends that while payment of the premium is a condition precedent to effective insurance coverage, the proper premium can be paid retroactively and the coverage will also become retroactive. While this interpretation of the rules is undoubtedly a valid one to shield an enrollee who did everything possible to obtain insurance coverage but, as here, was thwarted by delicts on the part of Respondent's employees, it does not follow that the same interpretation can be used as a sword to require the employee to pay for back coverage which he did not use, or the use of which was denied him the one occasion he attempted to use this coverage.

    
    

14. In interpreting rules as in interpreting statutes, the cardinal rule is to determine the intent of the lawmaker. In so doing the words used are to be given their generally accepted meaning and all parts of the rule must be read in para materia giving effect to all provisions of the rules. In applying these principles of statutory construction to the rules for the state employees health insurance program, it is clear the Petitioner cannot be required to now pay for that period from December 1, 1982, the date from which he requested coverage, but through error on the part of Respondent, he did not receive until September

1983, when proper deductions had been taken from his pay. However, in this situation the Petitioner is in the position of a new employee who does not apply for health insurance during the first thirty-one calendar days of his employment by the state. As such he is required to obtain medical approval for enrollment if he does not voluntarily repay the $436.14 premiums needed to make his coverage retroactive to December 1, 1982.

From the foregoing it is concluded that Petitioner should not be required to pay the $436.14 in back premium payments to make his health insurance coverage effective December l, 1982; but if he does not, he must medically qualify each member of his family for coverage effective with the payment of the first month's premium. It is

RECOMMENDED that Petitioner be advised he may enroll those family members in the state employees health insurance program who are medically qualified for enrollment, effective September 1, 1983 or he may enter the insurance program as a new enrollee effective December 1, 1982 by paying $436.14 in back premiums.

Entered this 23rd day of May, 1984 at Tallahassee, Florida.

K. N. AYERS, 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 23rd day of May, 1984.

COPIES FURNISHED:

William R. Ledden

406 Magnolia Avenue Seffner, Florida 33584

Daniel C. Brown, Esquire General Counsel

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: 84-000269

Orders for Case No: 84-000269