STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

GERALD B. RICHARDSON, )

)

Petitioner, )

)

vs. ) CASE NO. 84-4202

) DEPARTMENT OF ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

This matter came on for hearing on April 25, 1985, in Orlando, Florida, before the Division of Administrative Hearings and its duly appointed Hearing Officer, R. T. Carpenter. The appearances were as follows:

For Petitioner: Gerald B. Richardson

2909-198 Semoran Boulevard

Orlando, Florida 32822

For Respondent: Richard L. Kopel, Esquire

Deputy General Counsel Department of Administration

435 Carlton Building Tallahassee, Florida 32301

This matter arose on Respondent's denial of payment for certain medical expenses which Petitioner believes should have been covered by his State of Florida Group Health Insurance Plan. Respondent submitted proposed findings of fact which have been substantially adopted and incorporated herein.

FINDINGS OF FACT

1. Petitioner is an employee of the State of Florida, and was at all times pertinent, a member of the State Group Health Insurance Program administered by Blue Cross and Blue Shield of Florida, Inc.

   
   

2. In March of 1984, Petitioner was hospitalized due to severe indigestion and abdominal pain. Petitioner was discharged from the hospital and informed by his physician that if his condition worsened, surgery would be necessary. Petitioner's condition worsened and on May 28, 1984, his physician, R. Klein Bowen, M.D., admitted him to the hospital with a pre-operative diagnosis of chronic acalculus cholecystitis which is chronic inflammation of the gallbladder. On May 29, 1984, said physician operated upon petitioner and his operative report listed the following under the title "Operation":

   
   

   1. Cholescystectomy.

   2. Attempted operative cholangiogram.

   3. Incidental appendectomy.

3. The description of the operative procedure stated in the operative report (Respondent's Exhibit 1) establishes that the appendectomy which was performed was accomplished through the same incision which was made for performing the cholescystectomy (gallbladder removal). The operative report stated that the appendix was not acutely inflamed.

   
   

4. Subsequent to the operative procedures the Petitioner filed a claim with the State Group Health Insurance Plan administrator, seeking payment for the following charges: May 28, 1984, $90.00 for consultation and case history preparation prior to surgery; May 29, 1984, $1,350.00 Cholescystectomy; May 29, 1984, $375.00 Appendectomy. All of said services were performed by R. Klein Bowen, M.D.

   
   

5. The State Group Health Self-Insurance Plan paid the charge for the cholescystectomy and denied the claims for consultation and case history preparation prior to the surgery and for the appendectomy. The State Self- Insurance Plan justified its denial of Petitioner's claim for the above benefits based upon limitations it alleged were contained in the State of Florida Employees' Group Health Self-Insurance Plan Benefit Document (Respondent's Exhibit 2).

   
   

6. Section VIII entitled "Limitations" in paragraph I. specifies that payment may be made for in-patient medical care physician visits in addition to payment for surgery only when the condition which required medical care is not related to the surgery and does not constitute a part of the pre-operative or post-operative care. Additionally, Section VIII, F. specifies that no additional payment shall be made for a surgical procedure which is an incidental procedure performed through the same incision.

   
   

7. Petitioner did not dispute the provisions which Respondent alleged were limitations justifying denial of payment, although he asserted that the provisions contained within the Group Health Self-Insurance Plan Benefit Document were not cost effective and would result in additional expenses and lost time from work and were worthy of reconsideration. However, Petitioner did not present any competent evidence to support his claim or refute the limitations relied upon by Respondent.

   
   

   CONCLUSIONS OF LAW

   
   

8. Subsection 110.123(5), Florida Statutes (1983) assigns Respondent responsibility for administration of the state group insurance program including "the benefits to be provided."

   
   

9. Respondent's Benefit Document (Respondent's Exhibit 2) provides that "payment may be made for inpatient medical care physician visits in addition to payment for surgery . . . only when the insured's condition required medical care not related to his/her surgery and does not constitute a part of such insured's pre-operative or post-operative care (Section VIII, "Limitations," paragraph I). Petitioner's expenses incurred for consultation and case history preparation prior to surgery were directly related to the surgery and thus were properly disallowed.

   
   

10. Respondent's Benefit Document (Respondent's Exhibit 2) provides ". . . that no additional payment shall be made for an incidental procedure performed through the same incision." (Section VIII, "Limitations," paragraph F). Here, the surgical procedure to remove Petitioner's appendix was incidental to the gallbladder removal and payment was necessarily denied.

11. Petitioner argues that his appendix was a continuing source of difficulty, and removal at a later date would have been necessary. However, there is no basis or authority to apply the "common sense" standard for which Petitioner seeks recognition. Rather, the provisions of the existing Benefit Plan must be followed until modified.

    
    

12. Petitioner further asserts that a similar surgical procedure was followed in the case of a co-worker, and that this employee was covered for the surgical expenses denied here. Even if Petitioner had proven this allegation there is no authority to require that Respondent repeat an earlier error.

RECOMMENDATION

Based on the foregoing, it is

RECOMMENDED that Respondent enter a Final Order denying the Petition. DONE and ENTERED this 14th day of May, 1985, in Tallahassee, Florida.

R. T. CARPENTER, 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 14th day of May, 1985.

COPIES FURNISHED:

Gerald B. Richardson

2909-198 South Semoran Boulevard Orlando, Florida 32822

Richard L. Kopel, Esquire Deputy General Counsel Department of Administration

435 Carlton Building Tallahassee, Florida 32301

Gilda Lambert, Secretary Department of Administration

435 Carlton Building Tallahassee, Florida 32301

Docket for Case No: 84-004202

Orders for Case No: 84-004202