STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

CHARLES R. COUGHLIN, )

)

Petitioner, )

)

vs. ) CASE NO. 88-1450

) DEPARTMENT OF ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, a formal hearing was conducted in this case on September 1, 1988, at Fort Myers, Florida, before Veronica E. Donnelly, a duly designated Hearing Officer of the Division of Administrative Hearings.

Appearances for the parties at the hearing were as follows:

APPEARANCES

For Petitioner: Charles R. Coughlin, pro se

Box 1967

Fort Myers, Florida 32816

For Respondent: Larry D. Scott, Esquire

Assistant General Counsel Department of Administration

435 Carlton Building Tallahassee, Florida 32399-1550

The Petitioner requested an administrative hearing to determine whether the Respondent, under the State of Florida Employees Group Health Self Insurance Plan, properly refused to pay a claim submitted for payment when the claim was not filed within the sixteen-month time limit set forth in the contract of insurance.

During the hearing, the Petitioner testified in his own behalf. The Respondent submitted a composite exhibit consisting of the benefit denial form, correspondence between the parties prior to the filing of the petition, and the benefit document which is the contract of insurance between the parties. The exhibit was admitted into evidence without objection. No witnesses were called by the Respondent.

A transcript of the hearing was not ordered. The parties waived both the thirty-day time requirement for the filing of the Recommended Order and the opportunity to file proposed findings of fact.

FINDINGS OF FACT

1. In December of 1985, the Petitioner and his dependents were covered by the State Employees Group Health Self Insurance Plan.

2. Robert S. Coughlin, the Petitioner's nineteen-year-old dependent, was hospitalized in an out-of-state hospital from December 24, 1985, to December 26, 1985. The total expense for the hospitalization was $935.00.

   
   

3. A claim for insurance benefits to cover the expense was received by the Insurance Plan administrator on August 10, 1987. The claim was filed by the hospital on behalf of the insured dependent, Robert S. Coughlin.

   
   

4. The administrator for the Respondent refused to pay the claim as it was not submitted within the sixteen-month period set forth in the contract of insurance. The contract, which is referred to as the benefit document, contains a policy exclusion which provides that no payment shall be made under the Plan for claims made after the expiration of the sixteen-month time limit which begins to run from the date medical expenses are incurred.

   
   

5. The hospital did not timely file the claim because a mix-up had occurred during the hospital admission concerning the patient's insurance coverage. The dependent, Robert S. Coughlin, was unconscious during his emergency out-of-state hospital admission. Either the hospital personnel or the dependent's friends mistakenly used the information on another insurance card located in the patient's wallet as the applicable insurance. As the hospital directly filed the claim with the first insurance company, processing delays within the first company caused the hospital to miss the filing deadline for the actual insurance benefits. The Petitioner, Charles R. Coughlin, was not made aware of the situation until after the sixteen-month dime period had expired, and the claim for payment had been refused by the Respondent.

   
   

   CONCLUSIONS OF LAW

   
   

6. The Division of Administrative Hearings has jurisdiction over the subject matter of and the parties to this proceeding. Sec. 120.57(1), Fla. Stat., and State of Florida Employees Group Health Self Insurance Plan, Benefit Document, XVII "Review of Claims" [1985].

   
   

7. The State of Florida Employees Group Health Self Insurance Plan, Benefit Document, VII "Exclusions" [1985] provides:

   
   

   No payment shall be made under the Plan for the following:

   . . .

   V. No payment shall be made under the Plan for any claim which has been submitted for payment to the Administrator more than sixteen (16) months after the date services or supplies were received.

   
   

8. The insurance contract determines conditions and limits coverage unless its provisions are contrary to law. Travelers Indem. Co. v. Gorman, 404 So.2d 1147 (Fla. 5th DCA 1981). In order to decide whether the Petitioner has coverage benefits beyond those set forth in the benefit document, it is necessary to review the applicable statutes which regulate group health insurance contracts made in Florida.

9. Section 627.657(2), Florida Statutes, which specifically relates to group health insurance policies, provides in pertinent part:

   
   

   Unless otherwise stated in this part, the provisions of part VI of this chapter do not apply to group health insurance policies, but no such policy shall contain any provision relative to notice or proof of loss, to the time for paying benefits . . . which provision is less favorable to the individuals insured than would be permitted by the comparable provision required for individual health insurance policies.

   
   

10. This statute means that individuals who are covered by insurance under a group policy are entitled to the same protections as to notice of loss, proof of loss and the time of paying benefits as those which are given to individuals who have individual health insurance policies.

    
    

11. Section 627.610(1), Florida Statutes, which was referred to in the proceeding statute, requires an insured under an individual health insurance policy to provide the insurer with a written notice of claim within twenty days after a covered loss starts or as soon as reasonably possible.

    
    

12. Section 627.612, Florida Statutes, which was also referred to in Section 627.657(2), Florida Statutes, provides in pertinent part:

    
    

    . . . written proof must be given within 90 days after such loss. If it was not reasonably possible to give written proof in the time required, the insurer shall not reduce or deny the claim for this reason if the proof is filed as soon as reasonably possible. In any event, the proof required must be given no later than 1 year from the time specified unless the claimant was legally incapacitated.

    
    

13. In a comparison of the contract of insurance and the applicable statutes, it appears that the benefit document in this case allows an additional month for the presentation of claims beyond the time limits established by statute for even the most extraordinary cases. The statutes allow additional time limits beyond one year only when the claimant was legally incapacitated, and therefore unable to timely file a written claim. Because the nineteen-year- old dependent, Robert S. Coughlin, was not shown to be legally incapacitated during the time period for filing claims provided within the benefit document, the sixteen-month time period is the largest time deadline which can be granted by law or contract to the situation in which the Petitioner and his dependent have been placed. Accordingly, the Respondent properly refused to pay claim number 72221201420, which was received for payment seventeen months and seventeen days from the date medical expenses were incurred. The Respondent's decision complied with the contract of insurance and the applicable statutory law.

Based upon the foregoing, it is RECOMMENDED:

That a Final Order be entered finding that the Respondent, under the State of Florida Employees Group Health Self Insurance Plan and the statutory law regulating the group health insurance industry, properly refused to pay claim number 72221201420 when the claim was not filed within sixteen months from the date medical expenses were incurred.

DONE AND ENTERED this 18th day of October, 1988, at Tallahassee, Florida.

VERONICA E. DONNELLY, 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 18th day of October, 1988.

COPIES FURNISHED:

Charles R. Coughlin Box 1967

Fort Myers, Florida 32816

Larry D. Scott, Esquire Assistant General Counsel Department of Administration

435 Carlton Building Tallahassee, Florida 32399-1550

Adis Vila, Secretary Department of Administration

435 Carlton Building Tallahassee, Florida 32399-1550

Docket for Case No: 88-001450

Orders for Case No: 88-001450