STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
ANNEMARIE HARRIS, )
)
Petitioner, )
)
vs. )
) CASE NO. 88-5519 DEPARTMENT OF ADMINISTRATION, )
DIVISION OF STATE EMPLOYEES' ) INSURANCE, )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to Notice, this cause was heard by Linda M. Rigot, the assigned Hearing Officer of the Division of Administrative Hearings, on July 28, 1989, in Miami, Florida.
APPEARANCES
For Petitioner: James N. Hurley, Esquire
William P. Harris, Jr., Esquire Mitchell, Harris, Horr & Associates 2650 Biscayne Boulevard
Miami, Florida 33137-4590
For Respondent: William A. Frieder, Esquire
Department of Administration Office of the General Counsel
440 Carlton Building Tallahassee, Florida 32399-1550
STATEMENT OF THE ISSUES
Whether the State of Florida through its Employees Group Health Self Insurance Plan is responsible for paying medical expenses incurred by Petitioner's newborn child where Petitioner had only individual coverage in effect at the time of that child's birth?
PRELIMINARY STATEMENT
Petitioner submitted to Respondent claims for payment of medical expenses incurred by her newborn child, and Respondent rejected those claims for the reason that Petitioner's child was not an insured under the State of Florida Employees Group Health Self Insurance Plan. Petitioner requested a formal hearing on the question of whether those claims for payment of medical expenses were properly rejected.
Petitioner testified on her own behalf and presented the testimony of Faith Quincoses, Anita Farmer, and William R. Seaton. William R. Seaton also
testified on behalf of the Respondent. Additionally, Respondent's Exhibits numbered 1-8 were admitted in evidence.
Both parties submitted post-hearing proposed findings of fact. Specific rulings on each proposed finding of fact can be found in the Appendix to this Recommended Order.
FINDINGS OF FACT
The State of Florida makes available to its employees several group insurance programs. In the area of health insurance, employees may choose to participate in the State of Florida Employees Group Health Self Insurance Plan, or they may enroll in a number of different HMOs depending upon the county in which each employee resides.
The State of Florida Employees Group Health Self Insurance Plan (hereinafter "the Plan") is a plan of self insurance established by the State, specifically described in a Benefit Document, and administered by Blue Cross/Blue Shield. In addition to the provisions of the Plan embodied in the Benefit Document, the self insurance plan is regulated by those rules contained in Chapter 22K, Florida Administrative Code. If an employee voluntarily chooses to participate in the Plan, the State as the employer contributes to the employee's costs by paying a portion of the premium for each employee.
HMOs wishing to capture a portion of the State employee insurance market may participate in bidding procedures whereby the winner(s) can offer insurance to State employees in particular geographical locations. Winning HMOs must comply with many of the rules and provisions involved in the Plan but are still able to establish additional benefits and requirements for coverage. If an employee voluntarily chooses to participate in an HMO insurance program, the State will assist with the employee's costs by contributing to that employee's insurance premium expense.
At the time that they commence employment with the State, employees may elect to participate in the Plan, in one of the HMOs approved for that particular geographical location, or may choose to not participate in any of the voluntary insurance programs offered through the State. Thereafter, employees may only join one of the insurance programs or switch between programs during an annual open enrollment period.
An employee may purchase individual coverage, insuring only himself or herself, or an employee may purchase family coverage, insuring that employee and one or more of his or her eligible dependents. During an open enrollment period, an employee may switch between individual coverage and family coverage for the following year.
Under the State Plan, there is an exception to the restriction that employees may only change coverage and health plans during the open enrollment period. An employee having individual coverage may change to family coverage within 31 days after the date of acquisition of any eligible dependent. In that event, coverage for the eligible dependent does not relate back to the date of acquisition but rather will commence on some future date following the payment of the additional premium required for the additional family coverage. Similarly, an employee with only individual coverage may begin family coverage prior to acquiring eligible dependents and may obtain coverage for those dependents effective on the actual date the dependent is acquired by making application in time for a complete month's premium to be deducted prior to the
first day of the month during which the dependent(s) will be acquired. In other words, payment must be made prior to the acquisition of an eligible dependent and the change to family coverage with its increased premium must be made prior to the acquisition of the dependent in order that coverage can be effective as of the date of acquisition.
During open enrollment periods, all employees (even those not currently participating in any of the insurance programs offered by the State) are given summary information regarding the various programs in which they are being given an opportunity to participate. Brochures giving summarized comparisons of the Plan and the relevant HMOs are provided to all employees. Employees are advised, if they have questions regarding the Plan, to contact their personnel officer or the Division of State Employees' Insurance. After the employee makes a selection as to which health plan he or she wishes to participate in, if any, the employee will subsequently receive more detailed information about that plan. For example, an employee choosing to participate in the Plan will subsequently receive a copy of the State of Florida Employees Group Health Self Insurance Plan Brochure. The first page of that Brochure specifically advises the employee that the brochure does not include all of the provisions, definitions, benefits, exclusions, and limitations of the Plan. The Brochure specifically advises the employee that it is a summary of the benefits and that any questions the employee might have should be presented to the employee's agency personnel offices or the Office of State Employees' Insurance, and provides that latter office's address and telephone numbers. The Plan itself is a lengthy document which is not distributed to each individual employee but rather is made available to each agency's personnel office for reference by any interested employee.
Under the Plan, a woman with individual coverage is entitled to maternity or pregnancy benefits. As part of those benefits, charges for "well baby care," i.e., the charges for the nursery for the baby, are covered under the Plan as part of the maternity benefit of the mother. In well-baby care, charges are not incurred by the baby as a separate patient. On the other hand, if a baby is ill and is admitted to the hospital as a patient in its own right, well-baby care coverage does not apply, and family coverage must be in effect or the infant will be an uninsured individual under the State Plan.
The Dade County Public Defender's Office has approximately 265 employees. Faith Quincoses, an Administrative Assistant in that office, began her employment there in 1981 when the office had approximately 165 employees.
As the number of office personnel increased, it was determined that someone within that Office should be responsible for employee benefits. That assignment was given to Quincoses, who at the time had duties related to payroll.
Quincoses had no training in employee benefits, particularly employee insurance benefits, prior to her assuming responsibility for those duties at the Dade County Public Defender's Office. After she assumed those duties, the Public Defender's Office provided her with no training, and that office did not send her to any of the training sessions regularly conducted by Respondent for employees with and without personnel duties, including those seminars related to employee insurance benefits. When Quincoses would receive informational brochures and memoranda from Respondent regarding employee insurance benefits, she would read them but intentionally did not study them. She did not believe it was her responsibility to assist employees in selecting a particular insurance plan, or in advising employees as to which plan best met that employee's needs, or in answering any specific questions regarding coverage that any employee may have other than routine questions.
Although many, if not most, of the informational brochures received from time to time by Quincoses advised employees (including Quincoses) to contact the Division of State Employees' Insurance with any questions regarding benefits and coverage, Quincoses did not contact that office when she had questions about the several insurance plans offered by the State to its employees. She very seldom contacted the Division of State Employees' Insurance to ask questions; rather, she discussed insurance benefits and coverage questions on an almost daily basis with a payroll clerk who worked for the Justice Administrative Commission, an agency belonging to the judicial branch of government with no responsibility or authority for administering the various insurance programs for state employees.
Although Quincoses knew that she did not posses a copy of the State of Florida Employees Group Health Self Insurance Plan and had never read a copy, she made no effort to obtain a copy other than to once request a copy from the payroll clerk she daily contacted at the Justice Administrative Commission.
When told by that payroll person that she did not have a copy of the Plan, Quincoses made no further efforts to obtain a copy and never requested a copy from the Division of State Employees' Insurance.
Quincoses knew she was not an insurance expert and did not feel the need to become one. She believed that her responsibilities regarding the various insurance programs made available to employees by the State of Florida was to simply disseminate information provided to her, fill out the appropriate forms for payroll deductions, answer routine questions, and refer specific questions to the Division of State Employees' Insurance. She rightfully believed that each employee's decision as to which of the individual plans that employee should select was the employee's responsibility.
Petitioner Annemarie Harris is an attorney employed as an Assistant Public Defender by the Dade County Public Defender's Office since October, 1983. As a new employee, she chose to enroll in one of the group health insurance programs approved by the State. She chose to join an approved HMO plan rather than enroll in the State of Florida Employees Group Health Self Insurance Plan. Thereafter, and up through December of 1987, each year during the open enrollment period, Petitioner chose to participate in one of the approved HMOs rather than the State's Self Insurance Plan.
In December of 1987, the contract between the HMO of which Petitioner was a member and the State of Florida was being terminated, and Petitioner therefore had the option of selecting to participate in one of the other group health insurance programs offered through the State of Florida.
In December of 1987, Petitioner was three months pregnant. Her baby was due to be born approximately June 20, 1988. Petitioner was, therefore, very interested in the most extensive coverage which she could obtain for her maternity benefits.
Petitioner advised Quincoses that her expected delivery date was June 20, 1988, and that she wished her newborn to be covered by the insurance policy to be selected by Petitioner. Quincoses advised Petitioner that the baby's expenses would be covered if Petitioner added the newborn baby to Petitioner's coverage within 31 days after the date the baby was born. Quincoses did not advise Petitioner that waiting until after the baby's birth would mean that the baby would not be an individual insured until after Petitioner had paid the premium in time for the baby to be added as an insured by the first day of a
month subsequent to the baby's birth, since Quincoses did not understand that distinction.
The information Quincoses gave Petitioner was wrong and is not contained in any of the written materials describing the Plan which had been transmitted by the State to Quincoses or Petitioner, and is contrary to the information contained in Chapter 22K, Florida Administrative Code.
Petitioner then conducted her own investigation of which health plan she wished to choose by asking her friends that worked in the Public Defender's Office about their personal experiences. Further, as Petitioner testified at the final hearing in this cause, Petitioner's husband strongly insisted that she choose the State's Self Insurance Plan in which Plan he had previously participated as a State employee and with which he therefore had some familiarity. Petitioner did not contact the Division of State Employees' Insurance regarding her specific questions and specific situation, did not consult the Benefit Document itself and did not--although both she and her husband are attorneys--consult the rules and regulations regarding coverage contained within Chapter 22K, Florida Administrative Code.
Petitioner voluntarily selected the State's Self Insurance Plan and purchased only individual coverage, insuring herself at a lower premium than family coverage which would have covered the newborn infant as of the date of the baby's birth.
It is unknown whether Petitioner relied solely on the advice of Quincoses in choosing to purchase individual coverage rather than family coverage, whether Petitioner relied instead on the advice she obtained from questioning her friends or whether she relied upon her husband's desires, in choosing to participate in the State Plan or in choosing to purchase only individual coverage.
Although the basis for Petitioner's decision is unknown, her intentions at the time are clear. She planned to, and took steps to, initiate the paperwork necessary to switch to family coverage and pay the additional premium required early enough so that insurance for the baby would be in place on June 1, 1988, prior to the baby's expected arrival date. During April of 1988, Petitioner caused Quincoses to begin filling out the appropriate forms so that Petitioner would have family coverage in place as of June 1, 1988. Since Quincoses had earlier advised Petitioner that Petitioner could switch to family coverage after the baby's birth (which would make the baby's coverage effective subsequent to the baby's birth) but Petitioner chose instead to attempt to convert to family coverage prior to the baby's birth (which was contrary to Quincoses' advice and would have established coverage immediately upon the baby's birth), it can be reasonably inferred that Petitioner understood that the difference between converting to family coverage prior to the baby's birth rather than subsequent to the baby's birth involved the sole issue of the date on which the baby's coverage would become effective.
Although Quincoses initiated the paperwork to have family coverage in place for Petitioner prior to the baby's birth expected to occur on June 20, 1988, Petitioner experienced complications with her pregnancy causing the baby to be delivered prematurely on April 24, 1988, prior to Petitioner signing and processing the paperwork started by Quincoses.
Almost immediately after the baby's birth, the baby was transferred from the hospital in which her mother was a patient to another hospital where
the baby was admitted as a separate patient. The baby remained in that hospital for some time, incurring medical expenses of approximately $180,000.00.
Petitioner's medical expenses were paid by the Plan pursuant to her individual coverage. The baby's medical expenses were submitted to the Plan. Petitioner's claim for payment of the baby's medical expenses was denied for the reason that the baby was admitted to a different hospital than the mother as a separate patient but was not an insured under any insurance policy as of the date of the baby's birth, the date on which the baby commenced incurring her own personal medical expenses. When Petitioner converted her individual coverage to family coverage subsequent to the baby's birth, her claims for payment of the baby's medical expenses incurred subsequent to the date upon which the baby became an insured under the State Plan were denied since they arose from a condition pre-existing the date of commencement of insurance coverage.
On April 24, 1988, Petitioner's newborn child was not an insured under the State Plan since Petitioner only had individual coverage on that date.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter hereof and the parties hereto. Section 120.57(1), Florida Statutes.
Rule 22K-1.203, Florida Administrative Code, provides, in pertinent part, as follows:
(2) An employee, retiree or surviving spouse having individual coverage may apply for a change to family coverage within thirty-one
(31) calendar days after the date of acquisition of any eligible dependent or during the open enrollment period. ...
(3) An employee or retiree may begin family coverage prior to acquiring any eligible dependents. Since such coverage is
effective the first day of any given month, employees who will acquire eligible dependents during the month and are desirous of having immediate coverage of such dependents must 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 acquired.
On the date of Petitioner's child's premature birth, Petitioner had in place only individual coverage. Therefore, she was entitled to receive payment for maternity benefits pursuant to the terms of her contract under the State of Florida Employees' Group Health Self Insurance Plan. Although that Plan also provides for payment of nursery expenses for the newborn infant, known as well- baby care, attendant to its mother's hospital admission as a patient, Petitioner's baby did not receive well- baby care. Rather, the baby was admitted to a different hospital as a patient in its own right, and at the time of that admission the baby was not an insured under the State Plan. Since no insurance coverage was in effect on the date that the baby was born and admitted
to a hospital other than the hospital in which the baby's mother was a patient, Petitioner is not entitled to have her child's medical expenses paid by the State of Florida Employees' Group Health Self Insurance Plan.
Although Petitioner argues that other employees have been treated differently in the past, no evidence was offered to support that argument. Similarly, Petitioner argues that the State has changed its training procedures for personnel employees since this dispute arose with Petitioner, yet Petitioner offered no evidence to support that argument. The evidence in this record does reflect, on the other hand, that the Public Defender's Office has changed its procedures by participating in the training sessions which have been historically offered for employees by the State.
Petitioner also argues that the State should be estopped from denying coverage for her child since she relied on the advice given to her by Quincoses, that advice was wrong, and her baby's medical expenses were significant. Therefore, reasons Petitioner, since Quincoses works for a State agency, the State is bound by the wrong information given by Quincoses and must afford retroactive coverage to Petitioner's child. In this instance, Petitioner had a choice of several health plans. She asked Quincoses about coverage under the State Plan, and Quincoses gave her incorrect information. Petitioner did not respond to the written instructions that specific questions should be referred to the Division of State Employees' Insurance. Petitioner made her own decision about which plan she wished to participate in and whether she wished to buy individual coverage or family coverage. Although Petitioner alleges that she relied on Quincoses' advice, the record is clear that she also relied on other people's advice. Petitioner's own conduct belies her allegation that she was acting solely on Quincoses' advice since Quincoses had spoken to Petitioner about changing to family coverage after the birth of the baby, and the record is clear that Petitioner initiated conversion to family coverage with an effective date prior to the birth of the baby. Petitioner's attempt to invoke the doctrine of estoppel is without legal, factual, or equitable basis; rather, Petitioner voluntarily selected one type of coverage while circumstances reveal in retrospect that she needed a different kind of coverage.
Based upon the foregoing Findings of Fact and Conclusions of Law, it is,
RECOMMENDED that a Final Order be entered denying Petitioner's claims for payment of medical expenses incurred by Petitioner's newborn baby which are the subject of this proceeding.
DONE AND ENTERED in Tallahassee, Leon County, Florida, this 27th day of October, 1989.
LINDA M. RIGOT
Hearing Officer
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 27th day of October, 1989.
APPENDIX TO RECOMMENDED ORDER, CASE NO 88-5519
Petitioner's proposed Findings of Fact numbered 1-4, 7-9, 15-18, 34, 35, 37, 38, and 40-42 have been adopted either verbatim or in substance in this Recommended Order.
Petitioner's proposed Findings of Fact numbered 5, 6, 10-12, 21, and 33 have been rejected as not being supported by the weight of the credible evidence in this cause.
Petitioner's proposed Findings of Fact numbered 13, 14, 39, 44, and 45 have been rejected as being subordinate to the issues for determination herein.
Petitioner's proposed Findings of Fact numbered 19 and 22-25 have been rejected as not constituting findings of fact but rather as constituting recitation of the testimony, argument of counsel, or conclusions of law.
Petitioner's proposed Findings of Fact numbered 20, 26-31, and 43 have been rejected as being irrelevant to the issues under consideration herein.
Petitioner's proposed Finding of Fact numbered 32 has been rejected as being contrary to the weight of the totality of the evidence in this cause.
Petitioner's proposed Finding of Fact numbered 36 has been rejected as being unnecessary for determination of the issues involved herein.
Respondent's proposed Findings of Fact numbered 1-5, 7-18, the second 19-24, the first 27, the second 26, the second 27, and 28 have been adopted either verbatim or in substance in this Recommended Order.
Respondent's proposed Findings of Fact numbered 6, the first 19, 25, and the first 26 have been rejected as being subordinate to the issues required to be determined in this proceeding.
COPIES FURNISHED:
James N. Hurley, Esquire William P. Harris, Jr., Esquire
Mitchell, Harris, Horr & Associates 2650 Biscayne Boulevard
Miami, Florida 33137-4590
William A. Frieder, Esquire Department of Administration Office of the General Counsel
440 Carlton Building Tallahassee, Florida 32399-1550
A. J. McMullian, III Interim Secretary
Department of Administration
435 Carlton Building Tallahassee, Florida 32399-1550
Augustus D. Aikens, Jr. General Counsel
Department of Administration
435 Carlton Building Tallahassee, Florida 32399-1550
=================================================================
AGENCY FINAL ORDER
=================================================================
STATE OF FLORIDA DEPARTMENT OF ADMINISTRATION
ANNEMARIE HARRIS,
Petitioner,
v. CASE NO. 88-5519
STATE OF FLORIDA,
DEPARTMENT OF ADMINISTRATION,
DIVISION OF STATE EMPLOYEES' INSURANCE,
Respondent.
/
FINAL ORDER
THIS CAUSE is before me for the entry of a Final Order. Annemarie Harris, an employee of the Dade County Public Defender's Office, appealed the decision of the Division of State Employees' Insurance (DSEI) to deny health insurance coverage under the State Plan for her newborn child. A hearing was held before the Division of Administrative Hearings and a Recommended Order was rendered October 27, 1989. A copy of that Recommended Order is attached as Exhibit "A" and is made a part of this Order as if fully set out here.
I have reviewed the transcript of the proceedings before the Hearing Officer, the exhibits, and the record in this cause and have determined that the Findings of Fact made by the Hearing Officer are supported by the evidence.
They are, therefore, adopted as the Findings of Fact of this agency.
Petitioner has filed exceptions to the Findings of Fact numbered 6, 7, 8, 10, 11, 18, 21, 22, and 26 as being "Contrary to the weight of the evidence." The weight to be given to the evidence adduced at a Section 120.57(1), F.S., hearing is well within the discretion of the Hearing Officer who heard that evidence. MacDonald v. Department of Banking and Finance, 346 So.2d 569 (1 DCA Fla. 1977). This exception is, therefore, rejected.
Petitioner next excepts to the conclusion drawn by the Hearing Officer that Petitioner also relied upon advice other than that provided by her employer's personnel officer in determining whether to purchase individual or family coverage. With regard to that choice, Paragraph 21 of the Recommended Order recites:
21. It is unknown whether Petitioner relied solely on the advice of Quincoses in choosing to purchase individual coverage rather than family coverage, whether Petitioner relied instead on the advice she obtained from questioning her friends or whether she relied upon her husband's desires in choosing to participate in the state plan or in choosing to purchase only individual coverage. (Recommended Order page 10).
The Hearing Officer did not draw the conclusion of which Petitioner complains. Insofar as the exception deals with this point it is rejected as not supported by the record. The balance of Petitioner's exceptions in paragraph two of her pleading constitute argument and are therefore rejected.
In exception number 3 Petitioner objects to the Hearing Officer's failure to adopt Petitioner's proposed conclusions "in toto" (sic). Failure to incorporate Petitioner's proposed Findings of Fact numbered 5, 6, 10, 14, 19,
33, 36, 39, 43, and 45 is also excepted to in paragraph 3 of Petitioner's pleading. The determination by the Hearing Officer that certain of those proposed findings were not supported by the weight of credible evidence and that others were subordinate to the issues for determination in this cause may not be disturbed by this agency in the absence of some clear error which Petitioner has not shown. The third exception is also, therefore, rejected.
The Conclusions of Law set out by the Hearing Officer in the Recommended Order are adopted by this agency as if fully set out in this order.
Based upon my review of the Recommended Order, the proceedings before the Hearing Officer below, the exhibits admitted into evidence at the final hearing in this cause, and the record in this cause, and being otherwise fully advised in the premises, it is,
ORDERED that the request of Annemarie Harris for the reimbursement of additional medical expenses incurred on behalf of her daughter as a patient in her own right be in the same is hereby denied.
DONE AND ORDERED in Tallahassee, Leon County, Florida, this 8th day of December, 1989.
ALETTA L. SHUTES
Secretary
Department of Administration
435 Carlton Building Tallahassee, Florida 32399-1550 (904) 488-4116
Filed in the official records of the Department of Administration this 8th day of December, 1989.
Deputy Clerk
COPIES FURNISHED:
James N. Hurley, Esquire William P. Harris, Jr., Esquire
Mitchell, Harris, Horr & Associates 2650 Biscayne Boulevard
Miami, Florida 33137-4590
William A. Frieder, Esquire Department of Administration Office of the General Counsel
438 Carlton Building Tallahassee, Florida 32399-1550
Linda M. Rigot, Hearing Officer Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-1550
| Issue Date | Proceedings |
|---|---|
| Jun. 24, 1992 | (joint) Motion for Order Closing File filed. |
| Oct. 27, 1989 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Dec. 08, 1989 | Agency Final Order | |
| Oct. 27, 1989 | Recommended Order | Where mother voluntarily purchased individual rather than family coverage, state insurance plan did not cover medical expense incurred by child. |
