STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

SUSAN MILLARD, )

)

Petitioner, )

)

vs. ) CASE NO. 90-3569

) DEPARTMENT OF ADMINISTRATION, ) DIVISION OF STATE EMPLOYEES' ) INSURANCE, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, the above-styled matter was heard before the Division of Administrative Hearings by its duly designated Hearing Officer, Daniel M. Kilbride, on September 20, 1990, in Orlando, Florida. The following appearances were entered:

APPEARANCES

For Petitioner: Susan Millard, pro se

2391 Montano Street

Deltona, FL 32725

For Respondent: Augustus D. Aikens, Jr, Esq.

General Counsel Department of

Administration

435 Carlton Building Tallahassee, FL 32399-1550

STATEMENT OF THE ISSUES

Whether Petitioner is entitled to change from individual to family coverage under the State of Florida Employees' Group Insurance Plan more that thirty-one calendar days after the birth of her son and outside the open enrollment period.

PRELIMINARY STATEMENT

On April 27, 1990, Carl Ogden, Director of the Division

of State Employees' Insurance, informed Petitioner that her request to add her son to her health insurance coverage was denied. Therefore, on May 11, 1990, Petitioner submitted a petition for a Formal Administrative Hearing contesting the agency's action referred to above. The agency elected to request assignment of the case to a hearing officer of the Division of Administrative Hearings, and this matter was set for hearing.

At the hearing, Petitioner testified herself and introduced three exhibits in evidence. Respondent called one witness, offered the deposition testimony of Linda Boutwell, HRS District IV Insurance Coordinator, and offered three exhibits in evidence. A transcript was not prepared. Petitioner did not submit proposed findings of fact or conclusions of law as of the date of this order. Respondent submitted its proposals on October 2, 1990. The proposals and the record have been carefully considered. Respondent's specific proposals are addressed in the Appendix attached hereto.

Based upon all of the evidence, the following findings of fact are determined:

FINDINGS OF FACT

1. Petitioner was employed by Department of Health and Rehabilitative Services (HRS) District IV in 1986. For the past

   18 months she has worked in her present position with HRS District IV in Deland, Florida. She presently resides with her husband in Deltona, Florida.

   
   

2. HRS District IV personnel office is located at 5920 Arlington Expressway in Jacksonville, Florida.

   
   

3. Linda Boutwell is employed as the Insurance Coordinator for HRS District IV.

   
   

4. Petitioner gave birth to a son on January 6, 1990.

   
   

5. On January 8, 1990, Petitioner called Linda Boutwell concerning the addition of her son to her State Health Insurance which would require a change from individual to family coverage. Mrs. Boutwell advised Petitioner that she could change from individual coverage to family coverage, but that the child would not be covered until the form was returned and approved. Boutwell indicated she would send her the necessary paperwork to add her son as a dependent. Mrs. Boutwell prepared and mailed the paperwork on January 8, 1990. It was received by Petitioner on January 10, 1990.

   
   

6. Although Petitioner received the required enrollment papers on January 10, 1990, she did not return them to her personnel office.

   
   

7. Petitioner states she did not return the papers to

   her personnel office because she understood from conversation with Linda Boutwell that her son's hospital bills would not be paid by the State Plan, since the child was not enrolled in the State Plan prior to that date. Instead, Petitioner elected to enroll in family coverage under her husband's employer's carrier.

   
   

8. On March 15, 1990, Petitioner again called Linda Boutwell to request her son to be added to her insurance. Boutwell explained that Petitioner's request could not be honored since the request was beyond 31 days of the birth of the child.

   Therefore, Petitioner had to wait until the annual open enrollment period to obtain insurance coverage for the child.

   
   

9. Petitioner's March 15, 1990 request was prompted by

   her discovery that the hospital bill related to the birth of her son was covered under the State Plan, even though she had not yet converted to the family coverage provision of the State Plan.

   
   

10. Petitioner never asked Boutwell whether her individual hospital bill was covered or not.

    
    

11. Petitioner's conclusion that her son's hospital

    birth would not be covered was based partly on the statement of a close friend who called Petitioner on January 7, 1990, to warn her to "expect problems" with her State Plan coverage.

    
    

12. Petitioner has received a copy of the Amended State of Florida Employees Group Health Self Insurance Plan,

    Benefit Document, dated July 1, 1988. However, she did not examine it during the period January-March, 1990.

    
    

13. Section II of the Employees Group Health Self Insurance Plan states in pertinent part:

    
    

    II. Covered Hospital and Other Facility Services:

    The following services shall be covered when ordered by a physician and are medically necessary for the treatment of an insured as a result of a covered accident or illness. Inpatient hospital services under Subsections A., B., and H., are in connection with the pregnancy of only the employee . . . shall also include nursery charges of the child during the hospital stay of the mother.

    
    

14. Petitioner does not offer any credible explanation why she did not convert to family coverage prior to or at the time of the birth of her son or during the 1989 open enrollment

    period which occurred during Petitioner's seventh month of pregnancy.

    
    

    CONCLUSIONS OF LAW

    
    

15. The Division of Administrative Hearings has jurisdiction over the subject matter of this proceeding, and the parties thereto, pursuant to subsection 120.57(1), Florida Statutes.

    
    

16. Section 110.123(5), Florida Statutes, gives the Secretary of Administration the responsibility for administering the State Group Insurance Program. In administering the insurance program, the Department has promulgated administrative rules.

17. The most applicable and controlling law which

    applies in this case is Rule 22K-1.203, Florida Administrative Code, which was promulgated pursuant to Chapter 120, Florida Statutes, which 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 applications 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.

    
    

18. The facts in this case reveal that Petitioner did not prudently avail herself of the safeguards provided by Rules 331(- 1.203(2) or (3), Florida Administrative Code.

    
    

19. Petitioner had until February 6, 1990 to change to family coverage. The forms to accomplish the change were received and signed by Petitioner on January 10, 1990. However, she decided not to return them because of her erroneous conclusion that the hospital bill would not be paid. Petitioner can be afforded no relief for her error. Section II of the Benefit Document clearly provides that Petitioner's hospital charges are covered, and the nursery charges of the child during the hospital stay of the mother is also covered under the State Plan. These facts would have been known to Petitioner upon reasonable inspection of the documents provided to her during open enrollment.

    
    

20. Since Petitioner seeks to change her coverage under

the State of Florida's Employees' Group Self-Health Insurance Plan, outside the open enrollment period, she has the burden of proof to show entitlement. Tropical Park, Inc. v. Ratliff, 97 So.2d 160 (Fla. 1957). Please also see Fla. Department of Health and Rehabilitative Services v. Career Service Commission, 289 So.2d 412 (Fla. 4th DCA 1974). Petitioner did not establish an entitlement to any additional coverage.

RECOMMENDATION

Based on the foregoing findings of fact and conclusions of law, it is

RECOMMENDED that the petition be DENIED.

DONE AND ENTERED this 26th day of October, 1990, in Tallahassee, Leon County, Florida.

DANIEL M. KILBRIDE

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 26th day of October, 1990.

APPENDIX

The following constitutes my specific rulings, in accordance with section 120.59, Florida Statutes, on findings of fact submitted by the parties.

Petitioner did not file proposed findings of fact. Respondent's proposed findings of fact.

Accepted in substance: paragraphs 1 through 11.

COPIES FURNISHED:

Susan Millard, pro se 2391 Montano Street

Deltona, FL 32725

Augustus D. Aikens, Jr., Esquire General Counsel

Department of Administration

435 Carlton Building Tallahassee, FL 32399-1550

Aletta Shutes Secretary

Department of Administration

435 Carlton Building Tallahassee, FL 32399-1550

Docket for Case No: 90-003569

Orders for Case No: 90-003569