Hudson, Senior Clerk, USF Health Sciences Center, and William R. Seaton, Benefits Administrator, Division of State Employees' Insurance, and offered three exhibits in evidence. A transcript was not prepared. Petitioner did not submit proposed findings of fact. Respondent filed its proposals on November 19, 1990. The proposals and the record have been carefully considered. Respondent's specific proposals are addressed in the Appendix attached hereto.
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, under contract, by Blue Cross/Blue Shield (BCBS). 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 22D, 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.
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, unless an exception applies.
An employee may purchase individual coverage, insuring only herself, or an employee may purchase family coverage, insuring that employee and one or more of 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.
At the time a new employee is hired and during open enrollment periods, all employees are given brochures with summary information regarding the various programs in which they are being given an opportunity to participate. 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 she wishes to participate in, if any, the employee will subsequently receive more detailed information about that plan. 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 the 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 office's address and telephone numbers. The Plan itself 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 separate patient, well baby care coverage does not apply, and family coverage must be in effect or the infant will be an uninsured individual under the Plan.
The University of South Florida (USF) central personnel office is located on its main campus. The Health Sciences Center also maintains an adjunct personnel office for the convenience of employees of the Health Sciences Center at the adjunct personnel office where employees are able to gain assistance on personnel matters and obtain insurance benefit information. However, the employees' actual personnel files are located at the main campus personnel office.
Robin Hudson is employed by the University of South Florida in the Health Sciences Center adjunct personnel office as a senior clerk. As part of her duties, Ms. Hudson counsels USF employees on their insurance benefits.
Petitioner was employed by the University of South Florida Health Sciences Center on February 19, 1988, and chose to enroll in the State Employees' Group Health Program with family coverage effective March 1, 1988.
Subsequently, Petitioner changed from family coverage to individual coverage effective July 1, 1988.
Petitioner became pregnant in November 1988, with a due date of August 18, 1989, while she maintained individual coverage with the Plan.
Sometime during November 1988, Petitioner telephoned the Health Science Center personnel office and spoke with "someone" regarding maternity coverage. Petitioner was advised that she was covered under the Plan. Also during this same time period, Petitioner referred to the Group Health Self Insurance Plan Brochure and could find no explanation of maternity or new born coverage. She did not seek additional information from the personnel office, nor did she contact the Division of State Employees' Insurance, at that time.
The first communication involving Petitioner on the correspondence log maintained by Blue Cross and Blue Shield occurred on January 21, 1989, in a letter that was written to: Santiago and Arocho, M.D., P.A., Family Practice Physicians of Tampa, 5208 D. Fowler Avenue, #1, Tampa, Florida 33617-2152. The second correspondence occurred on May 9, 1989. It as an interpretation on lab work which had been performed on Petitioner. The third correspondence occurred on the same date when Blue Cross and Blue Shield advised provider 77566 was a preferred provided under Preferred Patient Care (PPC).
On June 14, 1989, Petitioner enrolled with Tampa General Hospital. Petitioner was advised by hospital personnel that she had well and sick baby coverage at that time. This information was wrong. Sick baby coverage is not included for an employee with individual coverage.
Petitioner delivered her daughter Lia at 32 weeks gestation by Cesarean Section on June 20, 1989, at Tampa General Hospital because her pregnancy was complicated by Severe Pre-Eclampsia with HELLP Syndrome.
On the date Petitioner delivered her daughter, June 20, 1989, her husband called Blue Cross and Blue Shield of Florida inquiring if pre-admission certification was required for maternity. He was informed that it was not required for maternity.
Due to the premature delivery, the child, Lia, was admitted as a patient and remained in the hospital for two weeks in order to gain weight.
On February 17, 1989, Respondent's January 30, 1989 Insurance Memorandum 89-001 was received at USF Central Personnel Office. In Respondent's Memorandum 89-001, the Respondent reiterates the provisions of Rule 22K- 1.203(3), Florida Administrative Code, and advises personnel offices to advise "an insured pregnant employee . . . that she should change to family coverage shortly after the pregnancy is diagnosed so that insurance benefits will be available to the employee's child in the event of premature birth."
The Personnel Office at USF printed the pertinent portions of Respondent's Memorandum 89-001 and distributed to each employee by placing an individually addressed copy of the Personnel Notes in each employee's mail box. Petitioner doesn't recall receiving the March 24 - April 3, 1989, edition of the news brochure; however, Petitioner asserts that she wouldn't have read it even if it was delivered, because the pertinent information was under the heading "Change in Appointment Status." The entire subject of the article under the heading Change in Appointment Status dealt with insurance benefits offered by Respondent and included a telephone extension number for interested employees to obtain additional information.
Petitioner did not request any information of the maternity benefits offered to employees with single coverage from her personnel office or Respondent until after the birth of her daughter.
Petitioner changed from single to family coverage, effective August 1, 1989, after consulting with Robin Hudson on July 21, 1989.
The Plan has refused coverage for the hospitalization of Petitioner's child, Lia, the expenses of which totaled $9,178.95.
CONCLUSIONS OF LAW
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.
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.
Rule 22K-1.203, Florida Administrative Code, applies in this case, 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.
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., in connection with the pregnancy of only the employee . shall also include nursery charges of the child during the hospital stay of the mother.
There is no provision covering hospital expenses for the child.
Petitioner could have changed to family coverage prior to the birth of her daughter. The information advising of this change was distributed in "Inside USF" Personnel Notes which was distributed to every employee.
Petitioner neither complied with the documents nor did she inquire of the individuals with knowledge, Ms. Hudson or the state office. 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. There is no provision for noncovered children. These facts would have been known to Petitioner upon reasonable inspection of the documents provided to her during open enrollment and by her employer, or upon reasonable inquiry.
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). See also: 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.
Petitioner voluntarily changed from family coverage to 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.
Petitioner also argues that the State should be estopped from denying coverage for her child since she relied on the information given to her by "someone" in the personnel office in November 1988 and the admissions office of Tampa General Hospital on June 14, 1989, that she had "sick baby" coverage as well as "well baby" coverage under her individual coverage then in effect. That advise was wrong, and her baby's medical expenses were significant. Petitioner further argues that the State is bound by the wrong information given to her and must afford retroactive coverage to Petitioner's child.
The Doctrine of Equitable Estoppel may be applied against the state, although only in exceptional circumstances. Cf. Fraga v. Department of Health and Rehabilitative Services, 464 So.2d 144 (Fla. 3d DCA 1985). To establish equitable estoppel, there must be a showing of the following elements: (1) A representation as to a material fact that is contrary to the later-assumed position: (2) reliance on that representation; and, (3) a change in position detrimental to the party claiming estoppel, caused by the representation and reliance thereon.
In this instance, Petitioner had a choice of single or family coverage. When first employed, she chose family coverage. A few months later she changed to individual coverage for her own reasons. After learning she was pregnant, she made one phone call and examined the Brochure she was given about the Plan. Although she knew the information she received was incomplete, she chose to rely on it and took no further action to insure that she had the coverage she desired prior to the birth of her child. In June, 1989, she received incorrect information from Tampa General Hospital concerning the extent of her coverage. Although she had read the Brochure given to her concerning the Plan, and it advised her to contact her personnel office or the Division of State Employees' Insurance for specific questions, Petitioner alleges she chose to rely on the information provided by the hospital. The state cannot be held bound by information given by the hospital. There was no proof that it was an agency of the state. In addition, the record is clear that Petitioner was aware that she should contact her agency personnel office or the state office for specific questions concerning coverage but chose not to do so until after the premature birth of her daughter. This is insufficient evidence to show detrimental reliance under Fraga, supra.
