STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DELLA G. SPHALER and WILLIAM SPHALER, )

)

Petitioners, )

)

vs. ) CASE NO. 93-5971

) DEPARTMENT OF MANAGEMENT SERVICES, ) 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 February 11, 1994, in West Palm Beach, Florida.

APPEARANCES

For Petitioners: John P. Marinelli, Esquire

John P. Marinelli, P.A. 1615 Forum Place

Suite 4-B, Barristers Building West Palm Beach, Florida 33401

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

Chief, Benefit Programs and Legal Services Division of State Employees' Insurance 2002 Old St. Augustine Road, B-12 Tallahassee, Florida 32301-4876

STATEMENT OF THE ISSUE

The issue presented is whether Petitioners are entitled to additional benefits pursuant to the State of Florida Employees Group Health Self Insurance Plan.

PRELIMINARY STATEMENT

By letter dated September 15, 1993, Respondent denied Petitioners' claim for additional benefits arising from a hospitalization of Petitioner Della G. Sphaler, and Petitioners Della G. Sphaler and her husband William Sphaler timely requested a formal hearing regarding that denial. This cause was thereafter transferred to the Division of Administrative Hearings to conduct the formal proceeding.

Petitioners testified on their own behalf, and Respondent presented the testimony of George Lee Peacock. Additionally, Petitioners' Exhibits numbered 1 and 2 and Respondent's Exhibits numbered 1-6 were admitted in evidence.

Both parties submitted post-hearing proposed findings of fact in the form of proposed recommended orders. A specific ruling on each proposed finding of fact can be found in the Appendix to this Recommended Order.

FINDINGS OF FACT

1. At all times material hereto, Petitioner Della G. Sphaler (hereinafter "Petitioner") has been an employee of the State of Florida with health insurance coverage under the State of Florida Employees Group Health Self Insurance Plan (hereinafter "the Plan"). The Plan is administered by Blue Cross and Blue Shield of Florida, Inc. (hereinafter "Blue Cross/Blue Shield"), pursuant to an Administrative Services Agreement between the State and Blue Cross/Blue Shield.

   
   

2. On or about November 14, 1989, Petitioner's doctor recommended that she be admitted to Humana Hospital-Palm Beaches for psychiatric services on an emergency basis. At the time, Petitioner knew that Humana was not a Preferred Patient Care Provider (hereinafter "PPC") under the Plan. A PPC provider has an agreement with Blue Cross/Blue Shield to provide health care services at set fees to individuals under the Plan. The Plan provides higher benefits when PPC providers are used.

   
   

3. Petitioner told her doctor that Humana was a non-PPC provider and that she did not want to go to a hospital unless her bill would be paid by her insurance. However, her doctor wanted her to go to Humana specifically, and she agreed.

   
   

4. Thereafter, Petitioner and William Sphaler (hereinafter "husband") went to Humana Hospital. They spoke to an employee at Humana regarding Petitioner's insurance coverage under the Plan, and that unidentified employee telephoned Blue Cross/Blue Shield. Petitioner was not a party to the conversation between the Humana Hospital admissions clerk and the unidentified employee of Blue Cross/Blue Shield, and her husband heard none of the conversation. Further, neither Petitioner nor her husband personally made any contact with Blue Cross/Blue Shield or Respondent regarding the existence or extent of any insurance coverage under the Plan if Petitioner were admitted at Humana.

   
   

5. After her conversation, the clerk at Humana told Petitioner that Blue Cross/Blue Shield would pay 80 percent for the first three days of admission and

   100 percent thereafter, according to Petitioner's and her husband's testimony.

   
   

6. Petitioner was admitted to Humana on November 14, 1989, with an admitting diagnosis of major depression. She remained there until her discharge on December 8, 1989.

7. As a result of the phone call from Humana, on November 14, 1989, the Blue Cross/Blue Shield computer generated a form letter to Petitioner advising her that under the Hospital Stay Certification component of the Plan Petitioner's emergency hospital stay was certified for three days and that contact by the hospital would be necessary to recertify the admission for additional days. That letter further advised as follows:

   
   

   We remind you that the review was limited to determining the appropriate length of stay for the emergency admitting diagnosis and did not question medical necessity. We further remind you that payment of benefits is still subject to the terms of your Health Insurance Policy.

   Neither Petitioner nor her husband contacted Blue Cross/Blue Shield to verify or ascertain benefits upon their receipt of that letter.

   
   

8. Petitioner's total bill for her stay at Humana was $17,652.53. The bill was primarily for room charges. Humana charged $463 a day for eleven days in a semi-private room and $713 a day for an additional thirteen days in a semi- private room. Blue Cross/Blue Shield paid a total of $6,751.50 of Petitioner's hospital bill. That payment covered portions of Petitioner's bill for the entire stay.

   
   

9. Since Humana is a non-PPC hospital, payment for services is controlled by Section II.A.1. of the Plan's Benefit Document, amended effective July 1, 1988, which covers non-PPC hospital inpatient room and board services as follows:

   
   

   When confined to a semi-private or private room or ward, 80 percent of the hospital's average semi-private room rate shall be paid but not to exceed an actual payment of one-hundred and fifty-two dollars ($152.00) per day.

   
   

10. The Benefit Document also establishes deductibles under the Plan in Section VI.C. as follows: "Two hundred dollars ($200.00) per admission to a non-PPC provider hospital, specialty institution or residential facility."

    
    

11. The Hospital Stay Certification component of the Plan, like the Pre- admission Certification component, if complied with, does not increase the benefits payable under the Plan. Rather, Section XXIV.C. of the Benefit Document provides that the benefits set forth in Section II.A. will be paid if an elective admission to a non-PPC hospital is certified and will not be paid if the admission is not certified. Since Petitioner obtained certification, she was entitled to benefits as provided in Section II.A., i.e., a maximum of $152 per day for room charges.

    
    

12. Blue Cross/Blue Shield properly calculated and paid the benefits to which Petitioner is entitled. Petitioner is entitled to no additional benefits under the Plan.

    CONCLUSIONS OF LAW

    
    

13. The Division of Administrative Hearings has jurisdiction over the parties hereto and the subject matter hereof. Section 120.57(1), Florida Statutes.

    
    

14. Petitioners have failed to carry their burden of proving entitlement to additional payments for Petitioner's hospitalization at Humana. The benefits to which Petitioner is entitled are controlled by the Plan's Benefit Document and are set forth clearly therein. That document sets forth a per admission deductible for a non-PPC hospital admission and a maximum payment for room charges.

    
    

15. The benefit levels provided under the Plan are approved in advance by the Legislature. Section 110.123(5)(a), Florida Statutes. Petitioners have cited no authority, and none has been found, for Petitioners' suggestion that the plan benefits can be altered from those legislatively-approved. To pay room charges greater than $152 per day at a non-PPC hospital would constitute an impermissible alteration of the Plan's benefits since such payment would not have prior legislative approval.

    
    

16. Although Petitioner testified that she would not have admitted herself to Humana but for the fact that she believed that Blue Cross/Blue Shield would pay her entire bill, she also admitted that she knew Humana was a non-PPC provider and that she knew she would have a problem with insurance coverage if she went there. Yet, she went to Humana because her doctor wanted her to even after she told him Humana was not a PPC hospital. It is concluded that Petitioner knew there was a difference in benefits paid to non-PPC providers and PPC providers.

    
    

17. Moreover, Blue Cross/Blue Shield cannot pay benefits in excess of those allowed by the Plan's Benefit Document simply because Petitioners testified they understood from an unidentified clerk at Humana Hospital that the Plan offered coverage different from the coverage set forth in the Benefit Document. What that clerk told Petitioners is hearsay and what the unidentified employee at Blue Cross/Blue Shield told the clerk is unknown.

    
    

18. To the extent that Petitioners are suggesting that Respondent is estopped from denying additional benefits, Petitioners have offered no evidence of any representation made to them by Respondent or by Blue Cross/Blue Shield upon which Petitioners relied. Petitioners had no contact with Respondent regarding Petitioner's hospitalization until after her discharge, and the only contact between Petitioners and Blue Cross/Blue Shield before or during Petitioner's hospitalization was in the form of a letter from Blue Cross/Blue Shield to Petitioner dated November 14, 1989, certifying a 3-day emergency stay and advising that the amount of benefits payable was subject to the terms of Petitioner's Benefit Document. Neither Respondent nor Blue Cross/Blue Shield ever represented to Petitioner or her husband that Blue Cross/Blue Shield would pay her entire hospital bill or would pay any benefits above those which Blue Cross/Blue Shield has already paid.

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered denying Petitioners' claim for

additional benefits for the November 14, 1989, Humana hospitalization.

DONE and ENTERED this 5th day of April, 1994, at Tallahassee, Florida.

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 5th day of April, 1994.

APPENDIX TO RECOMMENDED ORDER DOAH CASE NO. 93-5971

1. Petitioners' proposed findings of fact numbered 1-4 and 6 have been adopted either verbatim or in substance in this Recommended Order.

2. Petitioners' proposed finding of fact numbered 5 has been rejected as not being supported by the weight of the competent evidence in this cause.

3. Respondent's proposed findings of fact numbered 1-5 and 8-10 have been adopted either verbatim or in substance in this Recommended Order.

4. Respondent's proposed finding of fact numbered 6 has been rejected as being unnecessary to the issues involved herein.

5. Respondent's proposed findings of fact numbered 7, 11, and 12 have been rejected as not constituting findings of fact but rather as constituting argument of counsel, conclusions of law, or recitation of the testimony.

COPIES FURNISHED:

John P. Marinelli, Esquire John P. Marinelli, P.A.

1615 Forum Place

Suite 4-B, Barristers Building West Palm Beach, Florida 33401

Augustus D. Aikens, Jr., Esquire

Chief, Benefit Programs and Legal Services Division of State Employees' Insurance 2002 Old St. Augustine Road, B-12 Tallahassee, Florida 32301-4876

William H. Lindner, Secretary Department of Management Services Knight Building, Suite 307

Koger Executive Center 2737 Centerview Drive

Tallahassee, Florida 32399-0950

Paul A. Rowell, General Counsel Department of Management Services Knight Building, Suite 307

Koger Executive Center 2737 Centerview Drive

Tallahassee, Florida 32399-0950

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions to this Recommended Order. All agencies allow each party at least 10 days in which to submit written exceptions. Some agencies allow a larger period within which to submit written exceptions. You should contact the agency that will issue the final order in this case concerning agency rules on the deadline for filing exceptions to this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.

Docket for Case No: 93-005971

Orders for Case No: 93-005971