STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

CAROLE A. CLARK, )

)

Petitioner, )

)

vs. ) Case No. 99-2534

) DEPARTMENT OF MANAGEMENT SERVICES, ) DIVISION OF STATE GROUP INSURANCE, )

)

Respondent. )

)

RECOMMENDED ORDER

An administrative hearing was conducted on September 9, 1999, in Tallahassee, Florida, by Daniel Manry, Administrative Law Judge, Division of Administrative Hearings. Petitioner, her witness, and one of Respondent’s two witnesses attended the hearing by telephone conference from different locations. The court reporter, counsel for Respondent, the second witness for Respondent, and the undersigned participated by telephone conference from Tallahassee.

APPEARANCES

For Petitioner: Carole A. Clark, pro se

6325 Highland Gardens Court Lakeland, Florida 33813

For Respondent: Joan Van Arsdall, Esquire

Department of Management Services 4050 Esplanade Way, Suite 260

Tallahassee, Florida 32399-0950

STATEMENT OF THE ISSUE

The issue in this case is whether Petitioner is entitled to health insurance coverage for installation of temporary and

permanent dental crowns under Florida’s State Employees’ Group Health Self Insurance Plan.

PRELIMINARY STATEMENT

By letter dated February 23, 1999, Respondent denied Petitioner’s request for insurance benefits under the state’s self insurance plan. Petitioner timely requested an administrative hearing. Respondent referred the matter to the Division of Administrative Hearings to conduct the hearing.

At the hearing, Petitioner testified in her own behalf, presented the testimony of one expert witness, and submitted no exhibits for admission in evidence. Respondent presented the testimony of two witnesses and submitted eight exhibits for admission in evidence.

The identity of the witnesses and exhibits, and the rulings regarding each, are set forth in the Transcript of the hearing filed on September 23, 1999. By order issued on September 27, 1999, the undersigned granted Respondent’s Motion for Extension of Time to File Proposed Recommended Order. On October 8, 1999, the parties timely filed their proposed recommended orders ("PROs").

FINDINGS OF FACT

1. Petitioner claims to suffer from temporomandibular joint dysfunction ("TMJ"). Petitioner is a member of the State Employees’ Group Health Self Insurance Plan (the "Plan").

2. Respondent is responsible for administering the Plan. Blue Cross and Blue Shield ("Blue Cross") services the Plan for Respondent.

3. The Plan covers medical expenses incurred for the treatment of TMJ. The Plan paid for treatment of Petitioner’s TMJ symptoms on March 25, 1996, and on December 2, 1997. That treatment did not include crowns.

4. Dr. Michael Vallilo is one of Petitioner’s dentists. On May 28, 1998, Dr. Vallilo placed temporary crowns on 14 of Respondent’s teeth and bonded two of her teeth.

5. On May 29, 1998, Dr. Vallilo wrote Blue Cross and requested payment for the temporary crowns. Dr. Vallilo also requested prior approval for permanent crowns at an approximate cost of $14,000 for both sets. Dr. Vallilo requested payment and prior approval based on his opinion that the crowns are reasonably necessary for the treatment of TMJ.

6. The temporary and permanent crowns were necessary for the treatment of occlusion dysfunction. Occlusion dysfunction relates to the fit of the teeth when brought together. Occlusion dysfunction has no correlation to TMJ.

7. Petitioner’s symptoms and medical records are not consistent with TMJ. The diagnosis in Petitioner’s medical records describes oral dyskinesia. Oral dyskinesia involves muscle spasm, limited muscle function, the body’s reaction to the way teeth fit together, and an inability to keep the jaws closed. The diagnosis did not state a cause for the symptoms.

8. Even if oral dyskinesia were caused by TMJ, crowns are not covered by the Plan. Medical reimbursement under the Plan does not cover crowns, bridges, inlays, on-lays, fillings, equilibration of the teeth, or any other procedure that alters the tooth itself and can be performed only by a licensed dentist.

9. The Plan covers only specified treatment for TMJ. Covered treatment includes X-rays, clinical exams, splint therapy, physical therapy, surgical procedures of the joint itself, and other procedures not performed on the teeth.

10. The Plan covers repositioning devices necessary in the treatment of TMJ. Crowns are not repositioning devices. Petitioner had separate dental insurance at the time the crowns were installed in her mouth. Her dental insurance may, or may not, have covered the temporary and permanent crowns.

11. Even if the Plan did not exclude crowns as dental treatment, the placement of crowns for TMJ or occlusion disorder is not covered. Such services are not consistent with applicable standards of good medical practice.

    CONCLUSIONS OF LAW

12. The Division of Administrative Hearings has jurisdiction over the parties and the subject matter. Section 120.57(1), Florida Statutes (1997). The parties were duly noticed for the hearing. (All chapter and section references are to Florida Statutes (1997) unless otherwise stated.)

13. The burden of proof is on Petitioner. Petitioner must show by a preponderance of evidence that the placement of crowns

    in her mouth was covered under the Plan and medically necessary. Florida Department of Transportation vs. J.W.C. Company, Inc.,

    396 So. 2d 778 (Fla. 1st DCA 1981); Balino vs. Department of Health and Rehabilitative Services, 348 So. 2d 349 (Fla. 1st DCA 1977). Petitioner failed to satisfy her burden of proof.

14. The crowns were health care services performed directly on the teeth. Blue Shield of Florida, Inc. v. Woodlief, 359 So. 2d 883 (Fla. 1st DCA 1978). The Plan expressly excluded the such services, and a court may not re-write the Plan to create new coverage. Crown Life Insurance Company v. McBride, 517 So. 2d 660 (Fla. 1987).

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions of Law, it is

RECOMMENDED that Respondent enter a final order denying Petitioner's claim.

DONE AND ENTERED this 6th day of December 1999, in Tallahassee, Leon County, Florida.

DANIEL MANRY

Administrative Law Judge

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

(850) 488-9675 SUNCOM 278-9675

Fax Filing (850) 921-6847 www.doah.state.fl.us

Filed with the Clerk of the Division of Administrative Hearings this 6th day of December, 1999.

COPIES FURNISHED:

Thomas D. McGurk, Secretary Department of Management Services 4050 Esplanade Way

Tallahassee, Florida 32399-0950

Paul A. Rowell, General Counsel Department of Management Services 4050 Esplanade Way

Tallahassee, Florida 32399-0950

Carole A. Clark

6325 Highland Gardens Court Lakeland, Florida 33813

Joan Van Arsdall, Esquire Department of Management Services 4050 Esplanade Way, Suite 260

Tallahassee, Florida 32399-0950

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within 15 days from the date of 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: 99-002534

Orders for Case No: 99-002534