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UNITED WISCONSIN LIFE INSURANCE COMPANY vs DEPARTMENT OF INSURANCE, 01-003135RU (2001)

Court: Division of Administrative Hearings, Florida Number: 01-003135RU Visitors: 52
Petitioner: UNITED WISCONSIN LIFE INSURANCE COMPANY
Respondent: DEPARTMENT OF INSURANCE
Judges: HARRY L. HOOPER
Agency: Department of Financial Services
Locations: Tallahassee, Florida
Filed: Aug. 10, 2001
Status: Closed
DOAH Final Order on Tuesday, November 27, 2001.

Latest Update: Dec. 19, 2002
Summary: Whether the charges contained in the Administrative Complaint, which is the subject of Case Number 01-2295, reflect statements of agency policy which should have been adopted as rules pursuant to Chapter 120, Florida Statutes.Petitioner alleged that the matters contained in the Department`s Administrative Complaint were rules by definition. Held: the statutes alleged are not statements of the agency and therefore are not rules of the agency.
01-3135.PDF

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS


UNITED WISCONSIN LIFE INSURANCE ) COMPANY, )

)

Petitioner, )

)

vs. )

)

DEPARTMENT OF INSURANCE, )

)

Respondent. )


Case No. 01-3135RU

)


FINAL ORDER


Notice was provided and a formal hearing was held on October 3, 2001, in Tallahassee, Florida, and conducted by Harry L. Hooper, Administrative Law Judge with the Division of Administrative Hearings.

APPEARANCES


For Petitioner: John Radey, Esquire

Harry O. Thomas, Esquire Donna E. Blanton, Esquire

Katz, Kutter, Haigler, Alderman Bryant & Yon, P.A.

106 East College Street, Suite 1200 Post Office Box 1877

Tallahassee, Florida 32301


For Respondent: Michael H. Davidson, Esquire

Dennis Silverman, Esquire Department of Insurance

200 East Gaines Street 612 Larson Building

Tallahassee, Florida 32399-0333



STATEMENT OF THE ISSUE


Whether the charges contained in the Administrative Complaint, which is the subject of Case Number 01-2295, reflect statements of agency policy which should have been adopted as rules pursuant to Chapter 120, Florida Statutes.

PRELIMINARY STATEMENT


The Department of Insurance (Department) filed an Administrative Complaint (Complaint) against United Wisconsin Life Insurance Company (United), on May 10, 2001. United answered the Complaint and requested an administrative hearing. The hearing was set for September 19, 2001. On August 10, 2001, United filed a Petition Challenging Agency Statements Defined as Rules. The agency statements, which were challenged, were contained in the Complaint. The rule challenge was set for hearing on October 3, 2001, and the hearing addressing the Complaint was continued.

This case was heard as scheduled on October 3, 2001. At the hearing United offered 13 exhibits of which 12 were admitted.

United also presented the testimony of Frank Dino, an actuary employed by the Department. The Department offered one exhibit which was admitted. A Transcript was filed on October 18, 2001. Both parties timely filed Proposed Orders which were considered in the preparation of this order.

References to statutes are to Florida Statutes (2001) unless otherwise noted.

FINDINGS OF FACT


The Parties


  1. United is a foreign insurer, domiciled in the State of Wisconsin holding a certificate of authority from the Department to transact the business of insurance in this state. It is a wholly-owned subsidiary of American Medical Securities Group, Inc.

  2. The Department, through its agency head, the Treasurer and Insurance Commissioner, has regulatory jurisdiction over United in connection with certain matters set forth in the Complaint.

    The regulatory scheme for out-of-state health insurance companies


  3. Health insurance companies operating pursuant to


    in-state regulatory schemes are subject to oversight regulation of the corporate entity including financial solvency and market conduct. Rates are required to be filed and approved prior to being used in the state. The review process involves a review of the rates to determine if they are reasonable in relation to the benefits provided. In regard to this, the Department has rules which it has adopted pursuant to Chapter 120, Florida Statutes, which it uses to determine the standards and formulae for making that determination.

  4. Certain out-of-state health insurers, such as United, are not subject to such stringent regulation. No review of premium rates is conducted by the Department in the case of these insurers, but it would be incorrect to state that they are not subject to regulation by the Department at all. Approximately

    40 percent of the health insurance market in Florida is written through out-of-state group arrangements that do not provide policyholders consumer protections afforded to policyholders holding in-state policies regulated by the Department.

  5. United is required by Florida law to provide certain types of coverage. United must also ensure that certificates of coverage provided to residents of Florida contain the following language:

    The benefits of the policy providing your coverage are governed primarily by the law

    of a state other than Florida. Indent Background

  6. At all times pertinent, American Medical Security, Inc. (AMS), was a Florida-licensed administrator authorized to market and administer United's out-of-state group health insurance plans in Florida. AMS, like United, is a wholly-owned subsidiary of American Medical Securities Group, Inc.

  7. In May 1993, United, through AMS, filed for approval with the Department pursuant to Section 627.5515(2), Florida Statutes (1993), as an out-of-state group health insurer who

    would provide policies to be offered through an Alabama entity called the Prescription For Good Health Trust, which was formed primarily for the purpose of providing group insurance. The Department approved this filing.

  8. On March 2, 1995, the Department participated by conference call in a Regulatory Task Force of the National Association of Insurance Commissioners. The mission of the task force was to attempt to address a number of problems facing the insurance market. One of the problems discussed was rate protection for consumers when faced with "tier rating" or "tier blocking." The two terms are synonymous and mean, as to group health insurance, reclassifying insureds subsequent to having been initially placed in a class. This practice will be discussed in more detail below.

  9. In 1996, United made a filing for the Prescription For Good Health Trust which proposed tier rating. Sometime during 1996, after the Department objected to the filing, United withdrew it. The Department had never seen such a filing previously. United is the only health insurer to assert before the Department that reclassification by movement between classes would be permissible under the Florida Insurance Code.

  10. Section 627.6515(1), Florida Statutes, provides that a group health insurance policy issued or delivered outside this state under which a resident of Florida is provided coverage,

    shall comply with the provisions of Part VII, of Chapter 627, Florida Statutes, in the same manner as health policies issued within the state. Part VII of Chapter 627, Florida Statutes, provides for a comprehensive regulatory scheme for group health insurance. Section 627.6515(2), Florida Statutes, however, sets forth a number of exemptions. Section 627.6515(2), Florida Statutes, provides an exemption for an insurer like United, which provides health insurance through an association formed for a purpose other than that of offering insurance, which provides the language referred to in paragraph 5, supra, on the face of the certificate, and which offers the bundle of coverages provided in Subsection (c). This exemption applied to the Prescription For Good Health Trust.

  11. The Department concedes that it has no authority to set premium rates for out-of-state insurers like United.

  12. In November 1996, United through AMS, filed with the Department, pursuant to Section 627.6515(2), Florida Statutes, a request for approval of an out-of-state group health insurance policy termed the "MedOne Choice" plan. This plan was to be offered through an Ohio association called the Taxpayers' Network, Inc. (TNI). The association was formed primarily for purposes other than providing insurance. In January, 1997, the filing was accepted by the Department as meeting the requirements of Section 627.6515(2), Florida Statutes.

  13. Chapter 96-223, Laws of Florida, created Section 627.6425, Florida Statutes, effective May 25, 1996. When created, the section only addressed the renewability of individual coverage. Chapter 97-179, Laws of Florida, substantially amended Section 627.6425, Florida Statutes, effective May 30, 1997. Subsequent to the amendment, the section addressed certificates of coverage offered to individuals in the state as part of a group policy. This statute, along with Sections 627.6571 and 627.6487, Florida Statutes, implemented the federal Health Insurance Portability and Accountability Act (HIPAA). The basic theory of the HIPAA legislation is that an insurance company cannot simply cancel a health insurance policy without providing other options.

  14. On or about September 25, 1998, United, through AMS, notified all Prescription For Good Health Trust certificate holders that the policy forms through which their coverage had been provided were being discontinued, effective as of each certificate holder's 1999 renewal date.

  15. Upon discontinuance of the Prescription For Good Health Trust Plans, the only United health insurance plans available in Florida were the MedOne Choice plans offered through TNI.

  16. Membership in TNI was available to anyone upon submitting an application form and paying the membership fee. Membership in TNI was a prerequisite to continuance of a persons'

    health insurance coverage under United's MedOne Choice plan. United guaranteed each certificate holder, upon joining TNI, that upon request, they would be issued coverage under the Classic Benefit Plan (one of the TNI MedOne Choice plans) without regard to their health status. However, there was no guarantee that premiums would not rise.

  17. Certificate holders were also advised that if they desired coverage under a MedOne Choice plan other than the guaranteed issue Classic Benefit plan, they could apply for any of the other TNI plans. Only if the applicant met the underwriting guidelines for the plan for which they applied, would they be issued coverage under another MedOne Choice plan.

  18. Between October 1998 and early January 1999, United responded to questions and concerns raised by the Department about the decision to discontinue the Prescription For Good Health Trust plan, and whether the plan of discontinuance was in compliance with Section 627.6425, Florida Statutes.

    Specifically, discussions were had concerning the movement of insureds from the class in which they were originally assigned to another class at the time of renewal.

  19. United entered an agreement with the Department on January 14, 1999, whereby United would offer to certificate holders an additional guaranteed issue TNI plan and would cap the rate for the guaranteed issue plans at no more than twice the

    premium then currently being paid for the discontinued Prescription For Good Health Trust plan. In accordance with this agreement, United notified certificate holders of the additional guaranteed issue option available to them.

  20. Later in 1999, United discontinued the trust plan in accordance with their agreement with the Department. During the process of discontinuance, no certificate holder requested conversion coverage under Section 627.6675, Florida Statutes. Section 627.6675, Florida Statutes, provides that an insured may assert his or her right to a "converted policy," which provides for certain health insurance continuation rights.

  21. The Department determined that United's rate for the conversion policy, pursuant to the agreement, was within 200 percent of the standard risk rate and that the notice of the conversion privilege was contained in the certificate of coverage issued to Florida residents. Thus, the Department concluded that United was in compliance with the agreement of January 14, 1999.

  22. On May 19, 1999, a Department letter informed a consumer that the discontinuance of her coverage by United did not mean she was being discriminated against because the policy had been terminated for all members. The letter further recited that the Department did not have the ability to regulate United because it was not domiciled in Florida and her insurance was

    being provided to a group, referring to TNI, that was not registered in Florida.

  23. On July 27, 1999, a Department letter informed a consumer that United had an obligation to offer a replacement policy but that United had the right to underwrite the policy and charge additional premium. This statement also referred to TNI.

  24. Section 627.6425(1), Florida Statutes, provides that "except as otherwise provided in this section, an insurer that provides individual health insurance coverage to an individual shall renew or continue in force such coverage at the option of the individual." For the purpose of the aforementioned Section, the term "individual health insurance" means health insurance coverage, as described in Section 627.6561(5)(a)2, Florida Statutes, offered to an individual in the state, "including certificates of coverage offered to individuals in the state as part of a group policy issued to an association outside this state. "

  25. As noted earlier, Section 627.6425, Florida Statutes, is one of the statutes enacted in Florida which implemented HIPAA. HIPAA provides for continuation of health insurance of an insureds health policy but does not limit the premiums which an insurer can charge for coverage. Although Section 627.6425, Florida Statutes, does not have the words "guaranteed renewable" contained within the statute, the gist of the statute is that if

    a person has a health policy, the person has the right to continued coverage. The Department contends that the statute also means that there can be no reclassification or movement between classes at the time of renewal.

  26. On March 30, 2000, the Department notified United that it believed the discontinuance of Prescription For Good Health Trust plan, in accordance with the January 1999 agreement, may have violated Section 627.6425, Florida Statutes.

  27. A Department publication dated January 4, 2001, entitled, "The Florida Health Insurance Market, Issues and Possible Market Reform Measures," noted that there are "an increasing number of carriers attempting to establish HIPAA eligible individuals as a separate rating class with premium charges ranging from 300 to 500 percent of standard rates. While the Department has found such a rating practice to be in violation of the Florida Insurance Code, many carriers have continued to protest this interpretation. Carriers contend the

    surcharge practice is both actuarially sound and interpreted as a HIPAA permissible practice by other states."

  28. In the 2001 legislative session, the Department sought additional regulatory authority concerning out-of-state group insurers, such as United, along with numerous other changes to the Florida Insurance Code which are unrelated to the issues

    addressed in this Order. The Florida Legislature failed to approve the requested legislation.

    Tier rating


  29. When a group health policy is underwritten, the members of the group may be divided into classes. The classes are based on risk, which is a function of the probability of claims and the cost of claims.

  30. Classes may be denominated, for example, as preferred, manual, and substandard. Very healthy persons are put in the preferred class and pay lower premiums relative to other classes. Average persons are put in the manual class because the likelihood and cost of claims may be average. Persons who for actuarial reasons are determined to have an above-average likelihood of claims and whose claims are apt to be costly, are placed in the substandard class. It, perhaps, goes without saying that the individuals in the substandard class must pay higher premiums for the same coverage as others in the group.

  31. If the group health policy is guaranteed renewable, certificate holders may continue their coverage. However, premiums within a class can be increased. It is general industry practice to increase the premiums by class when the time for renewal occurs, if the loss experience is such that there is a requirement to increase premiums. As earlier noted, the Department asserts that only by raising premiums for an entire

    class may premiums be raised. The Department insists that this requirement is part of the definition of "guaranteed renewable."

  32. It became United's practice to move insureds between classes. Therefore, for instance, if a person in the group who had been a member of the preferred class experienced the need for costly medical services, then that person might be moved to the manual or substandard class. This would inevitably result in that person paying an increased premium. On the other hand, a person in the substandard class, who was subsequently determined to be a good risk, might be moved to the preferred or manual class and experience reduced premiums as a result.

  33. When a substandard class becomes populated with persons who cause the payment of costly claims, premiums increase within that class. Premiums may increase to the point where persons egress the plan, which leaves the class with fewer and sicker members. Eventually, under such a plan, there will be no members, because the premiums will inflate to the point that the benefits, in relation to the amount of the premium, will render the plan uneconomical. This sequence of events is often referred to as the health insurance "death spiral."

  34. One of the asserted evils which the Department seeks to combat in the Complaint is the "death spiral."

    HIPAA eligibles


  35. In 1996, when HIPAA became law and Florida enacted laws to implement it, a practice sometimes referred to as "rating up" occurred among some carriers in the industry. As noted earlier, HIPAA and the state statutes implementing it, guarantee that an individual, who through no fault of his own, loses his or her group health insurance coverage has the opportunity to obtain substitute health insurance. A person in this category is referred to as HIPAA eligible.

  36. Companies providing insurance under these laws are cognizant of the fact that persons in good health generally decline to purchase this type of insurance but that persons who are in bad health, and who will, therefore, likely have costly claims, will purchase it if they can afford it. This results in a desire on the part of insurers, to charge higher premiums for HIPAA eligible persons than they might charge persons in a comparable, non-HIPAA plan.

  37. It is a permissible underwriting practice to take into consideration age, health, and a myriad of other actuarial considerations when developing premium rates for HIPAA eligibles. If an insurer factors in the knowledge that unhealthy persons are more likely than healthy persons to obtain a policy based on HIPAA and charge higher premiums as a result, then "rating up" occurs. The Department contends in its Complaint that "rating

    up" is discriminatory and, therefore, forbidden by the Unfair Insurance Trade Practices Act (UITPA), Section 626.951, et seq., Florida Statutes. United allegedly arrives at rates for HIPAA eligibles solely based on the fact that the individuals are HIPAA eligible which if true, would be "rating up."

  38. Immediately prior to April 30, 1998, the Department received a memorandum from the federal Health Care Financing Administration addressing three general problems with insurance practices regarding HIPAA eligibles. One of the three problems addressed in the memorandum was the practice of "rating up."

    In response, the Department issued Informational Memorandum 98-103M on April 30, 1998, addressing the three problems. The

    Department announced that it had concerns similar to that of the Health Care Financing Administration, and would address them in administrative rules implementing HIPAA and Chapter 97-179, Laws of Florida. However, no rules addressing these concerns have been adopted.

  39. Insurance carriers disagree with the Department as to whether "rating up" is unfairly discriminatory and therefore a violation of the UITPA. The Department is addressing these differences on a case-by-case basis in the course of market conduct examinations. The evidence adduced at the hearing did not elucidate exactly what "addressing these differences on a case-by-case basis in the course of market conduct examinations"

    means. Count Three in the Complaint represents the first time an administrative action has been brought against an insurer addressing this practice.

    The definition of guaranteed renewable


  40. Chapter 4-149, Florida Administrative Code, is entitled "Filing of Forms and Rates for Life and Health Insurance."

    Rule 4-149.006(4)(o)3, Florida Administrative Code, provides for a definition of "guaranteed renewable." However, Chapter 4-149, Florida Administrative Code, does not address out-of-state group health insurers, such as United, because the Department has no authority to require the filing of forms and rates in the case of out-of-state health insurers like United.

  41. A life and health insurance treatise written by Black and Skipper states that the definitions of the categories of renewable health insurance policies are not uniform among the states.

  42. It is the Department's position that


    Section 627.6425, Florida Statutes, applies to out-of-state trusts, such as United's Prescription For Good Health Trust, even though the word "trust" is not used in the statute.

  43. It is apparent that if there is no limit on the amount of premium a health insurer can charge at the time of renewal, a guarantee of renewal can be meaningless. This fact is

    ameliorated by rate-setting in the case of highly regulated health insurers such as domestic insurers.

  44. In the context of this case, it is not the renewability of a policy that is the gist of the problem. Rather, it is whether rates can be increased on persons through the movement of insureds from one class to another.

    The allegations of the Complaint


  45. In order to determine which statements are alleged to be unadopted rules, it is necessary to refer to Counts Two through Seven of the Complaint. These counts will be summarized, in seriatim.

  46. Count Two alleges that persons who continued their participation in TNI were unlawfully and unfairly discriminated against because some members were reclassified based on their health status present at that time (1999), rather than being retained in the class in which they resided when the policy was initially issued. The Petition alleges, inter alia, that this practice violated Section 626.9541(1)(g)2., Florida Statutes, which is a section in the UITPA. This statement is alleged in the Petition to be a statement of general applicability.

  47. Count Three alleges that all of those individuals formerly covered through the Prescription For Good Health Trust who were at the time of their discontinuance HIPAA eligible, were, arbitrarily and without regard to health status, assigned a

    premium rate of either three or five times the base rate for TNI as a whole. Count Three alleges that this assignment unfairly discriminated against the HIPAA eligible individuals who were of the same actuarially supportable class and essentially the same hazard. Count Three further alleges, inter alia, that this violated Section 626.9541(1)(g)2., Florida Statutes. This statement is alleged in the Petition to be a statement of general applicability.

  48. Count Four alleges that the enactment of Section 627.6425, Florida Statutes, in 1996, as amended in 1997, statutorily determined that the Prescription For Good Health Trust plan was "guaranteed renewable" as that term is used and understood in the insurance industry. It further alleged that the term "guaranteed renewable” means that once an insurer classifies an individual as a member of an actuarially supportable class for rate and premium applicable to the specified coverage, that individual may not thereafter be charged a premium which is different from any other member of the same class and cannot be moved to another class. The complaint states that United unlawfully moved insureds from one class to another.

  49. Count Four additionally alleged that when United discontinued the Prescription For Good Health Trust, the prerequisite for individuals to obtain renewed health insurance coverage was reclassification of some of those individuals to

    different actuarially supportable classes based on their health status then pertinent to those individuals. It was further alleged that higher premiums were charged to approximately

    70 percent of those who renewed or continued, and that premium increases of 200 percent to 300 percent were experienced. Count Four asserted that Section 627.6425(3), Florida Statutes, prohibits such reclassification. Count Four also alleges, inter alia, that this violated Section 626.9541(1)(g)2., Florida Statutes, because such reclassification was discriminatory. This statement is alleged in the Petition to be a statement of general applicability.

  50. Count Five alleges that on the one year anniversary of renewal with TNI, United unlawfully reclassified additional individuals which resulted in a premium increases of up to

    60 percent. Count Five alleges, inter alia, that this violated Section 626.9541(1)(g)2., Florida Statutes, because this action was discriminatory. This statement is alleged in the Petition to be a statement of general applicability.

  51. Count Six alleges that within the tier blocks described in Count Two, United unlawfully established numerous sub- classifications based on health related factors pertinent to each individual within that class. It is alleged in the Complaint that these sub-classifications resulted in individuals within the same class being charged a different premium than are other

    members of the class. Count Six alleges, inter alia, that this violated Section 626.9541(1)(g)2., Florida Statutes, because this action was discriminatory. This statement is alleged in the Petition to be a statement of general applicability.

  52. Count Seven alleges that United used a point debit system where an arithmetic number of points are assigned to a corresponding health hazard. The higher the cumulative debit score, the higher the premium. United will decline to insure at all if the cumulative debit score gets sufficiently high. Count Seven alleges that the assignment of points with no criteria for decision-making results in arbitrary and discriminatory point scores. Count Seven alleges, inter alia, that this violated Section 626.9541(1)(g)2., Florida Statutes. This statement is alleged in the Petition to be a statement of general applicability.

  53. In summary, the three statements alleged to be rules


    are:


    1. Practicing tier rating is discriminatory and violates


      the UITPA.


    2. Placing HIPAA-eligible individuals in a premium classification solely on the basis of their HIPAA eligible status is discriminatory and violates the UITPA.

    3. The term "guaranteed renewable" prohibits the classification of individuals in a health insurance group at a time other than at the inception of coverage.

    CONCLUSIONS OF LAW


  54. United is "substantially affected" by the challenged agency statements and has standing to bring this proceeding pursuant to Section 120.56(4), Florida Statutes. The alleged statements were articulated in a Complaint directed at United that is pending before the Division of Administrative Hearings.

  55. The Petition challenges three Department statements defined as rules. A Department statement that is the equivalent of a rule must be adopted according to the rulemaking procedures in the Florida Administrative Procedure Act, Chapter 120, Florida Statutes (APA). Environmental Trust, Inc. v. State Department

    of Environmental Protection, 714 So. 2d 493 (Fla. 1st DCA 1998) and Christo v. State Department of Banking & Finance, 649 So. 2d

    318 (Fla. 1st DCA 1995).


  56. In a proceeding pursuant to Section 120.56(4), Florida Statutes, the issue to be decided is whether the challenged Department statement "violates s. 120.54(1)(a)." That section provides in relevant part:

    1. Rulemaking is not a matter of agency discretion. Each agency statement defined as a rule by s. 120.52 shall be adopted by the rulemaking procedure provided by this section as soon as feasible and practicable.


  57. Section 120.52(15), Florida Statutes, defines "rule" in relevant part as follows:

    "Rule" means each agency statement of general applicability that implements, interprets, or prescribes law or policy or describes the procedure or practice requirements of an agency and includes any form which imposes any requirement or solicits any information not specifically required by statute or by an existing rule.


  58. Section 626.9521, Florida Statutes, provides as follows:

    UNFAIR METHODS OF COMPETITION AND UNFAIR OR DECEPTIVE ACTS OR PRACTICES PROHIBITED; PENALTIES--.

    1. No person shall engage in this state in any trade practice which is defined in this part as, or determined pursuant to s. 626.951 or s. 626.9561 to be, an unfair method of competition or an unfair or deceptive act or practice involving the business of insurance.

    2. Any person who violates any provision of this part shall be subject to a fine in an amount not greater than $2,500 for each nonwillful violation and not greater than

    $20,000 for each willful violation. Fines under this subsection may not exceed an aggregate amount of $10,000 for all nonwillful violations arising out of the same action or an aggregate amount of $100,000 for all willful violations arising out of the same action. The fines authorized by this subsection may be imposed in addition to any other applicable penalty


  59. Section 626.9541(1)(a)1, Florida Statutes, provides as follows:

    1. UNFAIR METHODS OF COMPETITION AND UNFAIR OR DECEPTIVE ACTS.--The following are defined as unfair methods of competition and unfair or deceptive acts or practices:

      1. Misrepresentations and false advertising of insurance policies.--Knowingly making, issuing, circulating, or causing to be made, issued, or circulated, any estimate, illustration, circular, statement, sales presentation, omission, or comparison which:

    1. Misrepresents the benefits, advantages, conditions, or terms of any insurance policy.


  60. Section 626.9541(1)(g)2., Florida Statutes, provides as follows:

    (1) UNFAIR METHODS OF COMPETITION AND UNFAIR OR DECEPTIVE ACTS.--The following are defined as unfair methods of competition and unfair or deceptive acts or practices:


    * * *


    (g) Unfair discrimination.--


    * * *


    2. Knowingly making or permitting any unfair discrimination between individuals of the same actuarially supportable class and essentially the same hazard, in the amount of premium, policy fees, or rates charged for any policy or contract of accident, disability, or health insurance, in the benefits payable thereunder, in any of the terms or conditions of such contract, or in any other manner whatever.


  61. The first question to be resolved is whether any of the three statements challenged by United meet the definition of a "rule" as that term is defined in Section 120.52(15), Florida

    Statutes. If the statements alleged to be rules in the Complaint are not rules, then the inquiry needs to go no further.

  62. In determining whether or not these statements amount to rules by definition, it is important to note as a threshold matter, that for the purposes of this order, the merit, or lack thereof, of the Department's position in the Complaint is not at issue here. In other words, whether the facts asserted in the complaint can be proven, and if so, whether they are violations of the Florida Insurance Code, are matters which await decision on another day.

  63. Rulemaking is required only for an agency statement that is the equivalent of a rule, which is defined in Section 120.52(15), Florida Statutes. Environmental Trust, Inc. v. State Department of Environmental Protection, 714 So. 2d 493, 498 (Fla. 1st DCA 1998).

    Are the matters alleged in the Complaint agency statements?


  64. It would be inappropriate to speculate in this Order, as to whether the Department may have made statements reflecting generally applicable policies substantially affecting parties through other media which are similar to the allegations of the Complaint. What is clear, however, is that the matters alleged in the Complaint, which are the subject of this litigation, are not agency statements.

65. Sections 626.9541, 626.9541(1)(a)1, and 26.9541(1)(g)2,


Florida Statutes, are, taken together, statutes which prohibit described conduct. They are penal in nature. Some of the sections in the UITPA provide for criminal sanctions. They are announcements of policy enacted into law by the Florida Legislature. They represent the policy of the state. Because the Department is the agency charged with implementing these statutes, the Department is free to allege facts which might prove to be violations of these statutes, without resort to explanatory rules.

  1. It seems unlikely that the Florida Legislature intended that allegations under a prohibitory or penal statute could be subject to collateral attack through a Section 120.54, Florida Statutes, rule challenge. Such a procedure could result in two hearings each time a regulatory action was brought by an agency. In the pursuit of justice through the administrative process, simplicity and economy of resources are primary goals. Permitting collateral challenges in enforcement cases unreasonably derogate those goals.

  2. In any event, the "statements" alleged in the Petition to be rules by definition, are not statements of the Department. They are pleadings pertaining to alleged violations of a Florida Statute. Therefore they are not rules by definition. It is further apparent that the proper forum for the resolution of the

matters contained in the Complaint is a proceeding pursuant to Section 120.57(1), Florida Statutes.

FINAL ORDER


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

That United Wisconsin Life Insurance Company's Petition Challenging Agency Statements Defined as Rules, is dismissed.

DONE AND ORDERED this 27th day of November, 2001, in Tallahassee, Leon County, Florida.


HARRY L. HOOPER

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 27th day of November, 2001.


COPIES FURNISHED:


Michael H. Davidson, Esquire Dennis Silverman, Esquire Department of Insurance

200 East Gaines Street 612 Larson Building

Tallahassee, Florida 32399-0333

John Radey, Esquire Harry O. Thomas, Esquire Donna E. Blanton, Esquire

Katz, Kutter, Haigler, Alderman, Bryant & Yon, P.A.

106 East College Avenue, Suite 1200 Post Office Box 1877

Tallahassee, Florida 32301


Honorable Tom Gallagher

State Treasurer/Insurance Commissioner Department of Insurance

The Capitol, Plaza Level 02 Tallahassee, Florida 32303-4149


Mark Casteel, General Counsel Department of Insurance

The Capitol, Plaza Level 26 Tallahassee, Florida 32399-0307


NOTICE OF RIGHT TO JUDICIAL REVIEW


A party who is adversely affected by this Final Order is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings are commenced by filing one copy of a notice of appeal with the Clerk of the Division of Administrative Hearings and a second copy, accompanied by filing fees prescribed by law, with the District Court of Appeal, First District, or with the District Court of Appeal in the Appellate District where the party resides. The notice of appeal must be filed within 30 days of rendition of the order to be reviewed.


Docket for Case No: 01-003135RU
Issue Date Proceedings
Dec. 19, 2002 Mandate filed.
Nov. 04, 2002 Opinion filed.
Apr. 23, 2002 Supplemental Index sent out.
Feb. 25, 2002 Supplemental Index sent out.
Feb. 20, 2002 BY ORDER OF THE COURT: (Appellant`s motion filed February 5, 2002, seeking to supplement the record on appeal with department`s exhibit 1, is granted). filed.
Jan. 23, 2002 Index, Record, Certificate of Record sent out.
Jan. 22, 2002 Received payment in the amount of $37.00 for Record on Appeal.
Jan. 15, 2002 Index sent out.
Jan. 15, 2002 Statement of Service Preparation of Record sent out.
Dec. 05, 2001 Letter to A. Cole from J. Wheeler regarding Court`s case no. filed.
Dec. 03, 2001 Certified Notice of Administrative Apeal sent out.
Nov. 30, 2001 Notice of Administrative Appeal filed by H. Thomas
Nov. 27, 2001 Final Order issued (hearing held October 3, 2001). CASE CLOSED.
Oct. 29, 2001 Petitioner`s Proposed Final Order filed.
Oct. 29, 2001 Department`s Proposed Final Order filed.
Oct. 18, 2001 Transcript filed.
Oct. 09, 2001 Department`s Motion for Reconsideration (filed via facsimile).
Oct. 05, 2001 Order issued (Petitioner`s Exhibit 13 is admitted into evidence and the words"for identification" are stricken).
Oct. 03, 2001 CASE STATUS: Hearing Held; see case file for applicable time frames.
Oct. 02, 2001 Subpoena ad Testificandum, F. Dino filed.
Sep. 26, 2001 Notice of Appearance filed by Respondent.
Sep. 12, 2001 Revised Notice of Taking Deposition Duces Tecum, Department of Insurance filed.
Sep. 11, 2001 Notice of Hearing issued (hearing set for October 3 through 5, 2001; 9:00 a.m.; Tallahassee, FL).
Aug. 24, 2001 Notice of Taking Deposition Duces Tecum filed by Petitioner.
Aug. 17, 2001 Notice of Withdrawal of Request for Consolidation filed by Petitioner
Aug. 14, 2001 Order of Assignment issued.
Aug. 14, 2001 Letter to Liz Cloud from A. Cole with copy to Carroll Webb and the Agency General Counsel sent out.
Aug. 10, 2001 Petition Challenging Agency Statements Defined as Rules filed.

Orders for Case No: 01-003135RU
Issue Date Document Summary
Dec. 18, 2002 Mandate
Nov. 27, 2001 DOAH Final Order Petitioner alleged that the matters contained in the Department`s Administrative Complaint were rules by definition. Held: the statutes alleged are not statements of the agency and therefore are not rules of the agency.
Source:  Florida - Division of Administrative Hearings

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