STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
DEPARTMENT OF FINANCIAL SERVICES,
Petitioner,
vs.
ROGER LEE WHITE,
Respondent.
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) Case No. 03-2718PL
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RECOMMENDED ORDER
Pursuant to notice and in accordance with Section 120.57(1), Florida Statutes (2003), a formal hearing was held in this case on October 3, 2003, via video teleconference with Petitioner, Respondent, and the witnesses in Fort Lauderdale, Florida, and the designated Administrative Law Judge for the Division of Administrative Hearings, Fred L. Buckine, in Tallahassee, Florida.
APPEARANCES
For Petitioner: David J. Busch, Esquire
Department of Financial Services, Division of Legal Services
612 Larson Building
200 East Gaines Street Tallahassee, Florida 32399-0333
For Respondent: Roger Lee White, pro se
257 Coastal Hill Drive
Indian Harbour Beach, Florida 32937
STATEMENT OF THE ISSUE
The issue for determination in this case is whether the Florida insurance license of Respondent should be disciplined for violation of certain provisions of Chapter 626, Florida Statutes, as contained in allegations set forth in the five- count Administrative Complaint filed by Petitioner.
PRELIMINARY STATEMENT
On June 17, 2003, the Department of Financial Services (Department) filed a five-count Administrative Complaint against Robert Lee White (Respondent), a licensed Florida insurance agent, alleging that he had violated certain provisions of Chapter 626, Florida Statutes.
Specifically, the Administrative Complaint alleged that Respondent, with respect to five different families, had sold policies on behalf of Physicians Healthcare Plans (PHP) Medicaid Options Health Maintenance Organization, thereby enrolling minor children in the PHP Medicaid plan, without the knowledge or consent of their parents or guardians in every instance. Such actions are alleged to be in violation of several Florida Insurance Code provisions, as specified in Section 624.11 and Subsections 626.611(7), 626.611(9), 626.611(13), and
626.9541(1)(k)1., Florida Statutes (2001).
Respondent timely executed an Election of Rights form and requested a formal hearing pursuant to Section 120.57(1),
Florida Statutes (2003), and the matter was referred to the Division of Administrative Hearings on July 24, 2003.
On July 25, 2003, the Initial Order was entered, and on August 7, 2003, the Notice of Hearing was entered, scheduling the final hearing for October 3, 2003, in Viera, Florida.
Petitioner filed a Motion to Move Situs of Hearing, and on September 16, 2003, an order granting the Motion to Move Situs of Hearing was issued, changing the final hearing location to Fort Lauderdale, Florida. The matter was heard via video teleconference with the Administrative Law Judge located in Tallahassee, Florida, and the parties located in Fort Lauderdale, Florida.
The Department presented the testimony of four witnesses:
Vicky Camero, former Director of Medicaid Compliance for PHP; (2) Gladys Kennedy, Department employee as special investigator for Agent and Agency Investigations; (3) Julia Benefield, mother of T.K. and K.K., minor children entitled to receive Medicaid benefits (Count I); and (4) Dahlia Malcolm, mother of A.M., a two-year-old child entitled to receive Medicaid benefits (Count II). The following complainants were under subpoena but did not appear to testify: Calandra Birdine, regarding allegations contained in Count III, and Monique Young (Johnson), regarding allegations contained in Count IV. Jamie Powell was not under subpoena and did not appear to testify
regarding allegations contained in Count V. Four composite exhibits offered by the Department were accepted into evidence with the exception of page number 27 of Exhibit 2. Respondent testified in his own behalf and offered no exhibits in evidence.
Following the conclusion of the final hearing, a Transcript was filed on October 20, 2003. A Proposed Recommended Order was filed by Petitioner on November 21, 2003, and a Proposed Recommended Order, in the form of a letter, was filed by Respondent on November 17, 2003. Both post-hearing submittals were considered in preparation of this Recommended Order.
FINDINGS OF FACT
Based upon observation of the witnesses and their demeanor while testifying and documentary materials received in evidence, stipulations by the parties, evidentiary rulings made pursuant to Section 120.57, Florida Statutes (2003), and the record compiled herein, the following relevant and material facts are found:
The Department is the agency of the State of Florida vested with the statutory authority to administer the disciplinary provisions of Chapter 626, Florida Statutes (2001).
Respondent is and, at all times material, was licensed in Florida as a life and health insurance agent. His Florida insurance license number is A283290.
The Department has disciplined the license of Respondent on two previous occasions. The last discipline was taken pursuant to a Consent Order in Case Number 20371-97-A. Respondent was placed on probation for a period of three years beginning on July 29, 1999, and ending July 9, 2002, as a result of having enrolled five customers in a health plan without their knowledge or consent. A condition of his probation required Respondent to "strict[ly] adhere to all provisions of the Florida Insurance Code and Rules of the Department of Insurance and Treasurer" during his probation period. Respondent was also fined $7,500.
Respondent is and, at all times material, was operating as a health insurance agent for PHP. Respondent, as an employee of PHP, was paid a commission on his enrollment of each client with PHP. He was assigned PHP employee number 6232. His employment with PHP did not preclude nor deny his freedom to market life insurance.
PHP is an insurance company that maintains a contract with the State of Florida's Agency for Health Care Administration (AHCA) to deliver benefits to Medicaid recipients. The state screens potential Medicaid recipients to determine individual eligibility. The Medicaid plan "marketing agent," who is an insurance agent (Respondent), must hold an "event," invite the public, and explain benefits of the PHP
plan. Each such event shall be approved by AHCA. As a part of the terms of employment with PHP, certain activities are prohibited and are not to be engaged in by "marketing agents." The prohibitions included: knocking on doors and offering to parents of children who have been determined eligible for benefits monetary awards, gifts, rebates, or any other incentives to induce enrollment of a child in Medicaid plans.
PHP retained MDA Investigations, an independent investigative company, to investigate irregularities in the marketing processes resulting from marketing agents' conduct and/or client dissatisfaction brought to the attention of PHP and to provide PHP with an investigative report of each such irregularity. It was through this agency that complaints about Respondent were referred for investigation.
Count I
Julia Benefield (Ms. Benefield), complainant, has a high school diploma and is the mother of T.K. and K.K. Both children, having met certain entitlement criteria determined by the state, are entitled to receive Medicaid benefits.
Ms. Benefield decides what physician treats her children and, at all times material to this issue, had previously selected
Dr. Arlene Haywood as their chosen health care provider. From her past experience in selecting the health care provider for her children, Ms. Benefield was not new to the required
enrollment processes. She recalled initially meeting Respondent at the apartment rented by her mother. During the meeting, Respondent asked if her children were on Medicaid, to which she responded affirmatively, informing Respondent that they received medical services from Dr. Arlene Haywood, a physician who had previously treated Ms. Benefield when she was a child. During the course of his sales pitch conversation, Respondent discussed with Ms. Benefield life insurance policies for her minor children and intermingled his discussion with statements urging her to switch her Medicaid provider to PHP. During the course of this meeting and conversation, Ms. Benefield signed a "Request to Enroll Card" with the clear understanding that her signature thereon meant: "[I]t was to put my kids on life insurance." She emphatically denied ever intending or desiring to change from her then present physician provider and enroll her children in PHP offered by Respondent. During this process, Respondent presented Ms. Benefield with a Request to Enroll Card. The card, which Ms. Benefield acknowledged signing, contained the names, dates of birth, and social security numbers of her two children. Above the signature line, the Request to Enroll Card has printed the condition of enrollment, to wit: "By signing this card, I understand that I am only indicating my intent to enroll my family members in the Medicaid HMO plan listed above. To complete the enrollment process I will need to
sign and return an enrollment form that will be sent to my home by the Medicaid Options Program."
Ms. Benefield became aware of the switch of her Medicaid provider from Dr. Arlene Haywood to PHP when she received a letter mailed to her mother's apartment address informing her that her children were then enrolled (switched) with PHP. This switch to PHP caused her not to be able to obtain medical services from the children's regular pediatrician, Dr. Arlene Haywood. Ms. Benefield, dissatisfied with the method and manner of Respondent changing her Medicaid provider against her stated desires and without her permission, complained about the switch to PHP to the Department.
Respondent justified and defended his conduct in this instant with the summary statement: "that if she knew the difference of the two policies [PHP and life insurance] then how could she have made a mistake when life insurance cost money and Medicaid is free." Ms. Benefield firmly maintained, "[H]e went ahead and enrolled them anyway [in PHP] without my permission." At the time Ms. Benefield executed the enrollment card presented to her by Respondent, it was not her intent to switch from her then Medicaid provider, Dr. Arlene Haywood, to PHP. The intentional misrepresentations made by Respondent induced
Ms. Benefield to sign the enrollment card.
Count II
Dahlia Malcolm (Ms. Malcolm), complainant, is a high school graduate who also earned a cosmetology degree. She is the mother of A.M., a minor who is qualified to receive Medicaid benefits.
Ms. Malcolm recalled Respondent coming uninvited to her home during which time he repeatedly suggested switching from her Medipass provider to his employer, PHP provider. Following the pattern of his conversation with Ms. Benefield, Respondent discussed with Ms. Malcolm life insurance policies for her minor child intermingled with statements urging her to switch her Medicaid provider to PHP. In this instant, and as an additional inducement incentive, Respondent offered to give
Ms. Malcolm money to cover the cost of a "pizza" or "pizza party," if Ms. Malcolm would either invite her friends over or provide Respondent with the names of her friends with children who were Medicaid eligible. Ms. Malcolm recalled laughing at the suggestion of a "pizza party."
A few weeks later, she received a package mailed to her stating: "thank you for enrolling in PHP." According to Ms. Malcolm, the signature "Dahlia Malcolm" on the Request to Enroll Card, dated July 5, 2001, was "definitely" not her signature. She emphatically denied giving Respondent permission or authority to enroll her son in PHP. Dissatisfied with
Respondent switching her Medicaid provider, Ms. Malcolm complained to both PHP and the Department.
Respondent suggested that the mother of Ms. Malcolm was probably not happy with Ms. Malcolm enrolling her children with PHP and that to cover her mistake, Ms. Malcolm made a complaint to the Department; that suggestion is without merit. Ms. Malcolm at no time evidenced a knowing intent to switch her Medicaid provider to PHP. Assuming Ms. Malcolm did, in fact, sign the Request to Enroll Card, her inducement to sign the Request to Enroll Card was due to the intentional misrepresentations made to her by Respondent.
Count III
The complainant, Calandra Birdine, did not appear at the final hearing to testify. Respondent consented to admission of a Department Inquiry form containing statements from another person, written by Joseph Rufus, who also did not testify. Attached thereto were two Request to Enroll Cards containing the names and ages of six minor children who were qualified to receive Medicaid services, dated August 23, 2001. Although admitted into evidence without objection from the Respondent, the documents are hearsay, as are the contents. The Department failed to provide independent corroboration of the hearsay statements, and the documents and their contents are insufficient to support a finding of fact. Accordingly, the
Department failed to prove by competent substantial evidence the allegations contained in Count III of the Administrative
Complaint.
Count IV
The complainant, Monique Young, did not appear at the final hearing to testify. Respondent consented to admission of the Department Inquiry form that contained statements from another person, written by Keith Yore, who did not testify. Attached thereto were two Request to Enroll Cards containing the names and ages of eight minor children who were qualified to receive Medicaid services, dated May 11, 2001. Although admitted into evidence without objection from Respondent, the documents and contents are hearsay. The Department failed to provide independent corroboration of the hearsay evidence, and, therefore, the documents and their contents are insufficient to support a finding of fact. Accordingly, the Department failed to prove by competent substantial evidence allegations contained in Count IV of the Administrative Complaint.
Count V
The complainant, Jamie Powell, did not appear at the final hearing to testify. Respondent consented to admission of the Department Inquiry form containing statements of another person, written by Robekah (no last name in the record), who did not testify. Attached thereto was one Request to Enroll Card
containing the name and age of one minor child who was qualified to receive Medicaid services, dated June 2, 2001. Although admitted into evidence without objection of Respondent, the documents and contents are hearsay. For a lack of independent corroboration, the documents and contents are insufficient to support a finding of fact. Accordingly, the Department failed to prove by competent substantial evidence the allegations contained in Count V of the Administrative Complaint.
Respondent complained that he was employed with PHP for 11 months after the first complaint was filed against him in January 2001. He maintained that he was not notified of these complaints by the special investigator, Gladys Kennedy, until December 2001, one month after he no longer worked for PHP. It was his belief that PHP instigated the complaints because he went to work with a competing company. Respondent maintains that he had written over 1,500 applications per year with PHP and his success record demonstrated that "I must be doing something right."
Respondent, under the impression that the Department assumed he was taking advantage of his client because of their educational level, testified that he, too, has only a high school diploma.
Respondent, evidenced by Findings of Fact 3 through 12 hereinabove, violated his probation condition imposed in the Consent Order, of July 29, 1999, in Case Number 20371-97-A.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction of the subject matter and the parties of this proceeding pursuant to Subsection 120.57(1), Florida Statutes (2003).
The party asserting the affirmative of an issue before an administrative tribune has the burden of proof. Florida
Department of Transportation v. J.W.C. Company, Inc., 396 So.2d 778 (Fla. 1st DCA 1981). The Department must establish by clear and convincing evidence the guilt of Respondent for each offense alleged in the five-count Administrative Complaint. See Ferris
v. Turlington, 510 So. 2d 292 (Fla. 1987).
The evidence is clearly convincing that, at all times material to this cause, Respondent is and was issued insurance license number A283290 as a life and health insurance agent and a health only insurance agent.
During the incidents at issue in this case, Respondent was on probation pursuant to a Consent Order he had entered into with the Department. A condition of his probation required Respondent to "strict[ly] adhere to all provisions of the
Florida Insurance Code and Rules of the Department of Insurance and Treasurer" during his probation.
The statutory provisions pertinent to a determination of this matter of which Respondent violated are quoted in the numbered paragraphs below.
Subsection 624.11(1), Florida Statutes (2001), provides that:
No person shall transact insurance in this state, or relative to a subject of insurance resident, located, or to be performed in this state, without complying with the applicable provisions of this code.
Subsection 626.9541(1)(k)1., Florida Statutes (2001), provides:
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:
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(k) Misrepresentation in insurance applications.--
1. Knowingly making a false or fraudulent written or oral statement or representation on, or relative to, an application or negotiation for an insurance policy for the purpose of obtaining a fee, commission, money, or other benefit from any insurer, agent, broker, or individual.
Subsections 626.611(7), (9), and (13), Florida Statutes (2001), provide:
Grounds for compulsory refusal, suspension, or revocation of agent's, title agency's, solicitor's, adjuster's, customer representative's, service representative's, managing general agent's license or appointment. The department shall deny an application for, suspend, revoke, or refuse to renew or continue the license or appointment of any applicant, agent, title agency, solicitor, adjuster, customer representative, service representative, or managing general agent, and it shall suspend or revoke the eligibility to hold a license or appointment of any such person, if it finds that as to the applicant, licensee, or appointee any one or more of the following applicable ground exists:
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(7) Demonstrated lack of fitness or trustworthiness to engage in the business of insurance.
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(9) Fraudulent or dishonest practices in the conduct of business under the license or appointment.
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(13) Willful failure to comply with, or willful violation of, any proper order or rule of the department or willful violation of any provision of this code.
The record establishes by clear and convincing evidence that Respondent, a licensed Florida life insurance agent, failed to comply with the above applicable provisions of the Florida Insurance Code, and, thereby, violated the terms of his probation.
The evidence is clear and convincing that statements made by Respondent to Ms. Benefield, parent of Medicaid eligible children, were intentionally misleading for the purpose of his financial gain in the form of a commission for each PHP enrollee. To accomplish his ends, Respondent employed a "bait and switch" methodology. The "bait" was Respondent's weaving into his PHP presentation to Ms. Benefield matters regarding the purchase of life insurance. Based upon his personal prior experiences, Respondent was aware that applicants would unknowingly become confused and would sign the Request to Enroll Cards for him. Once the Request to Enroll Card was signed by the mother, Respondent would then "switch" the complainants to PHP and become eligible for a commission from PHP.
Ms. Benefield, a victim of Respondent's presentation, emphatically denied ever contemplating changing from Dr. Arlene Haywood, the Medicaid provider for her children, to some unnamed Medicaid provider through PHP. It is convincingly clear that at the conclusion of his sales pitch presentation and conversation with Ms. Benefield, followed by his presentation to
Ms. Benefield of a Request to Enroll Card, Ms. Benefield had been led to believe her signature on those card was to "put my kids on life insurance." A holistic view of the evidence factually established that the conduct of Respondent hereinabove caused harm to the victims by discontinuing their receiving
medical service from their regular medical care providers; such conduct was willful and was motivated by personal financial gain of Respondent.
Likewise, regarding Count II of the Administrative Complaint, the record is clear and convincing that Respondent came uninvited into the home of Ms. Malcolm. Once there, the oral presentation made by Respondent to Ms. Malcolm, parent of a Medicaid eligible child, was intentionally misleading.
In this particular instance, Respondent sought to enlarge his potential audience of mothers with children who were Medicaid eligible by offering to provide money to Ms. Malcolm for a "pizza party," should she agree to identify and provide Respondent with names of her "friends" (other mothers) with Medicaid eligible children. The not so subtle intent and absurdity of a "pizza party" offer caused Ms. Malcolm to laugh at his suggestion. Ms. Malcolm was unequivocal on two points. First, "I did not choose PHP." Second, "I did not agree to change from Medipass to PHP." Nevertheless, a few weeks later Ms. Malcolm received a package from Respondent via mail thanking her for enrolling in PHP. After receiving the "thank you for changing note" in the mail, Ms. Malcolm complained to both PHP and the Department. A holistic view of the evidence of record factually established that the conduct of Respondent hereinabove caused harm to the victims by discontinuing their medical
service from their regular medical care providers; such conduct was willful and was motivated by personal financial gain of Respondent.
The Department produced no witness to testify regarding allegations contained in Count III, IV, or V. Therefore, the record is clear that the Department failed to adduce competent, substantial evidence to support findings of material fact in support of the allegations in Counts III, IV, and V of the Administrative Complaint.
The 1999 conduct of Respondent ("enroll(ing) five consumers into [sic] health plan without their knowledge or consent") for which he was placed on three years probation and fined $7,500, and the conduct of Respondent hereinabove found in this case ("enrolling two consumers into [sic] health plan without their knowledge or consent") evidence confirmation of a lack of fitness or trustworthiness to engage in the business of insurance where the license agent stands in a fiduciary relationship to both the client and insurance company.
The timing of these several incidents covering a three- to five-year time span, holistically viewed, evidences a pattern of fraudulent and dishonest practice by Respondent. Fraud, not a mistake by each consumer, is the only rational inference drawn that would explain how each separate consumer, after a sales-pitch visit by Respondent, ended up enrolled into
Medicaid plans they did not want. The two incidents in this case, each from which Respondent received a commission, were not the result of negligence but were "intentional and willful" regarding the intent of Respondent and his failure to comply with the prior Consent Order entered by the Department of Insurance on July 29, 1999. These intentional and willful violations constitute a violation of Subsection 626.611(13), Florida Statutes (2001).
Under Florida Administrative Code Rule 4-231.080(7) and (13), the stated penalty for violation of either Subsection 626.611(7) or 626.611(13), Florida Statutes, is a six-month suspension of the license. Florida Administrative Code Rule 4-
231.100 provides for a six-month suspension for violation of Subsection 626.9541(1)(k)1., Florida Statutes.
Under Florida Administrative Code Rule 4-231.080(9), the stated penalty for violation of Subsection 626.611(9), Florida Statutes, is a nine-month suspension of license.
Regarding Count I of the Administrative Complaint, there has been a violation of a statute carrying a nine-month suspension penalty. Under Florida Administrative Code Rule
4-231.040(1)(a), the highest "penalty per count" is therefore a nine-month suspension. Fla. Admin. Code R. 4-231.040(2).
Regarding Count II of the Administrative Complaint, there has been a violation of a statute carrying a nine-month suspension penalty. Under Florida Administrative Code Rule
4-231.040(1)(a), the highest "penalty per count" is therefore a nine-month suspension. Fla. Admin. Code R. 4-231.040(2).
Under Florida Administrative Code Rule 4-231.040(2), the total penalty count is determined by adding together each penalty per count, an 18-month suspension in this instance.
Florida Administrative Code Rule 4-231.160 sets forth aggravating and mitigating factors to be considered. The following are determined and considered to be aggravating factors: (1) there is competent and substantial evidence in the record to demonstrate that Respondent's conduct was willful;
this willful conduct caused injury to the victims by effectively cutting them off from medical services with their regular medical care providers; (3) Respondent was motivated by his personal financial gain; (4) each transaction was personally effectuated by Respondent; (5) Respondent had been previously disciplined (twice) by the Department for having violated the Florida Insurance Code; and, more importantly, (6) Respondent was on probation for precisely the type of conduct alleged and proven as violations in this case.
Respondent offered no mitigating factors and a review of the evidence of record does not reveal a factor that could reasonably be considered as mitigating.
There was a violation by Respondent of Subsection 626.611(7), Florida Statutes (2001), "lack of fitness or trustworthiness to engage in the business of insurance." There was a violation by Respondent of Subsection 626.611(9), Florida Statutes, "fraudulent or dishonest practice in the conduct of business under the licensee." There was a violation by Respondent of Subsection 626.611(13), Florida Statutes, "willful failure to comply with or willful violation of, any proper order or rule of the department or willful violation of any provision of this code." There was also a violation by Respondent of Subsection 626.9541(1)(k)1., Florida Statutes, "misrepresentation in insurance applications by knowingly making a false or fraudulent written or oral statement or representation on, or relative to, an application or negotiation for an insurance policy for the purpose of obtaining a fee, commission, money, or other benefit from any insurer, agent, broker, or individual."
Under Florida Administrative Code Rule 4-231.040(3), the appropriate penalty in this circumstance is revocation of the license of Respondent. Dyer v. Department of Insurance and Treasurer, 585 So. 2d 1009 (Fla. 1st DCA 1991).
Based upon the foregoing Findings of Fact and Conclusions of Law, it is
RECOMMENDED that the Department of Financial Services enter a final order as follows:
Finding Respondent, Roger Lee White, guilty, as alleged in Count I and Count II of the Administrative Complaint, of violating Section 626.611 and Subsections 626.9541(1)(k)1. and 626.611(7), (9), and (13), Florida Statutes.
Revoking the license of Respondent and eligibility for licensure.
Dismissing Counts III, IV, and V of the Administrative Complaint filed against Respondent, Roger Lee White.
DONE AND ENTERED this 16th day of December, 2003, in Tallahassee, Leon County, Florida.
S
FRED L. BUCKINE
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 16th day of December, 2003.
COPIES FURNISHED:
David J. Busch, Esquire Department of Financial Services,
Division of Legal Services 612 Larson Building
200 East Gaines Street Tallahassee, Florida 32399-0333
Roger Lee White
257 Coastal Hill Drive
Indian Harbour Beach, Florida 32937
Honorable Tom Gallagher Chief Financial Officer
Department of Financial Services The Capitol, Plaza Level 11 Tallahassee, Florida 32399-0300
Mark Casteel, General Counsel Department of Financial Services The Capitol, Plaza Level 11 Tallahassee, Florida 32399-0300
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.
| Issue Date | Document | Summary |
|---|---|---|
| Feb. 03, 2004 | Agency Final Order | |
| Dec. 16, 2003 | Recommended Order | Respondent, by misrepresentation and fraud, induced parents with children who were Medicaid eligible into switching to Physicians Healthcare Plans HMO, his employer who paid a commission for each enrollee. |
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