vs.
Case No. 13-2095
Respondent.
Pursuant to notice, a final hearing was held in this case on August 16, 2013, by video teleconference at sites in Tallahassee and St. Petersburg, Florida, before Lawrence P. Stevenson, a duly designated Administrative Law Judge of the Division of Administrative Hearings.
For Respondent: Sonja P. Mathews, Esquire
Department of Management Services Office of the General Counsel 4050 Esplanade Way, Suite 160
The issue is whether Respondent properly denied payment for Petitioner‟s lodging at the Hackerman-Patz Pavilion in Baltimore, Maryland, from December 30, 2011, through January 31, 2012, pursuant to the State Employees‟ PPO Group Health Insurance Plan.
By letter dated December 12, 2012, Respondent, Department of Management Services, Division of State Group Insurance (“DSGI”), notified Petitioner, Tayna Alexander, that it intended to deny her Level II Appeal, by which Petitioner challenged the decision of Blue Cross & Blue Shield of Florida (“Florida Blue”), to pay $2,912.00 for her lodging after her hospitalization at Johns Hopkins Hospital in November 2011.
Petitioner submitted to DSGI a request for an informal hearing1/ on the basis that the lodging in question was not excluded as a “motel/hotel accommodation” under the Florida Blue plan. The informal hearing was convened on April 26, 2013, after which the presiding officer recommended that the matter be sent to the Division of Administrative Hearings (“DOAH”) for the conduct of a formal hearing. DSGI referred the matter to DOAH on June 12, 2013.
The final hearing was scheduled for August 16, 2013, on which date it was convened and completed. At the final hearing,
Petitioner testified on her own behalf and presented the testimony of her father, Michael L. Alexander. Petitioner‟s Exhibits 1 through 6 were admitted into evidence. Respondent presented the testimony of Kathy Flippo, a registered nurse and Respondent‟s Legal Nurse Specialist, and of Jessica Bonin, Florida Blue‟s Critical Inquiry Analyst. Respondent‟s Exhibits
1 through 4, 6, 7, 10 and 11 were admitted into evidence.
No transcript of the hearing was submitted. On August 27, 2013, Respondent filed an unopposed motion to extend the time for filing proposed recommended orders to September 4, 2013, which was granted by an order entered on August 27, 2013.
Petitioner filed her Proposed Recommended Order on August 30, 2013. Respondent filed its Proposed Recommended Order on September 4, 2013.
Unless otherwise noted, all statutory references are to Florida Statutes (2013).
At all times relevant to this proceeding, Petitioner was an attorney in the Pinellas County Public Defender‟s office and was enrolled as a member of the State Employees‟ PPO Plan. At the time of the hearing, Petitioner was 36 years old. Petitioner was provided with the State Employees‟ PPO Plan Group Health Insurance Plan Booklet and Benefits Document (the “Benefits Document”). The version of the Benefits Document
entered into the record in this proceeding bore the statement, “Effective January 1, 2012.” Because Petitioner did not dispute that this was the applicable edition of the Benefits Document, it is assumed to be identical in all relevant respects to the version that was in effect during November and December of 2011.
DSGI is the state agency responsible for administration of the state group insurance program. Pursuant to statute, DSGI has contracted with Florida Blue to act as its third-party medical claims administrator for employee health insurance benefits.
In 2004, Petitioner was diagnosed with acquired aplastic anemia. A variety of treatments were attempted during the intervening years with some success, but Petitioner‟s overall condition continued to decline.
By 2011, Petitioner was a candidate for a bone marrow transplant. Her siblings were tested and found not to be human leukocyte antigen identical to Petitioner, meaning they were not candidates for the transplant and that Petitioner would require a matched unrelated donor, or MUD, bone marrow transplant. She went to Johns Hopkins in November 2011 to begin the evaluation process and receive the transplant. Her attending physician was Robert A. Brodsky, the Director of Hematology at Johns Hopkins.
Two weeks prior to her admission to the hospital, Petitioner came to Johns Hopkins for testing. She was
accompanied by her mother. Petitioner was provided with housing options and was given a form titled “Bone Marrow Transplant (BMT) Housing and Caregiver Information” that contained the following information:
Housing:
The BMT team wants to watch you closely during your transplant care. Depending on your type of transplant, you will spend some, to all of your time, as an outpatient in the IPOP [Inpatient/Outpatient] clinic. Anytime you are an outpatient in the IPOP clinic, you must stay within 30-60 minutes (including traffic) of The Johns Hopkins Hospital. If you do not already live locally, you and your caregiver must arrange local housing during this time. Talk with your BMT Case Manager about when you will need housing.
Some insurances cover housing/relocation costs, but many do not. If you need to arrange local housing, call your insurance company as soon as possible and inquire about their housing coverage policy. If your insurance has a case management option you may want to request this to help with housing coverage questions. You can also talk with your BMT Case Manager and the BMT Finance Office about your housing coverage.
* * *
The Housing Referral Service has information on many housing options. Prices for housing vary depending on location and amenities....
Petitioner testified that after reviewing all the options, she chose the Hackerman-Patz Patient and Family Pavilion (“H-P Pavilion”) as the best and cheapest option. The
H-P Pavilion is a facility located on the Johns Hopkins campus within easy walking distance of the hospital and provides short and long-term housing options for patients and their caregivers. The H-P Pavilion‟s informational materials state that it “offers gracious, supportive and affordable hospitality in a home-like atmosphere, a welcoming alternative to hotel living when traveling to receive specialized medical treatment.” It is designed specifically to provide housing for cancer patients and their caregivers, and offers suites for $60.00 per night and apartments for $87.00 per night.
The H-P Pavilion is not a hotel that offers accommodations to the general public. In order to stay at the H-P Pavilion, one must be a Johns Hopkins patient or a patient‟s caregiver. The patient must be receiving treatment at Johns Hopkins for a minimum of three consecutive days, or at least three days a week. The patient must have a 24-hour per day caregiver who has agreed to stay for the duration of treatment. Children under 12 are not permitted to stay overnight
In a letter addressed “To Whom It May Concern” and dated November 9, 2011, Dr. Brodsky wrote as follows, in relevant part:
This is to document that Ms. Tayna Alexander has specific housing requirements dictated by the Bone Marrow Transplant Program at the Sidney Kimmel Comprehensive Cancer Center.
On November 15, 2011, Ms. Alexander will be
admitted to start preparatory chemotherapy for her bone marrow transplant. This is done on an inpatient basis. From the day the preparative regimen begins (six days before the transplant), until approximately 6-8 weeks after transplant she will be inpatient. The hospital stay may be longer if complications occur. After discharge from the hospital, Ms. Alexander is required to stay specifically within an hour of the hospital for daily outpatient clinic visits. She should stay in local housing facilities approved by the transplant team which complies with the housekeeping guidelines established by the Transplant Program.
Petitioner was admitted to Johns Hopkins on
November 15, 2011, and the bone marrow transplant was performed on November 22. Petitioner remained in the hospital until December 30, 2011, her immune system “wiped out,” in the words of Dr. Brodsky. She received immunosuppressive therapy and daily transfusions of red blood cells and platelets. She suffered from persistent nausea and incontinence. She had a renal insufficiency that led her to gain 50 pounds of water weight. Her physicians repeatedly noted that “due to the nature of her disease and therapy, she continues to be at high risk for morbidity and mortality.”
Petitioner testified that she was still so sick on December 30, 2011, that she was surprised that the hospital wanted to release her. She stated that she was taking large doses of Ativan for nausea. She was disoriented and in a poor overall mental condition. Her platelet count remained very low.
She continued to experience incontinence and vomiting.
Petitioner‟s father, Michael Alexander, undertook the task of being Petitioner‟s 24-hour-a-day caregiver during the outpatient portion of her post-surgical treatment. He took a skilled caregiver class at Johns Hopkins taught by a registered nurse. The class taught Mr. Alexander how to maintain a sterile environment in the living area, how to prepare proper meals for his daughter, how to monitor her vital signs, and how to clean and flush her Hickman line, the central venous catheter used to administer medications.
Mr. Alexander testified that about a week before Petitioner‟s release, the medical team asked him about going to the H-P Pavilion. The team believed that getting out of the hospital room would speed Petitioner‟s recovery. Mr. Alexander stated that the team was “pushing” the idea. Mr. Alexander told the team that he and his daughter would have to think about it, because she was still very sick. Petitioner told her father that she was willing to try it, though he remained skeptical.
Petitioner testified that the hospital gave her the option of staying in the hospital or going to the H-P Pavilion or some other nearby accommodation. Both Petitioner and her father testified that the hospital assured them that she could return to the hospital if she was not comfortable in the H-P Pavilion. In a written statement, Mr. Alexander wrote, “Had I
known that this would result in an insurance dispute, I would have suggested an easier route to stay in Johns Hopkins inpatient care and just let the insurance company pay 80 times the cost.”
Neither DSGI nor Florida Blue disputed that Petitioner‟s insurance would have paid for her continued stay in the hospital, had she decided that she was not well enough to cope with outpatient procedures. Billing information submitted into evidence indicated that a bed in Johns Hopkins was priced in excess of $1,500.00 per day, before any other expenses were added on.
On December 30, 2011, Petitioner was discharged from Johns Hopkins and moved into an apartment in the H-P Pavilion with her father.2/ Petitioner continued daily outpatient treatments at Johns Hopkins, most days spending several hours receiving blood transfusions. The H-P Pavilion was attached to the hospital via a walkway and was across the street from the IPOP facility. Petitioner and her father walked back and forth between the pavilion and the IPOP facility every day.
Mr. Alexander cared for his daughter throughout their stay at the Pavilion. He flushed the Hickman line every two days and checked for infection. He replaced the Hickman line ports every five days and applied a special bandage for the Hickman line to Petitioner‟s chest. He maintained a sterile
environment in the living area. He prepared the specific foods required for Petitioner‟s restricted diet. He monitored her vital signs and body functions and reported those to Petitioner‟s medical team. He dispensed and kept logs of the many medications that Petitioner took every day. He assisted Petitioner with all of her activities of daily living, as well as cleaning up her vomit and urine and washing her clothing and bedding.
Petitioner and her father stayed in the H-P Pavilion until January 31, 2012. At that point, they returned to Florida and Petitioner resumed treatment with her local doctors.
Petitioner‟s stay at the H-P Pavilion was billed directly to her. The bill itself is on the letterhead of Johns Hopkins Hospital and lists Petitioner as the “patient.”
Petitioner submitted the bill to Florida Blue for reimbursement. When Florida Blue initially denied her reimbursement, Petitioner sought a Level I Appeal pursuant to section 12 of the Benefits Document. By letter dated October 29, 2012, and signed by Kelly Register, a Critical
Inquiry Analyst for Florida Blue, Petitioner was informed that Florida Blue “remains unable to approve additional coverage and/or payment for the Non-Covered Services: Housing.” The sole ground cited by Florida Blue for this denial was that page 5-3 of the Benefits Document excludes “personal comfort, hygiene or
convenience items,” which expressly include “motel/hotel accommodations.”3/
Petitioner then pursued a Level II Appeal to DSGI. In a letter signed by Division Director Barbara M. Crosier, dated December 12, 2012, DSGI rejected Petitioner‟s appeal. The letter stated as follows, in relevant part:
While researching this appeal, we reviewed all documentation you provided, including your letter of appeal, the invoice from The Hackerman-Patz Patient and Family Pavilion, and a letter from Dr. Robert Brodsky stating that you were required to stay within one hour from the hospital. We also reviewed the letter of denial BCBSF sent in response to your prior benefit determination request for coverage of housing costs.
While we empathize with your situation, the [Benefits Document] effective January 1, 2007, and as amended by the State Employees‟ PPO Plan Summary of Plan Description Material Modification, effective January 1, 2009,[4/] states on page 5-3 under Exclusions:
“Personal Comfort, Hygiene or Convenience Items and services deemed to be not medically necessary and not directly related to your treatment including but not limited to:
travel expenses (other than medically necessary ambulance services);
motel/hotel accommodations;” Page 15-4 states:
“Medically necessary . . . services required to identify or treat the illness, injury, condition, or mental and nervous disorder a
doctor has diagnosed or reasonably suspects. The service must be:
consistent with the symptom, diagnosis, and treatment of the patient‟s condition;
in accordance with standards of good medical practice;
required for reasons other than convenience of the patient or the doctor;
approved by the appropriate medical body or board for the illness or injury in question; and
at the most appropriate level of medical supply, service, or care that can be safely provided.
The fact that a service is prescribed by a doctor does not necessarily mean that the service is medically necessary. BCBSF and DSGI determine whether a service or supply is medically necessary.”
Based upon careful review of the information you provided to us, we find that medical necessity has not been demonstrated or documented. You did not meet criteria for in-patient hospitalization, and housing during outpatient treatment is not covered by your PPO Plan.”
“Personal comfort, hygiene or convenience items and services” is undefined in the Benefits Document except by the list of examples provided. This provision of the Benefits Document provides as follows, in full:
Personal comfort, hygiene or convenience items and services deemed to be not Medically Necessary and not directly related to your treatment including, but not limited to:
beauty and barber services;
clothing including support hose;
radio and television;
guest meals and accommodations;
telephone charges;
take-home supplies;
travel expenses (other than Medically necessary Ambulance services);
motel/hotel accommodations;
equipment which is primarily for your convenience and/or comfort, or the convenience of your family or caretakers; modifications to motor vehicles and/or homes such as wheelchair lifts or ramps; electric scooters; water therapy devices such as Jacuzzis, hot tubs, swimming/lap pools or whirlpools; membership to health clubs, exercise, physical fitness and/or massage equipment; hearing aids; air conditioners and purifiers, furnaces, air filters, humidifiers; water softeners and/or purifiers; pillows, mattresses or waterbeds; escalators, elevators, stair glides; emergency alert equipment; blood pressure kits, handrails and grab bars; heat appliances and dehumidifiers, vacuum cleaners or any other similar equipment and devices used for environmental control or to enhance an environmental setting;
heating pads, hot water bottles, or ice packs; and
massages except as described in section 3.
The Benefits Document also provides no definition of the term “motel/hotel accommodations.” The common dictionary definition of “hotel” is “an establishment providing accommodations, meals, and other services for travelers and tourists.”5/ The plain meaning of the term “hotel” includes the concept of a place providing temporary accommodations that is open to all travelers, not a limited purpose facility such as the H-P Pavilion.6/
This distinction is recognized in section 509.013, Florida Statutes, which sets forth the definitions used by the state in regulating lodging and food service establishments. A “hotel” is included in the definition of a “transient public lodging establishment” under section 509.013(4)(a)1., as “any unit, group of units, dwelling, building, or group of buildings within a single complex of buildings which is rented to guests more than three times in a calendar year for periods of less than 30 days or one calendar month, whichever is less, or which is advertised or held out to the public as a place regularly rented to guests.”
The H-P Pavilion was not “held out to the public” as a place offering overnight accommodations but was strictly limited to Johns Hopkins‟ patients and their families. Section 509.013(4) expressly recognizes such a facility as excluded from the definition of a public lodging establishment and therefore
not subject to regulation by the Division of Hotels and Restaurants:
(b) The following are excluded from the definitions in paragraph (a):
* * *
Any nonprofit organization that operates a facility providing housing only to patients, patients‟ families, and patients‟ caregivers and not to the general public.
The H-P Pavilion does not meet the ordinary definition of the term “hotel” and would not be considered a “hotel” for purposes of regulation by the state of Florida. The term “hotel” is not otherwise defined by the Benefits Document. Therefore, DSGI cannot rely on the H-P Pavilion‟s status as a “hotel” in order to deny reimbursement to Petitioner without twisting the meaning of the term beyond recognition.
Ms. Crosier‟s letter also quotes the Benefits Document‟s definition of “medically necessary,” presumably to bring Petitioner‟s stay at the H-P Pavilion under the category of “personal comfort, hygiene or convenience items and services” even if the H-P Pavilion were found not to be a hotel.
Ms. Crosier‟s letter does not offer an explanation as to the connection between the definition of “medically necessary” and the H-P Pavilion, as if it were self-evident that Petitioner‟s stay at that facility does not meet the terms of the definition. The connection is not self-evident. Petitioner‟s medical
provider directed her to stay at the H-P Pavilion or a similar facility, as indicated in an August 6, 2013, “To Whom It May Concern” letter from Dr. Brodsky:
Ms. Tayna Alexander was under my care from November 2011, until Jan. 31, 2012, for her severe aplastic anemia. She underwent a bone marrow transplant during that time. In preparation for the transplant, she received very high doses of chemotherapy that wiped out her immune system. This made her extremely susceptible to infections and bleeding. Since an infection or issue with bleeding can be fatal if not treated promptly, she was required to stay in housing no farther than 1 hour away from the hospital. As this was medically necessary, she was approved by the bone marrow transplant team and me to stay at the Hackerman-Patz house in Baltimore, Maryland. She was also required to have a 24-hour caregiver to provide assistance and to get her to the hospital for daily visits and to help with any emergencies that might arise.
I would like to reiterate that both the housing within an hour of the hospital as well as having a caregiver are not suggestions but rather are medically necessary requirements for patients undergoing a bone marrow transplant.
The Benefits Document states that a doctor‟s prescription “does not necessarily mean that the service is Medically Necessary.” However, when DSGI determines that the physician‟s estimate of medical necessity is incorrect, it must do more than merely cite the definition of “medical necessity” in its determination letter.
Moreover, the language in the “personal comfort, hygiene, or convenience items and services” provision of the Benefits Document is in the conjunctive: “deemed to be not Medically Necessary and not directly related to your treatment.” Even if DSGI were correct in determining that Petitioner‟s stay in the H-P Pavilion was not “medically necessary,” DSGI would still need to make a determination that the stay was not directly related to Petitioner‟s treatment. No such determination was made in Ms. Crosier‟s letter, and the facts found above lead to the finding that Petitioner‟s stay at the
H-Pavilion was directly and intrinsically related to her continuing treatment at Johns Hopkins.
Petitioner‟s medical team believed it necessary for her to stay nearby because Petitioner‟s proximity to the Johns Hopkins facility directly assisted her access to treatment during a time when she was extremely vulnerable physically and mentally. Petitioner‟s proximity to the medical facility also eliminated an unnecessary source of anxiety as to emergencies that might arise. Petitioner was very near death at the time of her transplant and remained “at high risk for morbidity and mortality” during the month that she spent at the H-P Pavilion. This was no mere “convenience” but a vital part of Petitioner‟s recovery.
At the final hearing, Jessica Bonin, a critical analyst for Florida Blue, testified as to a reason for rejection of Petitioner‟s claim that was not addressed in the rejection letters of either the Level I or the Level II Appeal. Ms. Bonin stated that the claim should be rejected because it was submitted by Petitioner, not by Johns Hopkins. Section 11 of the Benefits Document states that PPC Network providers such as Johns Hopkins “will file the claim for you and you will be responsible for paying any Co-insurance, deductibles, Co- payments and non-covered services.” From this, Ms. Bonin concluded that Johns Hopkins does not consider the H-P Pavilion as one if its services and that Petitioner‟s claim should be rejected.
Section 11 of the Benefits Document states, “When you go to a Network Provider or Non-Network Provider participating in the Traditional Program, you do not need to file a claim.”
In its Proposed Recommended Order, DSGI cited this language as a “benefit” of the PPC Plan, presumably because it placed the onus for filing a claim on the network provider rather than the covered individual. The Benefits Document does not address the covered individual‟s remedy in those instances when the provider fails to file the claim on her behalf. In this instance, Petitioner chose to file the claim directly with Florida Blue.
The Benefits Document does not forbid the covered individual
from filing a claim within the network. Thus, there is no basis for rejecting Petitioner‟s claim solely because she filed it.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction of the subject matter of and the parties to this proceeding. §§ 120.569 and 120.57(1), Fla. Stat.
Respondent is the agency charged by the legislature with the duty to oversee the administration of the State Group Insurance Program, including the group disability insurance program.
Section 110.123, titled “State Group Insurance Plan,” describes the powers and duties conferred on Respondent as follows, in relevant part:
(5) DEPARTMENT POWERS AND DUTIES. — The department is responsible for the administration of the state group insurance program. The department shall initiate and supervise the program as established by this section and shall adopt such rules as are necessary to perform its responsibilities. To implement this program, the department shall, with prior approval by the Legislature:
(a) Determine the benefits to be provided and the contributions to be required for the state group insurance program. Such determinations, whether for a contracted plan or a self-insurance plan pursuant to paragraph (c), do not constitute rules within the meaning of section 120.52 or final orders within the meaning of
section 120.52. Any physician‟s fee schedule used in the health and accident
plan shall not be available for inspection or copying by medical providers or other persons not involved in the administration of the program. However, in the determination of the design of the program, the department shall consider existing and complementary benefits provided by the Florida Retirement System and the Social Security System.
* * *
Final decisions concerning enrollment, the existence of coverage, or covered benefits under the state group insurance program shall not be delegated or deemed to have been delegated by the department.
The general rule is that the burden of proof, apart from a statutory directive, is on the party asserting the affirmative of an issue before an administrative tribunal. Young v. Dep't of Cmty. Aff., 625 So. 2d 831, 833-834 (Fla. 1993); Dep't of Transp. v. J.W.C. Co., 396 So. 2d 778, 788 (Fla. 1st DCA 1981); Balino v. Dep't of HRS, 348 So. 2d 349, 350 (Fla. 1st DCA 1977). Petitioner, as the party asserting the right to payment of her claim under the State Employees‟ PPO Plan, has the initial burden of demonstrating by a preponderance of the evidence that her claim qualified for coverage. If Petitioner meets this requirement, the burden shifts to Respondent to prove that the claim was not covered due to the application of a policy exclusion. Herrera v. C.A. Seguros Catatumbo, 844 So. 2d 664, 668 (Fla. 3d DCA 2003); State Comprehensive Health Ass‟n v.
Carmichael, 706 So. 2d 319, 320 (Fla. 4th DCA 1997).
Insurance contracts are to be construed in accordance with the plain language of the policy, with any ambiguity construed against the insurer, and in favor of coverage. U.S.
Fire Ins. Co. v. J.S.U.B., Inc., 979 So. 2d 871, 877 (Fla.
2007); Kohl v. Blue Cross & Blue Shield of Fla., Inc., 988 So.2d 654, 658 (Fla. 4th DCA 2008). Exclusionary clauses are to be construed even more strictly than coverage clauses. Purelli v.
State Farm Fire & Cas., 698 So. 2d 618, 620 (Fla. 2d DCA 1997).
Based on the Findings of Fact set forth above, Petitioner has met her initial burden of demonstrating entitlement to reimbursement for her stay at the H-P Pavilion. The facts established that her medical team determined that it was a medical necessity for her to stay in the H-P Pavilion or a similar facility7/ in order to receive her continuing transfusions and other treatments at Johns Hopkins. Petitioner at all times had the option of remaining in or returning to Johns Hopkins, at a much greater, and clearly reimbursable, expense. The H-P Pavilion was located on the John-Hopkins campus and served only John-Hopkins patients and their families. The H-P Pavilion‟s billing document includes the Johns-Hopkins Hospital on its letterhead.
DSGI‟s rejection of Petitioner‟s Level II appeal was based on its interpretation of the undefined term “hotel” in the Benefits Document. “When an insurer fails to define a term in a
policy, as it failed to do in this case, the insurer cannot take the position that there should be a „narrow, restrictive interpretation of the coverage provided.‟” State Comprehensive
Health Ass‟n v. Carmichael, 706 So. 2d 319, 320-321 (Fla. 4th DCA 1997), (citing Budget Rent-a-Car Sys., Inc., v. Gov‟t Empl.
Ins. Co., 698 So. 2d 608, 609 (Fla. 4th DCA 1997) and quoting Nat‟l Merchandise Co. v. United Serv. Auto Ass‟n, 400 So. 2d 526, 530 (Fla. 1st DCA 1981)). Neither the normal dictionary definition of “hotel” nor the specific regulatory definition of the term set forth in section 509.013, is applicable to the H-P Pavilion.
The undersigned is mindful of the proposition that an agency‟s construction or application of a statute it is charged with enforcing is entitled to great deference. However, such deference is not necessary where the decision in question requires no special agency expertise, or if the agency‟s interpretation conflicts with the plain and ordinary meaning of the statute. Fla. Hosp. v. Ag. for Health Care Admin., 823 So. 2d 844, 848 (Fla. 1st DCA 2002). In this case, no special agency expertise was required to read the plain language of the Benefits Document and find that H-P Pavilion was not a “hotel” under any reasonable definition of the term, and that Petitioner‟s stay at the H-P Pavilion was medically necessary and directly related to her treatment at John Hopkins.8/
Respondent has failed to meet its burden to prove that Petitioner‟s claim was not covered due to the application of a policy exclusion. Petitioner is therefore entitled to reimbursement for her stay at the H-P Pavilion.
RECOMMENDED that the Department of Management Services, Division of State Group Insurance, enter a final order finding that Petitioner is entitled to reimbursement for her stay at the Hackerman-Patz Pavilion in Baltimore, Maryland, from
December 30, 2011, through January 31, 2012.
DONE AND ENTERED this 18th day of November, 2013, in Tallahassee, Leon County, Florida.
LAWRENCE P. STEVENSON
Filed with the Clerk of the Division of Administrative Hearings this 18th day of November, 2013.
1/ The date of Petitioner‟s request for informal hearing was unclear from the record, but DSGI has not raised the issue of timeliness in this proceeding.
2/ Mr. Alexander testified that they chose an apartment rather than a suite because the apartment had a range for cooking and a washer and dryer. The range was necessary because Petitioner required a special diet that her father had to prepare. The washer and dryer were necessary because Petitioner‟s incontinence and persistent vomiting necessitated virtually constant washing of her clothing and bedclothes.
3/ At the final hearing, Florida Blue analyst, Jessica Bonin, testified that Florida Blue did not review Petitioner‟s claim in terms of “medical necessity.” She confirmed that Florida Blue‟s sole ground for rejecting Petitioner‟s Level I Appeal was that the H-P Pavilion was a “motel/hotel accommodation.”
4/ DSGI submitted neither of the cited documents into evidence. As noted in Finding of Fact 1, supra, it is assumed that the version of the Benefits Document that was submitted into evidence contains the identical information.
/hotel.
6/ At the hearing, DSGI‟s nurse consultant Kathy Flippo attempted to broaden the Benefits Document‟s exclusionary language to cover all “housing accommodations,” but the clear language of the Benefits Document is limited to “motel/hotel accommodations.” Ms. Flippo also attempted to broaden the exclusion to apply to any location where medical services are not offered, but the language of the Benefits Document is limited to items or services that are not “directly related to your treatment.” There was an essential relationship between Petitioner‟s stay at the H-P Pavilion and her continuing treatment at Johns Hopkins.
7/ Had Petitioner chosen to stay in a hotel, then her accommodations would not have been reimbursable under the plain language of the Benefits Document.
8/ It is again emphasized that the exclusionary language in the Benefits Document was stated in the conjunctive. To deny Petitioner‟s claim, DSGI was required to find that her stay was not medically necessary and that it was not directly related to her treatment. Even if DSGI were correct that the stay in H-P Pavilion was not “medically necessary” as that term is defined in the Benefits Document, there is no rational ground for concluding that Petitioner‟s stay was not directly related to her treatment at Johns Hopkins.
Sonja P. Mathews, Esquire Department of Management Services Office of the General Counsel 4050 Esplanade Way, Suite 160
Clifford A. Taylor, Esquire Department of Management Services Suite 160D
Jason Dimitris, General Counsel Department of Management Services 4050 Esplanade Way, Suite 160
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.
