Findings Of Fact In 1975 the Florida Legislature passed the Medical Malpractice Reform Act, Chapter 75-9, Laws of Florida, now codified in Chapter 768, Florida Statutes. Part of this legislative package included the creation of the Fund. This legislation was passed in response to a medical malpractice insurance crisis which arose when the primary underwriter for the Florida Medical Association sought to stop issuing medical malpractice policies in Florida, thus making it difficult, if not impossible, for physicians or hospitals to obtain medical malpractice insurance coverage at reasonable rates. As a result of this problem, many physicians began to practice defensive medicine, curtail or abandon their practices or practice without coverage of any kind. The Fund is a private not-for-profit organization, participation in which is totally voluntary for its member-health care providers. Insofar as Petitioners are concerned, membership in the Fund is but one of several options available to provide legally required evidence of financial responsibility in order to obtain licensure as a hospital facility in Florida. Physicians, hospitals, health maintenance organizations and ambulatory surgical centers who become members of the Fund must maintain at least $100,000 in primary professional liability insurance. Membership in the Fund grants to each participant a limitation of liability above the $100,000 in primary coverage. To the extent that any settlement or judgment exceeds the primary coverage of the participant, it is paid by the Fund without limitation. The Fund is operated subject to the supervision and approval of a board of governors whose membership is required by law to consist of representatives of the insurance industry, the legal and medical professions, physicians' insurers, hospitals, hospitals' insurers and the general public. The Department is charged by statute with certain regulatory functions concerning the Fund. As the law existed in 1980 a base fee for Fund membership was set by statute at $500 for physicians, after an initial $1,000 enrollment fee for the first year of participation, and at $300 per bed for hospital members. The statute required the Department to set additional fees based upon the classifications of health care providers contained in the statute. In the event that base fees are insufficient to pay all claims asserted against the Fund for a given fund year, the Department is empowered, upon request of the Board of Governors of the Fund, to order assessments against Fund participants to meet any such deficiency. Under the original legislation, all classes of health care providers could be assessed unlimited amounts to make up any deficiencies. As a result of legislative amendments which became effective July 1, 1976, the amount which participants, other than hospitals, could be assessed was limited to the amount each Fund member had paid to join the Fund for that particular coverage year. 1976 legislative amendments also required that each fiscal year of the Fund, which runs from July 1 through June 30, be operated independently of preceding fiscal years, and further required that occurrences giving rise to claims in a particular fund year be paid only from fees or investment income on those fees collected for that particular year. Thus, it is entirely possible for the Fund to experience deficits in a given year, and yet hold surplus funds for other years. On March 14, 1983, the Department of Insurance issued a "Notice of Assessment for 1980-81 Fiscal Fund Year" (hereinafter called the "Notice of Assessment). (exh. 20) Notice of this Notice of Assessment was published in the Florida Administrative Weekly, March 25, 1983, Vol. 9, no. 12. The Notice of Assessment announced that the Insurance Commissioner intended to levy and authorize the Fund to collect an assessment in the amount of $23,684,511 from those health care providers that were members of the Fund in fund year 1980-81 (exh. 20). Each of the hospitals named as Petitioners in the Petition for Administrative Proceedings in Case Dos. 83-1067 and 83-1068 were members of the Florida Patient's Compensation Fund during the fund year 1980-1981. (exh. 40; P.H.S. V 1) The chart below contains the following information concerning fund year 1980-81: the amount of the total proposed assessment described in the Notice of Assessment (dated March 14, 1983); the amount of the losses experienced by doctors and hospitals, respectively; the amount of the fees originally paid by doctors and hospitals; and the amount of the proposed assessments for doctors and hospitals; 1980-1981 Fund Year - Total Assessment $23,684,511 DOCTORS HOSPITALS Losses $19,086,800 Losses $29,798,500 Fees Paid 4,299,117 Fees Paid 6,015,827 Assessments 4,322,233 Assessments 18,734,918 (P.H.S. V 9) The Department computed the portion of the assessment to be paid by the different classes of health care providers for the 1980-1981 fund year based upon an "indicated rate method." This method is represented by the following formula: The Department started with the actuarially indicated rate for each class of health care provider as described in the October, 1981 Actuarial Report prepared by Tillinghast, Nelson, et al. This is called the "indicated rate by class." The Department then applied the following formula for each class: Indicated Rate by Class x No. of Members in the Class = Total indicated fees by Class Total Indicated Fees by Class divided by total Indicated Fees for ALL Classes = Percentage of Indicated Fee by Class Percentage of Indicated Fee by Class x Total Expected Loss for ALL Classes = Expected Loss by Class (Expected loss is ALL losses for the fund year including claims previously paid, reserves established on claims asserted and IBNR [incurred but not reported].) (P.H.S. V 12) The "indicated rate method" for allocating assessments among the various classes of health care providers was selected by the Department as the method which most fairly reflected the classifications prescribed in Section 768.54(3)(c), Florida Statutes. The record in this proceeding establishes that this method is the most feasible mechanism for fairly reflecting classifications established by statute, and, at the same time, providing immediate funds necessary to meet all claims against the Fund. (P.H.S. V 13) The difference between the results derived by the "indicated rate method" and the amounts reflected in the Notice of Assessment is due to the application of the statutory cap on assessments against physician members, as applied by the Department of Insurance. (P.H.S. V 14) Exhibit #17 shows (a) the calculations utilized by the Department in spreading the assessments for the 1980-81 fund year, (b) the amount each class would have paid under the "indicated rate method" for the fund year 1980-81 and (c) the amount actually described in the 1980-81 Notice of Assessment of the Department of Insurance. The Notices of Assessment issued by the Department of Insurance for fund years 1980-1981 allocated the "excess assessments" (which could not be applied to physician members because the 768.54(3)(c)'s limitation on the amount physicians could be assessed) among the other classes of health care providers based upon their percentage of "expected losses." (P.H.S. V 16) The amounts of the assessments sought by the Fund, and described in the Notices of Assessment, were calculated by the Fund by using the following formula: Total fees paid during the Fund Year + Investment Income attributable to the Fund Year Expenses allocated to that Fund Year Amount paid on claims for that Fund Year Amount reserved for all known claims for that Fund Year. (P.H.S. V 17) The fees ordered by the Department of Insurance and collected by the Fund plus the interest income generated by such fees for fund year 1980-81 are inadequate to cover claims against the Fund for that year. (P.H.S. V 19) Petitioners, for purposes of this proceeding, do not contest: (a) the method by which the Fund establishes reserves; (b) the amount of the reserves established for any individual claim file; or (c) the amount of the total deficit described in the Notices of Assessment dated March 14, 1983 for fund year 1980-1981. Nonetheless, Petitioners do not concede that the Fund needs all of the money described in the Notice of Assessment dated March 14, 1983 at this time. (P.H.S. V 33,34) The record in this cause establishes that as of March 14, 1983, there existed a deficiency in the Fund's account for the 1980-1981 fund year of at least $23,684,511 for the payment of settlements, final judgments and reserves on existing and known claims. Approximately $19,405.00 of this deficit is directly attributable to one judgment - Von Stetina v. Florida Medical Center. This was a malpractice judgment against a hospital which has been affirmed on appeal by the First District Court. An appeal has been filed in the Florida Supreme Court. (exh. nos. 1, 2, 18, 19, 26, 27 and 38) In view of the statutory cap on the amounts that may be assessed against physician members of the Fund, the foregoing dollar amounts for assessments for the 1980-81 fund year, and the manner in which they are proposed to be allocated among the remaining classes of health care providers are appropriate. The original fees for the 1980-1981 fund year were set in June of 1980. The Fund by letter dated April 21, 1980 requested that the Department approve an increase in membership fees for physicians and surgeons in the amount of twenty-five (25) percent and a redefinition of rate classes that would move eighteen (18) percent of the physicians and surgeons from Class 3 to Class 2. The Department published notice in the Florida Administrative Weekly and notified interested parties on its mailing lists that a public hearing was to be held on June 2, 1980. This hearing was held pursuant to 627.351, 768.54, and Chapter 120, Florida Statutes. The purpose of the hearing was identified as "to afford the Fund an opportunity to present evidence and agreement in support of its filing and, further, to afford any affected person an opportunity to present evidence and argument relating to the filing." A hearing was in fact held on June 2, 1980. The Fund presented evidence and argument in support of its request for twenty-five (25) percent increase in fees. No parties argued or presented evidence contending that the fees should have been higher. Subsequent to the hearing, the Department notified the Fund by letter dated June 12, 1980 that its request was approved. Acting on the Department's approval, the Fund sent all prospective members of the Fund for the 1980-81 year membership forms. These forms notified each health care provider what the fees for membership for all health care providers would be. In order to join the Fund each health care provider was required to fill out and sign these forms, thereby agreeing to pay the membership fees and any future assessments which might be levied. Both Petitioners and Respondent have submitted proposed findings of fact for consideration by the Hearing Officer. To the extent that those proposed findings of fact are not included in this Recommended Order, they have been specifically rejected as being either irrelevant to the issues involved in this cause, or as not having been supported by evidence of record.
The Issue Whether Respondents violated Sections 475.25(1)(e), (k), Florida Statutes, and Chapter 61J2-14, Florida Administrative Code.
Findings Of Fact Petitioner, Department of Business and Professional Regulation, Division of Real Estate (Division), is a state licensing and regulatory agency charged with the responsibility and duty to prosecute administrative complaints pursuant to Chapters 455 and 475, Florida Statutes. Respondent, Lynda J. Lobsitz (Lobsitz), is and was at all material times to this proceeding licensed as a real estate broker in accordance with Chapter 475, Florida Statutes, having been issued license number 0377747. Respondent, Jaclo, Inc. (Jaclo), is and was at all times material to this proceeding, a licensed real estate brokerage corporation, having been issued license number 0275422. During May 1997, the Division conducted an office inspection and escrow audit of Respondents' real estate office. On the day of the audit, Respondents maintained an escrow account for rental security deposits, which account had an adjusted trust liability of $85,300.89.1 The adjusted bank balance was $85,185.22, resulting in a shortage of $115.67. Respondents prepared bank reconciliation reports for January, February, March, and April 1997 for the rental security deposit account and for the rental escrow account. Attached to each of the reports was the monthly bank statement for the account and period covered in the bank reconciliation report. The bank statements identified the name of the bank, the name of the account, the account number, the account balances and dates. A list of outstanding checks, identifying the outstanding checks by date and number, was attached to each report. The dates used to reconcile the balances were not included in the bank reconciliation reports. For the January 1997 bank reconciliation report for the rental rents deposits account, there was a difference of $7,616.25. Respondents stated on the report that $7,630.00 was for a check which was returned for endorsement. The report further stated that $13.75 had not been located. For the February 1997 bank reconciliation report for the rental rents deposits account, there was a difference of $1,756.75. The report contained an explanation for the difference and the corrective action taken. For the March 1997 bank reconciliation report for the rental rents deposits account, there was a difference of $500 which was explained with the corrective action noted. For the bank reconciliation report for January 1997 for the rental security deposit and account, there was an overage of $531.33. The report stated that the amount had not been located. For the bank reconciliation for the rental security deposit and account for February, 1997, there was an overage of $2,234.33. The report explained that $1,700 was a bank error deposit; $3.00 was sales tax which was to be transferred to rents account; and the remaining $531.33 could not be located. For the bank reconciliation for the rental security deposit and account for March 1997, there was an overage of $31.33. The explanation and corrective action stated on the report was "Bank wire to incorrect account Mushlin will transfer from rents accounts. $531.33 have not located." For the bank reconciliation report dated April 1997 for the rental security account, there was an overage of $531.33 with the explanation of "Have not located difference."
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered finding that Respondents violated Sections 475.25(1)(e), Florida Statutes, issuing a reprimand for the Respondents, requiring that Respondent Jaclo, Inc., pay an administrative fine of $100, and requiring that Respondent Lynda J. Lobsitz take a seven-hour broker management course. DONE AND ENTERED this 14th day of July, 1998, in Tallahassee, Leon County, Florida. SUSAN B. KIRKLAND 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 Filed with the Clerk of the Division of Administrative Hearings this 14th day of July, 1998.
The Issue Whether Petitioners are liable for the payment of amounts set forth in Respondent's Notice of Assessment for fiscal fund years 1977-78, 1979-80, 1980- 81, and 1981-82, dated November 9, 1984, pursuant to Chapter 768, Florida Statutes. This proceeding arose as a result of petitions filed by two groups of hospitals contesting Notice of Assessment issued by the Department of Insurance on November 9, 1984, based upon the certification by the Board of Governors of the Florida Patient's Compensation Fund to the Insurance Commissioner of a deficiency in the amount of money available to pay claims for the 1977-78, 1979- 80, 1980-81, and 1981-82 fiscal Fund Years. The proposed assessment seeks payment of the alleged deficiency in the total amount of some 57 million dollars from health care providers who were members of the Fund during the fund years in question, pursuant to Section 768.54, Florida Statutes. Two groups of hospitals subsequently filed petitions contesting the proposed assessment. They consist of Tallahassee Memorial Regional Medical Center and 42 other hospitals (Case No. 34-4398), and Southeast Volusia Hospital District and 64 other hospitals (Case No. 85-4399). A third petition was filed by Miami General Hospital, Inc. shortly before the final hearing herein (Case No. 85-0992). The three cases were consolidated for hearing. An additional petition filed by Harborside Hospital was merged with the petition of Tallahassee Memorial Regional Hospital, et al. Mount Sinai Medical Center of Greater Miami, Inc., one of the petitioners in Case No. 84-4398, filed a "Supplemental Petition" raising additional disputed issues, including the question of whether the Department of Insurance was required to consider the impact of the loss of Medicare reimbursement on individual member hospitals in allocating the proposed assessment to such hospitals. Intervention as a party respondent was granted to the Florida Patient's Compensation Fund. By prehearing orders, it was determined that questions involving Medicare reimbursement, the setting of fees for various classes of health care providers, and the repeal of the "statutory cap" by Chapter 83-206, Laws of Florida, amending Section 768.54, Florida Statutes, were not properly in issue in this proceeding. The parties entered into a prehearing stipulation that set forth certain agreed facts. However, Respondents reserved the right to object to their relevance or materiality. Such of the agreed facts as are deemed relevant are included hereinafter. The following issues of law remain for determination: Whether the Fund and the Department properly applied Section 768.54, Florida Statutes, in certifying and approving a deficit and assessment for each of the subject Fund years based on the reserving practices and procedures employed by the Fund; particularly: (a) in failing to adjust or write down reserves to reflect the amounts of known settlements and verdicts, plus accrued interest as of the certification date. (b) by the manner in which claims supervisors and the claims committee for the Fund posted or set reserves on individual cases. (c) in that the reserves set by the Fund on known cases are redundant. Whether the Fund and the Department properly applied the $15 million maintenance cap with respect to the actual assessment for each Fund Year. At the hearing, Petitioners presented the testimony of Lee M. Smith, who was accepted as an expert in actuarial science, and Catherine M. Sims, Administrative Manager of the Florida patient's Compensation Fund. Additionally, petitioners submitted deposition testimony of Michael Rinehart, Administrator for Automobile and General Liability Claims for the Division of Risk Management, Department of Insurance, and excerpts of prior testimony of John W. Odem. Petitioners submitted 16 exhibits in evidence which are numbered according to the exhibit list contained in the Prehearing Stipulation. Respondents presented the testimony of Ms. Sims, Charles Portero, Claims Manager of the Florida Patient's Compensation Fund, who was accepted as an expert in claims handling and reserving practices, and Jerome Vogel, an actuary with the Department of Insurance who was accepted as an expert in that field. Respondents also submitted the deposition testimony of Ward Johnson, Vice President of Claims for Alexsis Risk Management, and James O. Wood, a Consultant Actuary employed by Tillinghast, Nelson and Warren, Inc. Respondents submitted 18 exhibits, including supplemental excerpts of the prior testimony of John W. Odem and Michael Rinehart. Respondents' exhibits also follow the numbers set forth in the Prehearing Stipulation, except for exhibits which were not listed therein. At the conclusion of the hearing, certain of Respondents' answers to Petitioners' request for admissions were received in evidence. Certain other answers were proffered, as were a number of Petitioners' exhibits, as reflected on the record. The parties have submitted proposed recommended orders that have been fully considered. All matters therein have been ruled on directly or indirectly herein, except for proposed findings of fact that have been rejected as subordinate, cumulative, immaterial, or unnecessary.
Findings Of Fact The Florida Patient's Compensation Fund (Fund) is established under Chapter 768, Florida Statutes, for the purpose of paying claims against member health care providers, including hospitals, in amounts exceeding statutory limits which must be maintained by the health care provider as primary coverage. The Fund is operated subject to the supervision and approval of a Board of Governors which consists of members representing the insurance industry, the legal and medical professions, hospitals and the general public. Annually, each health care provider electing to become a member of the Fund pays certain fees established by statute for deposit into the Fund. Each fiscal year of the Fund operates independently of preceding fiscal years and participants are only liable for assessments for claims from years during which they were members of the Fund. If the Fund determines that the amount of money in an account for a given fiscal year is insufficient to satisfy claims, it certifies the amount of projected excess or insufficiency to the Insurance Commissioner with a request that he levy an assessment against Fund participants for that fiscal year. Subsection 768.54(3)(c), Florida Statutes (1981), which was the statutory language applicable during all fund years in question, provides that the Insurance Commissioner shall levy such assessment against the participants in amounts that "fairly reflect the classifications prescribed above and are sufficient to obtain the money necessary to meet all claims for said fiscal year." For all years at issue in this proceeding, a statutory limitation was in effect on the amount physician members of the Fund could be assessed. Petitioner hospitals were members of the Fund during one or more of Fund Years 1977-78, 1979-80, 1980-81, and 1981-82 (Stipulation). Each month, the Administrative Manager of the Fund follows a prescribed procedure to determine if an assessment is required for a particular Fund Year, utilizing what is termed a "retrospective rating plan." The plan provides that assessments will not be levied in any year until the cash available for paying claims in that membership year is down to 33 percent of the loss and expense reserves for all known losses. It further provides that the amount should be sufficient to create enough cash flow to pay known reserved claims for the year showing such deficit. In reviewing the Fund's monthly financial report of March 31, 1984, it was determined that a sufficient deficit existed to warrant the levy of an assessment. Thereafter, an outside audit of the Fund accounts was conducted and presented to the Fund Board for certification. At a meeting of the Fund Board of Governors on May 12, 1984, the Board approved the verifications that assessments had been triggered for the 1978, 1980, 1981, and 1982 fiscal years and voted to submit the deficit certification to the Insurance Commissioner for assessment. Thereafter, by letter of May 23, 1984, the proposed assessment was certified to the Insurance Commissioner. (Respondents' Exhibits 2 a, b, c, 4-5, 7, 9, 17; Testimony of Sims.) Prior to the issuance by the Department of an assessment order, the 1982 Fund Year triggered an additional deficit in excess of nine million dollars. The Fund's Board of Governors, at their October 25, 1984 meeting, accepted the audit substantiating the need for the additional amount to be added to the 1982 Fund Year assessment. On November 9, 1984, the Department issued a Notice of Assessment for Fund Years 1977-78, 1979-80, 1980-81, and 1981-82. The Notice of Assessment announced that the Insurance Commissioner intended to levy and authorized the Fund to collect an assessment in accordance with the Fund's certification of deficits as follows: 1977-78 Membership Year $ 7,467,603.00 1979-80 Membership Year 3,952,812.00 1980-81 Membership Year 18,448,460.00 1981-82 Membership Year 16,154,699.00 (amount certified May 23, 1984) 1981-82 9,047,785.00 (amount certified October 29, 1984) The Notice of Assessment of November 9, 1984, further provided that the assessment shall be divided among the various classes of health care providers for each year as follows: CLASS OF HEALTH CARE PROVIDERS AMOUNT OF ASSESSMENT Class 1977-78 1979-80 1980-81 1981-82 Physicians & Surgeons (a) Class 1 0 0 0 $ 1,370,677 (b) Class 2 0 0 0 1,974,946 (c) Class 3 0 0 0 6,476,422 2. Hospitals 7,467,603 3,924,941 18,309,420 14,668,665 3. HMO 0 9,764 44,203 97,207 4. Ambulatory Surg. Center 0 18,107 94,837 38,555 5. Professional Assoc. 0 0 0 576,012 The notice further provided that each health care provider that was a member of the Fund during one or more of the specified Fund Years shall pay a pro rata portion (based on premium paid) of the total amount assessed against the class of health care providers for each year of which the health care provider was a member. It further stated that each health care provider failing to pay its share of the assessment within 21 days of date of receipt of the order or its publication in the Florida Administrative Weekly, whichever date is earlier, shall pay an additional amount in interest of 12 percent per year. (Respondents' Exhibits 3 a-d, 6, 11-12, Stipulation, Testimony of Sims.) The Fund used the same procedure in preparation of Certification to the Department in this fifth assessment since the inception of the Fund as it used in the first four assessments. The Department used the same procedure and methodology (indicated rate method), in allocating the assessment among the various classes as it used in the first four assessments. The Fund levies assessments based on the amount needed to pay known claims. Usually, the Fund becomes aware of a claim by service of process incident to a civil action. The Fund's reserves are estimates of the amount needed to pay known claims. The Fund follows standard industry reserving practices, as modified in several respects by its particular needs and procedures. Each claim is assigned to a claims supervisor who obtains information concerning the claims incident from the primary insurance carrier. The initial reserve on a claim is based on a variety of factors, including the type of injury, potential damages, liability considerations, geographic location, and the particular attorney for the claimant. After a determination that a reserve is needed on the file, the claims supervisor makes an initial determination of the amount which is referred to the claims manager for approval. Final approval of the posted reserve lies in the hands of the Claims Committee of the Fund. The figure is usually fixed at a sum for which it is believed that the claim could be settled and the potential liability arising from a jury verdict. The necessity of obtaining approval of the Claims Committee for the initial reserve and any subsequent changes creates a certain amount of delay in obtaining such decisions. Changes may be effected in the reserve when injuries are found to be greater than anticipated, or because of the discovery of additional facts affecting potential liability. It is not unusual for a particular claim to be submitted three or four times to the Claims Committee before it is settled. In recent years, the Fund has not had sufficient cash available to pay all the required settlements or verdicts due to the lack of ability to collect prior assessments which have been in litigation. The Fund has found that such delays have increased the settlement value of claims, and plaintiffs unwilling to wait for payment of a settlement amount have gone on to trial and obtained verdicts in excess of what the case could have been settled for if the funds had been available. The reserve for a particular case is normally adjusted following settlement or verdict within a period of approximately 90 days. Although such an adjustment includes anticipated interest, interest is not taken into consideration in setting initial reserves. Past experience has shown that a lag time of about two years will elapse before funds are available to pay settled claims and, accordingly, interest is projected for a substantial period when reserves are adjusted. (Testimony of Portero.) Although individual claims have been found to be "over-reserved" at a particular point in time, it is also true that other claims are sometimes "under-reserved." The setting of reserves is based upon past experience and is necessarily subjective to a certain extent. As indicated above, changes in the status of a claim may require an increase or decrease in the amount of reserve. Additionally, a number of claims settled shortly before certification of the deficit for the assessment herein reflected that the Fund did not reduce the reserves to the amount of settlement prior to the certification dates. Several such instances were brought to the attention of the Fund in a claims audit made by an independent firm in March 1984. However, the audit report also noted that although the claims staff recognized the potential of large exposure claims, the Claims Committee was not allowing them to set a sufficient reserve on the "million dollar plus exposure claims." The auditor found that overall, the file reserves were in line by the time a case went to trial, but that the reserves could probably have been established more promptly if traditional claims handling procedures had been employed. The report found that there were many cases of reserve requests being made by the claims personnel which were turned dawn or drastically cut by the Claims Committee, and recommended that the claims staff should be allowed to set the reserves to properly reflect the exposure that the claim had at the time the file is examined. It was the opinion of the individual who conducted the claims audit, Ward W. Johnson, Vice President Of Claims, Alexsis Risk Management Services, Inc., that the number of cases that were under-reserved exceeded the cases that had potential of being over- reserved. He was of the further opinion that generally the Fund did a "good job of reserving." (Respondents' Exhibits 13, 23, (Deposition of Ward Johnson); Petitioners' Exhibits 23, 58.) Conflicting expert testimony and statistical data concerning the reasonableness of the Fund's reserving practices in general and for the Fund Years in question were presented by the parties at the hearing. Based on the totality of the evidence presented, it is found that the Fund's procedures conform generally to standard insurance industry practices. Although there is evidence as indicated heretofore that individual cases have been both "over- reserved" and "under-reserved," and that required adjustments to reserves have not always been made in a timely manner, the evidence does not show that the reserves as a whole or as to the instant assessment are unreasonable. (Petitioners' Exhibits 10-13, 62-63; Respondents' Exhibits 13, 18, 20-24; Testimony of Wood (deposition), Johnson (deposition), Vogel, Smith, Portero, Rinehart (deposition), Odem (prior testimony).) It is further found that the present assessment was prepared in accordance with standard procedures, that the amounts proposed to be levied as an assessment for each Fund Year in question represent a deficiency in the Fund Account for such years, and that the proposed allocations of such amounts among the specified health care providers are appropriate. (Respondents' Exhibits 2- 3, 5-7, 9, 11-12, 17, 29; Joint Exhibit 1 (Stipulation) testimony of Sims, Vogel.) 12. During Fund Years 1979-80, 1980-81, and 1981-82, Section 768.54, Florida Statutes, provided that the Fund shall be "maintained" at no more than $15 million per fiscal year. There was a $25 million maintenance cap applicable to Fund Years prior to 1979-1980. The limitation was removed by statutory amendment in 1982 (Chapter 82-236, Laws of Florida). Petitioners contend that the present assessment exceeds the $15 million "can" for Fund Years 1980-81 and 1981-82, but failed to submit competent substantial evidence to support such contention. The Fund apparently used the limitation as applicable to membership fees and not to assessments. The letter of the Fund to the Department, dated May 23, 1984, certifying the assessment, stated in part as follows: During the 1981-82 membership year the Fund's membership fees exceeded the $15 million cap and, by your Order, the excess was returned to those members. We are requesting that your Order of Assessment for the 1982 membership year include an Order for the overage refunds to be repaid to the Fund. In any other respects, the Fund did not take the monetary limitation into consideration with regard to the present assessment. (Petitioners' Exhibit 24; Respondents' Exhibit 2b; Testimony of Sims, Vogel.)
Recommendation In view of the foregoing, it is recommended that a final order be entered by the Department of Insurance levying assessments in accordance with the Notice of Assessment, dated November 9, 1984, for the Fund Years specified therein. DONE and ENTERED this 9th day of May, 1985, in Tallahassee, Florida. THOMAS C. OLDHAM Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 9th day of May, 1985. COPIES FURNISHED: Honorable William Gunter Treasurer and Insurance Commissioner The Capitol Legal Division Tallahassee, Florida 32301 William C. Owen and Doug Hall, Esquires Carlton, Fields, Ward, Emmanuel, Smith and Cutler Post Office Drawer 190 Tallahassee, Florida 32302 Cathi C. O'Halloran, Esquire Pennington, Wilkinson and Dunlap Box 3985 Tallahassee, Florida 32315-0985 James Wing, Esquire Myers, Kenin, Levingson, Frank and Richards 1428 Brickel Avenue Miami, Florida 33131 Louis F. Robinson, III, Esquire Barnett and Alagia 250 South County Road Suite 201 Palm Beach, Florida 33480 David A. Yon and Dennis S. Silverman, Esquires Department of Insurance Legal Division Room 413-B Larson Building Tallahassee, Florida 32301 E. Clay McGonagill, Jr., Esquire 241 East Virginia Street Tallahassee, Florida 32301
The Issue Whether Respondent is entitled to a Consumer Certificate of Exemption under Section 212.08?
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Respondent is a nonprofit Florida corporation that was formed in 1980 to promote economic development and revitalization (and the resultant creation and retention of jobs) in targeted areas in the City of Miami and Dade County, Florida, by lending money to business desiring to locate or remain in these targeted areas. Article II of Respondent's Articles of Incorporation sets forth the "purposes" of the corporation. It reads as follows: This corporation is organized exclusively for charitable, education and economic development purposes which include promotion of community welfare by: (i) lessening of neighborhood tensions, (ii) lessening discrimination and (iii) combatting community deterioration by promoting and fostering the economic development of the City of Miami and Dade County, Florida. In furtherance of these purposes the corporation intends to engage in the following types of activities: Making investments in, and loans to, corporate or other business entities with monies which are directly or indirectly attributable to funds provided by the City of Miami, Dade County, Florida or other funds provided by the United States, the State of Florida or any agency or instrumentality of any of the foregoing, with funds generated by the repayment of the principal amount and accrued interest thereon of any loans made with such funds, or any dividends or other distributions paid to the corporation by any entity in which the corporation has an ownership interest, and with any funds contributed to the corporation by any individual or entity; Providing assistance for individuals, groups and organizations in planning and executing successful economic development projects; Providing professional assistance and counseling of all types, including business planning for individuals, organizations and their members where such counseling may be necessary for the economic development of low income or low employment areas; Acting as an intermediary, where appropriate, between various economic development programs and between organizations and individuals which may be involved in any capacity in economic development; Acquiring charitable contributions and assistance capital including seed money, which may be necessary for successful economic development projects; and Engaging in such other activities as the Board of Directors shall from time to time approve, provided that in no event shall this corporation be operated for purposes other than those permitted under Section 501(c)(3) of the Internal Revenue Code of 1954 or corresponding sections of any prior or future law. The corporation shall have the power, either directly or indirectly, either alone or in conjunction or cooperation with others, to do any and all lawful acts and things and to engage in any and all lawful activities which may be necessary, useful, suitable, desirable or proper for any and all of the purposes for which the corporation is organized, and to aid or assist other organizations whose activities are such as to further accomplish, foster or attain any of such purposes. Such activities shall include, but shall not be limited to, acceptance of gifts, grants, devises or bequests of funds, or any other property from any public or other governmental body and any private person, including but not limited to, private and public foundations, corporations and individuals. 2/ Notwithstanding anything herein to the contrary, this corporation may exercise any and all, but not other, powers as are in furtherance of the exempt purposes of organizations set forth in Section 501(c)(3) of the Internal Revenue Code of 1954 and its regulations as the same now exist, or as they may be hereafter amended from time to time. No part of the income or principal of this corporation shall inure to the benefit of or be distributed to any member, director or officer of the corporation or any other private individual in such a fashion as to constitute an application of funds not within the purpose of exempt organizations described in Section 501(c)(3) of the Internal Revenue Code of 1954. However, reimbursement for expenditures or the payment of reasonable compensation for services rendered shall not be deemed to be a distribution of income or principal. In the event of the complete or partial liquidation or dissolution of the corporation whether voluntary or involuntary, no member, director or officer shall be entitled to any distribution or division of the corporation's property or its proceeds, and the balance of all money and other property received by the corporation from any source shall, after the payment of all debts and obligations of the corporation in accordance with Chapter 617 of the Florida Statutes, be distributed and paid over by the Board of Directors to the City of Miami for public purposes. The corporation does not contemplate receiving any pecuniary gain or profit, incidental or otherwise. No substantial part of the activities of the corporation shall be the carrying on of propaganda or otherwise attempting to influence legislation, and the corporation shall not participate or intervene in, directly or indirectly, (including the publishing or distribution of statements) any political campaign on behalf of or in opposition to any candidate for public office. Over the past 16 years, Respondent has made 472 direct low interest business loans amounting to approximately $31.4 million. 3/ The recipients of these loans have collectively received from both public and private sources nearly $16.3 million in additional, matching funds. A potential borrower need not be disadvantaged or suffering from a hardship in order to receive a loan from Respondent. Indeed, as a general rule, Respondent will not make a loan unless the applicant demonstrates, during the application process, an ability to repay the loan. To this extent, and to this extent alone, Respondent takes into consideration the applicant's economic status in determining whether to grant the applicant's loan application. An intended 4/ by-product of Respondent's lending activities has been the creation and preservation of jobs in the targeted areas. The business investment that Respondent's activities have made possible has produced approximately 3,313 new jobs and preserved an estimated 1,391 jobs in these areas. The Internal Revenue Service treats Respondent as an exempt organization under Section 501(3)(c) of the Internal Revenue Code. In 1991, Respondent received from the Department a Consumer Certificate of Exemption, which, according to the cover letter that accompanied the Certificate, was "granted to [Respondent] in accordance with Section 212.08(7), Florida Statutes" and "exempt[ed Respondent] from the payment of sales and use tax on purchases of tangible personal property." The Certificate had an "issue date" of February 7, 1991, and an "expiration date" of February 7, 1996. Prior to the "expiration date," Respondent filed an application with the Department to renew the Certificate. The Department has preliminarily determined that the Certificate should not be renewed. It is this preliminary determination that is the subject of the instant controversy
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Department enter a final order finding that Respondent is not entitled to the Consumer Certificate of Exemption it is seeking pursuant to Section 212.08(7)(o)2.b.(IV), Florida Statutes. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 16th day of January, 1997. STUART M. LERNER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 SUNCOM 278-9675 Fax Filing (904) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 16th day of January, 1997.
The Issue The issue for consideration in this case is whether the Respondent's licenses as a real estate broker should be disciplined because of the matters set forth in the Administrative Complaint filed herein.
Findings Of Fact At all times pertinent to the allegations of misconduct in the Administrative Complaint, the Petitioner, Division of Real Estate, was the state agency charged with the responsibility for the licensing and regulation of the real estate profession in this state. The Respondent, Richard L. Bohner, was licensed as a real estate broker in Florida operating, with his wife, Kirsten, Bohner Real Estate, located at 205 E. Osceola Street in Stuart, Florida. On October 1, 1989, Mr. Bohner as owner/lessor, entered into separate rental agreements with Trudy Dohm and Thelma Reynolds, with Bohner Real Estate identified as agent, for the lease for 12 months each of apartments number 105 and 204, respectively, at 1674 S.E. St. Lucie Blvd. in Stuart, Florida, for a monthly rental of $350.00 each. Each lease provided for the placement of a security deposit and last month's rental in advance; those sums, according to the terms of the lease, to be held by the agent, Bohner Real Estate, in a non- interest bearing escrow account at the Florida National Bank in Stuart. In actuality, the sums above-mentioned were, in each case, deposited into an account at the First National Bank and Trust Company in Stuart. This account, number 8000030400, was held in the name of Richard L. Bohner or Kirsten L. Bohner, Trust account. This account was an interest bearing account and, over the time in question, also received several large deposits of funds by or on behalf of the Respondent, Richard L. Bohner which were his personal funds and not funds received as a part of or in conjunction with his activities as a real estate broker or those of Bohner Real Estate. For the most part, the funds placed in that account were Bohner's personal funds and security deposits and last month's rent on apartments in the building owned as a personal investment by Mr. and Mrs. Bohner. On February 20, 1990, Sharon Thayer, an investigator for the Department, in the normal course of business, went to the Respondent's real estate office, unannounced as was her prerogative, and asked to speak with Mr. Bohner. He was not present at the time and she asked Mrs. Bohner, who was present, to produce the Respondent's books for the brokerage's escrow account, which she did. In the course of their conversation, Mrs. Bohner identified herself as being in partnership with the Respondent and admitted to assisting him in the maintenance of the escrow account. When Ms. Thayer asked for the backup documents for the escrow account, these were produced. Ms. Bohner also provided Ms. Thayer with copies of the bank account she maintained. On inquiry, Mrs. Bohner said the deposits thereon were, in the main, representative of rental and security deposits from tenants on leases which Bohner Real Estate managed. Ms. Thayer asked about the large deposits made on May 3, June 7, and July 7, 1989. These were for $104,542.50, $50,000.00, and $4.600.00 respectively. In response, Mrs. Bohner indicated these were personal monies which came from personal sources and funds which had been put in that account because that's where they would get the most interest. They were not escrow funds related to the real estate brokerage. Ms. Thayer made an appointment to return to the brokerage office on February 23, 1990 to speak with Respondent. When she did so, Mr. Bohner accounted for the trust liability of $6,885.00 which existed on that date. This sum was verified with the bank by phone. The trust account had an overage of somewhat more than $881.00 which Respondent explained as accrued interest not removed from the account. Mr. Bohner admitted at hearing that he earned interest on the security and rental deposits he held in that account and used that earned interest to offset the low rentals he charged his tenants. He asserted, and there was no evidence to rebut this assertion, that the only security and rental deposits placed in that account were from tenants in the apartment building he and his wife owned personally. Neither he nor Bohner Real Estate managed or served as rental agent for any rental properties owned by others. It is so found. Ms. Thayer pointed out, and it is accepted as fact, that a broker is required to reconcile his trust account on a monthly basis and file a monthly reconciliation form which accounts for overages and shortages. Respondent admits he had not completed or filed these reconciliations because neither he nor Bohner Real Estate has a trust or escrow account into which client funds are deposited. He manages no property from which rents would be collected other than his own, and when he takes a deposit on a sale or transfer, a separate trust account is opened for that particular transaction with any interest earned going to the buyer. Petitioner showed, through the testimony of Ms. Casale, the bank records custodian, that the largest deposit in issue, that one in excess of $100,000.00, was the result of the maturity of a certificate of deposit that was transferred to the account in question. Respondent did not endorse the check for deposit or sign any deposit document. He submitted a letter from the bank chairman to support his thesis that he was not a party to the transfer, but the letter, admitted over objection by counsel for Petitioner, indicates the deposit was made by the bank's investment counselor who handled the transaction consistent with telephone instructions given her by the Respondent. This is a collateral matter, however. When Ms. Thayer completed her audit, she prepared and filed a report on which she indicated, inter alia, that the office met inspection standards and that the property management escrow/trust account was satisfactory. She noted an overage of $889.31 in the account and that it was an interest bearing account although the leases state it would be non-interest bearing. No deadline was given for the correction of this item. Mrs. Bohner admits that when she gave the apartment security escrow account to Ms. Thayer at her request and described it as a trust account, she was not thinking. In fact, and it is so found, neither Respondent nor Bohner Real Estate have a trust account for the business and have not had one for several years. She reiterates Mr. Bohner's assertion that the only money usually kept in the account referenced by Ms. Casale and referred to by Ms. Thayer, is money received as security deposits and last month's rental from tenants in their own building. In the absence of any evidence to the contrary, it is so found.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore: RECOMMENDED that a Final Order be entered in this case dismissing all allegations of misconduct by Respondents as outlined in the Administrative Complaint filed herein. RECOMMENDED in Tallahassee, Florida this 1st day of April, 1992. ARNOLD H. POLLOCK Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 1st day of April, 1992. APPENDIX TO RECOMMENDED ORDER The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties to this case. FOR THE PETITIONER: - 3. Accepted and incorporated herein. Accepted. - 7. Accepted and incorporated herein. Accepted and incorporated herein. First sentence accepted and incorporated herein,. Balance is not Finding of Fact but lore legal conclusion. Accepted and incorporated herein. Accepted and incorporated herein. FOR THE RESPONDENTS: None submitted. COPIES FURNISHED: Theodore Gay, Esquire Department of Professional Regulation 401 NW Second Avenue, Suite N-607 Miami, Florida 33128 Richard L. Bohner Bohner Teal Estate 205 East Osceola Street Stuart, Florida 34994 Jack McRay General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, Florida 32399-0792 Darlene F. Keller Division Director Division of Real Estate 400 W. Robinson Street Post Office Box 1900 Orlando, Florida 32802 - 1900
The Issue Here Petitioner has alleged that Respondent has violated Section 120.535, Florida Statutes, by failing to adopt its policies as rules. Those alleged policies are more completely described in the fact finding.
Findings Of Fact Mitchell has been subjected to the proposed agency action set forth in the order to show cause described in the preliminary statement. James Mitchell and Company, JMC Insurance Services, Inc., and JMC Financial Corporation are California corporations authorized to do business in Florida. JMC Insurance Services, Inc., and JMC Financial Corporation are wholly owned subsidiaries of James Mitchell and Company. James K. Mitchell is a resident of California. He is the president, chief executive officer and founder of James Mitchell and Company. He is also licensed by the Department as a nonresident life insurance agent. The Department is a regulatory agency in Florida who has the responsibility for implementing and enforcing the Florida Insurance Code. The Florida Insurance Code includes Chapters 624 and 626, Florida Statutes. The Department is headed by the Insurance Commissioner and Treasurer. The order to show cause forms the sole basis for action taken against Mitchell. The order to show cause has allegations by the Department concerning alleged violations of Section 626.988, Florida Statutes, attributed to Mitchell. It is the alleged interpretation which the Department has placed on Section 626.988, Florida Statutes, which Mitchell asserts is in violation of Section 120.535, Florida Statutes. The present petition sets forth that Mitchell's substantial interest are affected in accordance with Section 120.535(2)(a)1, Florida Statutes, in that: JMC is substantially affected by the Department's interpretation of s. 626.988 in that the Department would use the interpretation to require JMC to cease and desist from all current business activities in Florida, i.e., JMC's sale of annuities to Barnett as trustee to hold in trust for the benefit of trust participants/beneficiaries. The present petition then describes those agency statements by the Department which Mitchell claims constitute a rule as defined by Section 120.52(16), Florida Statutes, and thus subject to the requirements of Section 120.535(2)(a)2, Florida Statutes. The first statement by the Department which Mitchell claims violates Section 120.535(1), Florida Statutes, is to this effect: Abandoned Former Section .003 of Rule Chapter 4-223. Pursuant to Section 120.535(2)(a)(2) and 120.535(2)(b), the text of one of the statements which substantially affects JMC is the text of former Section .0003(2) (now abandoned) of Rule Chapter 4-223, promulgated by the Department on October 16, 1992 (copy attached as Exhibit F). The text of former Section .003(2) is as follows: For purposes of this entire rule chapter and enforcement of Section 626.988, Florida Statutes, the Department interprets the terms "associated" and "associate" as those terms are used in Section 626.988, as meaning: united in a relationship, or connected or joined together, or connected in mind or imagination. Therefore instances of prohibited association included, but are not limited to, situations wherein an agent or solicitor, themselves or through their employer: is in law or fact related or connected to the Financial Institution, as by formal or informal arrangement, contract, etc.; or is or may reasonably be expected to be connected with the Financial Institution in the mind or imagination of the general pubic using the Financial Institution's facilities, as a result of the agent or solicitor's presence or activities on Financial Institution premises, or other conduct or activities by the agent or solicitor or done with their consent. Section .003(2) of Rule Chapter 4-223 was promulgated ostensibly under F.S., s. 626.988(2), which provides: (2) No insurance agent or solicitor licensed by the Department of Insurance under the provisions of this chapter who is associated with, under contract with, retained by, owned or controlled by, to any degree, directly or indirectly, or employed by, a financial institution shall engage in insurance agency activities as an employee, officer, director, agent, or associate of a financial institution agency. By its terms Section .003(2) of Rule Chapter 4.223 defines the "associated" and associate" language in F.S. s.626.988(2). On July 30, 1993, the Department's Section .003(2) "mind or imagination of the consumer" definition of the "associated" and "associate" language in s. 626.988(2) was struck down by DOAH Hearing Officer Mary Clark in the Rule Challenge as irredeemably vague and exceeding proper agency discretion. In her Final Order in this proceeding, Officer Clark concluded as follows: Aside from idiosyncratic grammar and the ambiguous use of an open-ended "etc.," this definition offends any rational interpretation of s. 626.988, F.S. and is thoroughly useless as a standard for the agency's enforcement of that and other relevant statutes. It is vague and incomprehensible, like beauty, an "association" lies in the eyes (or mind) of the beholder. The definition relegates to the mind or imagination of the general public the determination of what relationships are prohibited. This is a fragile basis for enforcement, as should be apparent to the agency by the fact that so few complaints have come from the general public. That such definition is unenforceable is obvious from the agency's pained attempts to craft its earlier guidelines and from its inability to articulate how it should be applied. (see generally, testimony of Dowdell and Shropshire). Proposed Rule 4 Final Order, Great Northern Annuities Corp. v. Department of Insurance, et al., No. 92-4332RP, etc., paragraph 56, at 29 - 30 (July 30, 1993)(Copy attached as Exhibit C). As noted above, Officer Clark's Final Order in the Rule Challenge was appealed in part by the Department. However, the Department did not appeal that portion of the Final Order striking down Section .003(2), the definition of "associated" and "associate" when the Department noticed its appeal on August 15, 1993, and filed its amended notice of appeal on August 27, 1993 (copies attached Exhibits D and E). On October 10, 1993, the Department filed Rule Chapter 4 State. The Rule Chapter as filed on October 10, 1993, did not include Section .003(2), and included no other rule interpreting "associated" or "associate" from F.S. s. 626.988(2). The Department has abandoned Section .003(2) (Rule Chapter 4 rule defining the "associated" and "associate" language in F.S. s. 626.988(2), and has abandoned any and all other efforts to promulgate a rule defining "associated" or "associate." Despite the Department's voluntary abandonment of Section .003(2), the Department is now relying on the substance of its Section .003(2) "mind or imagination of the consumer" definition of "associated" and "associate," and is attempting to enforce this definition in its Order to Show Cause filed against JMC on March 11, 1993, and now pending in DOAH before Hearing Officer Chad Adams. Department of Insurance v. James Mitchell & Co. et al. DOAH Cased No. 93-2422 (hereinafter the "Order to Show Cause Proceeding") (copy attached as Exhibit A). The Department has admitted its reliance on the abandoned Section .003(2) "mind or imagination of the consumer" definition. In a deposition on December 22, 1993, in the Order to Show Cause Proceeding of Douglas A. Shropshire, the Department's Director of Division of Legal Services and its Rule 1.310(b)(6) designated Department representative, the Department stated the following: [p. 136] Q: There is no current rule defining [F.S. Section 626].988, subparagraph (2) with respect to what is or is not an association at this time, correct? A: No, I wouldn't say that at all. [p. 212] . . . Q: What is the definition of "associate" for the purposes of the enforcement proceeding against my client [JMC]? Mr. Silverman [Department attorney]: Objection. The order to show cause doesn't use the term "associate," it uses the term "association." The term "associate" is only used in Webster's dictionary definition. [p. 218] . . . Q: All right. So that in defending JMC next month, am I able to rely on the association definition that uses "in the mind of the customer" as a standard? [p. 219] . . . Q: Answer yes or no first, please. A: No, I can't. What you should rely on is the guidelines, I believe, and I refer there to the '85, '86 [guidelines], and the Department's concern with appearances. Shropshire depo 136, 212, 218, 219 (emphasis added) (copies of these pages attached as Exhibit F). "[T]he Department's concern with appearances" that the Department's representative testified to, a concern that focuses on the possible perceptions of the consumer, merely recapitulates the Department's "mind or imagination of the consumer" definition in abandoned Rule Chapter Section .003(2). (The 1985 and 1986 Department guidelines, to which the Department representative also refers to in this testimony, do not contain a definition of, or refer directly to, the "associated" or "associate" language in s. 626.988(2)). The foregoing statements have not been adopted by the rulemaking procedure provided for in F.S. ss. 120.535(1) and 120.535(1)(a)3. The statements have been struck down by Officer Clark, are not currently contained in any promulgated rule, and have been abandoned as the basis for any rule as a result of the Department's decision not to appeal Officer Clark's Final Order striking the statements.
The Issue Whether Petitioner's September 29, 1993, claim (Claim No. 34092993) for reimbursement of expenses for medical services rendered in 1992 should be denied on the ground that said claim was not timely filed with Department of Management Services, Division of State Employees' Insurance (hereinafter referred to as the "Department")?
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Petitioner is now, and has been at all times material to the instant case, a participant in the State of Florida Flexible Benefits Plan (hereinafter referred to as the "Plan") with an established Medical Reimbursement Account. The following were among the medical expenses incurred by Petitioner and members of her immediate family during the 1992 calendar year: DATE TYPE OF SERVICE AMOUNT 6/29/92 Dental $70.00 7/9/92 Dental $310.00 7/11/92 Endodontic $450.00 7/17/92 Optical $266.75 7/22/92 Dental $500.00 7/27/92 Optical $84.70 8/19/92 Optical $416.50 12/29/92 Dental $210.00 In August of 1992, Hurricane Andrew ravaged parts of South Florida. Petitioner's residence was extensively damaged by the storm. Most of the contents of the residence, including medical records and receipts, were destroyed. Petitioner and her family were forced to vacate the premises. They packed their remaining belongings and moved to another location in Dade County, with the intention of returning to their home once the damage to the structure had been repaired. As of the date of the hearing in this case, all of the necessary repairs to the home had yet to be made and therefore the family had not moved back in. Petitioner and the other members of her family were among those residents of South Florida whose lives were significantly disrupted by the hurricane and the destruction and devastation it caused In the aftermath of the hurricane, Petitioner directed her energies toward obtaining a return to normalcy in her life. Although she realized that there were medical expense reimbursement claims that she needed to file with the Department, filing these claims was not a priority of hers. She focused her attention on other matters that she considered to be more deserving of her time given her situation. In January or February of 1993, Petitioner telephoned the Department to inquire if extensions of time for filing reimbursement claims were being given to Plan participants, such as herself, who were still suffering from the consequences of Hurricane Andrew. The person to whom Petitioner spoke advised her that such extensions were indeed being given. Based upon what she had been told by this Department representative, Petitioner reasonably believed that she would be able to file reimbursement claims for 1992 medical expenses after March 1, 1993, without having these claims rejected on the ground that they had been untimely filed. She therefore felt that there was no urgency with respect to the filing of these claims and she acted accordingly. Shortly after gathering all of the supporting documentation she believed she needed, 1 Petitioner, on September 29, 1993, filed a claim with the Department requesting that she be reimbursed from her Medical Reimbursement Account for the medical expenses enumerated in Finding of Fact 2 of this Recommended Order. The Department designated the claim as Claim No. 34092993. Petitioner also sought reimbursement, through the filing of this claim, of certain medical expenses incurred in 1993, including $140.00 for dental work that Petitioner had inadvertently indicated on the claim form had been performed in July of 1992. The work had actually been done in July of 1993. By letter dated October 8, 1993, the Department advised Petitioner that "[o]nly expenses for services rendered during the January 1, 1993 through December 31, 1993 plan year are eligible for reimbursement" and that "[s]ince [her] 1992 expense does not fall within this plan year, it is not reimbursable." Petitioner responded to this advisement by sending the following letter, dated November 28, 1993, to the Department: This is a petition or application requesting a formal hearing on my Claim #34092993 for Payment/Reimbursement for expenses incurred during my period of coverage for 1992. This Claim was denied. My Name is: Luretha F. Lucky My Address is: 10430 S.W. 162nd Terrace (temporary) Miami, Florida 33157 My permanent address is: 10361 S.W. 139th Street Miami, Florida 33176 I am employed at Florida International University, Miami, Florida 33199. I filed my claim late because my home was severely damaged when hit [b]y Hurricane Andrew, August 24, 1992. In addition, the content[s] in my home w[ere] destroyed, therefore, it took awhile for me to collect documentation for my claim from medical personnel. Also, I had to move and the few items saved were packed away. Lastly, I called the Department of Management Services, Division of State Employees' Insurance to inform them of what had happened to me and asked if . . . they were providing extensions on submitting claims. I was told they were. My mistake was not asking and recording the name of the person with whom I spoke. As you can see from my temporary address, I am still not back in my home! In fact we just settled (with the assistance of the Insurance Commissioner's Office) with our insurance company to complete the work on our home. We had to request an extension on filing our income tax for 1992. This past year has been an awful experience for us, and I do hope you will provide me a hearing on my reimbursement. My Claim # is: 34092993. The decision that my claim was denied was received by regular mail. Thank you very much for considering my request.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby: RECOMMENDED that the Department enter a final order finding Petitioner's September 29, 1993, claim (Claim No. 34092993) for reimbursement of expenses for medical services rendered in 1992 to have been timely filed and therefore subject to consideration on its merits. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 15th day of April, 1994. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings 15th day of April, 1994.
Findings Of Fact Edward D'Alesio, Jr., is a registered general contractor with the Board and holds license no. RG00A3370. Pursuant to an agreement signed on January 26, 1976, between Respondent and Mr. Wernley, Respondent agreed to construct a home for Mr. Wernley for a price of $39,500.00. On April 21, 1975, Mr. Wernley gave Respondent a check for $2,000 made payable to "D.R.G. Builders Trust Fund Account" which was deposited in the account of D.R.G. Builders. According to the terms of the agreement entered into by Mr. Wernley and Respondent, construction of the home was to be completed within 120 days. Evidence reveals that substantial progress was made toward construction of the Wernley home during August and September, 1975, however, little if any progress was made during late 1975. Mr. Wernley registered complaints to Respondent about the progress of construction Inasmuch as he (Wernley) had secured permanent financing at a favorable Interest rate which was due to expire during January or February, 1976. On March 11, 1976, Mr. Wernley demanded the return of his $2,000 security deposit which Respondent advised, by letter dated March 23, that he was unable to return due to financial difficulties. (See Petitioner's Exhibit #5) However, Respondent advised Mr. Wernley that he "would like to offer [him] the model home which was similar ... at the purchase price we had agreed upon." Respondent also agreed to assist in securing a competitive mortgage. Mr. Wernley was allowed five days to signify his acceptance of the model home which he (Mr. Wernley) rejected. Mr. Crass, Secretary-Treasurer for D.R.G. Builders, Inc., testified that the deposit monies used as mortgage commitments were issued and that at no time were monies diverted from one project to complete construction for other projects. Evidence reveals that during November, 1976, the Board through its investigator, Mr. Wallace Norman, issued a warning to Respondent for his failure to qualify D.R.G. Builders, however, Respondent took no action to correct this because at this juncture, the corporation had been dissolved by the State of Florida. Respondent also testified that the project was abandoned inasmuch as he was unable to secure additional financing from Southeast Mortgage Company. He testified that he had approximately 13 houses under construction and Southeast Mortgage Company shut off funds and demanded full payment of a $420,000 construction loan obligation. He testified that he needed approximately $60,000 to complete the houses under construction but was unable to secure additional financing. He testified further that the Wernley home was completed except the trim work during January of 1976. He advised Mr. Wernley during January, 1976, of the firm's cash flow problems and in an effort to amicably settle their differences, offered the model home which, according to his testimony, was equal or better, in all respects, than the home he contracted to build for the Wernleys. Respondent testified that he recently filed bankruptcy which should be final on June 20, 1977. Respondent takes the position that since he converted none of the money deposited by the Wernleys, it is D.R.G. Builders, Inc. that owes the Wernleys $2,000. However, it was noted under the bankruptcy proceeding liability list, that Wernley was a possible business obligation. Respondent testified further that he was advised by the Board's predecessor investigator that it was permissible to pull permits as an owner- builder and that Cooper City, the locality which issued the permits, through its building department, advised that the procedure which D.R.G. had utilized for at least 18 months was proper and acceptable.
Recommendation Based on the foregoing findings of fact and conclusions of law, I hereby recommend that the administrative complaint filed herein be dismissed in its entirety. RECOMMENDED this 30th day of June, 1977, in Tallahassee, Florida. JAMES E. BRADWELL Hearing Officer Division of Administrative Hearings 530 Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Barry Sinoff, Esquire 1010 Blackstone Building Jacksonville, Florida 32202 F. F. Mallard, Chief Investigator Florida Construction Industry Licensing Board Post Office Box 8621 Jacksonville, Florida 32211 Mr. Edward D'Alesio, Jr. 3760 North 55th Avenue Hollywood, Florida 33010 ================================================================= AGENCY FINAL ORDER ================================================================= BEFORE THE FLORIDA CONSTRUCTION INDUSTRY LICENSING BOARD FLORIDA CONSTRUCTION INDUSTRY LICENSING BOARD, Petitioner,
The Issue At issue in this case is whether Respondents, the Office of Insurance Regulation ("OIR" or "the Office") or the Financial Services Commission ("the Commission") have developed agency statements of general applicability meeting the definition of a rule in section 120.52(10), Florida Statutes (2011), governing its review, evaluation, recalculation, and disposition of excessive profits filings submitted pursuant to section 627.215, Florida Statutes (2011). If so, it must be determined whether those statements have been adopted as rules pursuant to the rulemaking process in section 120.54(1).
Findings Of Fact Premier is a foreign insurer authorized to write workers' compensation insurance in the State of Florida. As a workers' compensation insurer, Premier is subject to the jurisdiction of the Office. Premier began writing workers' compensation insurance coverage in Florida on January 1, 2005. The Office is a subdivision of the Financial Services Commission responsible for the administration of the Insurance Code, including section 627.215. Section 627.215(1)(a) requires that insurer groups writing workers' compensation insurance file with the Office on a form prescribed by the Commission, the calendar-year earned premium; accident-year incurred losses and loss adjustment expenses; the administrative and selling expenses incurred in Florida or allocated to Florida for the calendar year; and policyholder dividends applicable to the calendar year. Insurer groups writing other types of insurance are also governed by the provisions of this section. The purpose of section 627.215 is to determine whether insurers have realized an excessive profit and if so, to provide a mechanism for determining the profit and ordering its return to consumers. Insurer groups are also required to file a schedule of Florida loss and loss adjustment experience for each of the three years prior to the most recent accident year. Section 627.215(2) provides that "[t]he incurred losses and loss adjustment expenses shall be valued as of December 31 of the first year following the latest accident year to be reported, developed to an ultimate basis, and at two 12-month intervals thereafter, each developed to an ultimate basis, so that a total of three evaluations will be provided for each accident year." Section 627.215 contains definitions that are critical to understanding the method for determining excess profits. Those definitions are as follows: "Underwriting gain or loss" is computed as follows "the sum of the accident-year incurred losses and loss adjustment expenses as of December 31 of the year, developed to an ultimate basis, plus the administrative and selling expenses incurred in the calendar year, plus policyholder dividends applicable to the calendar year, shall be subtracted from the calendar-year earned premium." § 627.215(4). "Anticipated underwriting profit" means "the sum of the dollar amounts obtained by multiplying, for each rate filing of the insurer group in effect during such period, the earned premium applicable to such rate filing during such period by the percentage factor included in such rate filing for profit and contingencies, such percentage factor having been determined with due recognition to investment income from funds generated by Florida business, except that the anticipated underwriting profit . . . shall be calculated using a profit and contingencies factor that is not less than zero." § 627.215(8). Section 627.215 requires that the underwriting gain or loss be compared to the anticipated underwriting profit, which, as previously stated, is tied to the applicable rate filing for the insurer. Rate filings represent a forecast of expected results, while the excess profits filing is based on actual expenses for the same timeframe. The actual calculation for determining whether an insurer has reaped excess profits is included in section 627.215(7)(a): Beginning with the July 1, 1991, report for workers' compensation insurance, employer's liability insurance, and commercial casualty insurance, an excessive profit has been realized if the net aggregate underwriting gain for all these lines combined is greater than the net aggregate anticipated underwriting profit for these lines plus 5 percent of earned premiums for the 3 most recent calendar years for which data is filed under this section. . . Should the Office determine, using this calculation, that an excess profit has been realized, the Office is required to order a return of those excess profits after affording the insurer group an opportunity for hearing pursuant to chapter 120. OIR B1-15 (Form F) is a form that the Office has adopted in Florida Administrative Code Rule 69O-189.007, which was promulgated pursuant to the authority in section 627.215. The information submitted by an insurer group on Form F is used by the Office to calculate the amount of excessive profits, if any, that a company has realized for the three calendar-accident years reported. The terms "loss adjustment expenses," and "administrative and selling expenses," are not defined by statute. Nor are they defined in rule 69O-189.007 or the instructions for Form F. On or about June 30, 2009, Premier filed its original Form F Filing with the Office pursuant to section 627.215 and rule 69O-189.007. Rule 69O-189.007 requires that a Form F be filed each year on or before July 1. The first page of Form F includes section four, under which calendar year administrative and selling expenses are listed. Section four includes five subparts: A) commissions and brokerage expenses; B) other acquisition, field supervision and collection expense; C) general expenses incurred; D) taxes, licenses and fees incurred; and E) other expenses not included above. Premier subsequently filed three amendments to its Form F filing on December 11, 2009; on June 21, 2010; and on January 13, 2012. In each of its amended filings, Premier included the federal income tax expense attributable to underwriting profit it earned during the 2005-2007 period. These expenses were included under section four(E). No guidance is provided in section 627.215, in rule 60O- 189.007, or in the instructions for Form F, to identify what expenses may properly be included in the Form F filing. There is no indication in any of these three sources, or in any other document identified by the Office, that identifies whether federal income taxes are to be included or excluded from expenses to be reported in a Form F filing. While the form clearly references taxes, licenses and fees incurred under section 4(D), the instructions do not delineate what types of taxes, licenses and fees should be included. The instructions simply state: "for each of the expenses in item 4, please provide an explanation of the methodology used in deriving the expenses, including supporting data." The Office takes the position that federal income taxes should not be reported as an expense for the purpose of determining excess profits. It position, as characterized by Petitioner, is that "in determining what expenses may be deducted in calculating whether and to what extent excessive profits have been realized during the reporting period, the Office shall disallow any deduction for federal income tax or the net effect of federal income tax accrued or paid during the reporting period." According to James Watford, a Department actuary who reviews the excess profits reports, this position has not changed at any time in the last ten years. In August 2009, a petition was filed against the Office challenging the statement stated above as an unadopted rule. FFVA Mutual Insurance Co. v. Office of Insurance Regulation, DOAH Case No. 09-4193RU. The proceeding in the FFVA case was placed in abeyance based upon the Office's agreement to initiate rulemaking. A Notice of Development of Rulemaking was published and a workshop was conducted on February 22, 2010. On or about June 17, 2010, James Watford circulated proposed changes to rule 69O-189.007, which included changes to the instructions to Form F. Among those proposed changes was the addition of the following statement: "[f]ederal income tax is not to be included as an expense because the 'anticipated underwriting profit' is based on a pre-Federal income tax profit and contingencies factor." This language would have placed the position consistently taken by the Office in the materials incorporated into the rule. On November 17, 2010, a second rule development workshop was held on the proposed changes to rule 69O-189.007. However, no further action toward adopting the proposed revisions took place. At some point, the FFVA challenge was dismissed based upon a settlement between the parties, and the Office never sought approval from the Commission to notice the proposed changes for rulemaking. No further action has been taken to adopt the Office's position through the chapter 120 rulemaking process, and no credible explanation was provided to explain why the Office did not present the proposed changes to the Commission to obtain permission to notice the proposed rules. Although Mr. Watford testified that the Office has "clearly enunciated [its] position on federal income tax," he acknowledged that it has not been adopted through the rulemaking process. He stated, "before that ever came into existence, we had discussions with companies about the appropriateness of including that the fact that it is already included in the profit factor. . . . It was not published in a rule, because it is -- we thought it was pretty commonly understood by most parties." The Office insists that it is not feasible to consider federal income taxes in the excess profits calculation. It pointed to no real impediment to adopting its position of not considering federal income taxes through the rulemaking process. On January 4, 2011, Governor Scott issued Executive Order 11-1, which temporarily suspended rulemaking for executive branch agencies reporting to the Governor. Executive Order 11-1 was issued 11 months after the Office published its first Notice of Rule Development in February 2010, and did not apply to either the Office or the Commission. The Office also points to publications published by other entities, such as the Actuarial Standards Board and the National Association of Insurance Commissioners ("NAIC"), to support its position that federal income taxes may not be considered in determining excess profits. However, section 627.215 does not reference any of these publications, and they are not incorporated by reference in the Office's rule regarding excessive profits. Nor do these publications expressly reference what can be considered for excess profits calculations. During the 2012 legislative session, section 627.215 was amended to delete the excess profits filing requirement for workers' compensation insurance. § 7, ch. 2012-213, Laws of Fla. Section 627.213 had not been amended prior to this year since 2003. However, the Office continues to assert its position with respect to the exclusion federal income taxes as an expense to those filings remaining in the "pipeline." Section 627.215 continues to apply to other types of insurance.
