Findings Of Fact Based upon the oral and documentary evidence adduced at the final hearing and the entire record in this proceeding, the following findings of fact are made. At all times pertinent hereto, Respondent has been licensed in the State of Florida as a limited surety agent (bail bondsman), a life and health agent and a general lines agent. Respondent has been licensed as an insurance agent for more than eleven years. He has been a licensed limited surety agent for more than ten years. Pursuant to Section 648.442(3), Florida Statutes, all collateral received by Respondent or others acting under his supervision or control in transactions under his surety agent license constituted trust funds received in a fiduciary capacity. At all times pertinent to this proceeding, Respondent has been doing business as Protective Insurance Center, Jenkins Bail Bonds. Until early February of 1991, Respondent's general agent was Banker's Insurance Company. However, in early February, Respondent's relationship with that company was terminated. Respondent's current general agent is American Bankers Insurance Company of Florida. Russell Faibish, Respondent's general agent with American Bankers since February of 1991, has expressed via affidavit that Respondent is in good standing with that company and the company has been satisfied with his performance to date. On January 25, 1991, Respondent, while acting in his capacity as a limited surety agent for Banker's Insurance Company, posted a surety bond, No. 339658, (the "Bond") in the amount of $752.00 to obtain the release of Kim Reinhold Whitford from custody in Clay County, Florida. In connection with the posting of the Bond, Respondent received from Earnest R. Justice (the "Indemnitor") a $75.00 premium payment and a $350.00 cash collateral payment. At the time the Indemnitor arranged with Respondent for the issuance of the bond, the Indemnitor was advised that his collateral would be returned within twenty one days of the receipt of written notice of the discharge of the bond. Respondent was provided with a notice from the Clerk of Court that Ms. Whitford was scheduled for a court appearance on April 3, 1991 for a "plea." Respondent never made any inquiry as to the results of that April 3, 1991 hearing. On April 3, 1991, the Bond was discharged and the obligation of the surety, Banker's Insurance Company, was released in writing by the County Court of Clay County, Florida. Respondent contends that he never received notification of the discharge of the Bond. While the Court document indicates that a notice of the discharge of the Bond was sent to Respondent at the time the requirements for the discharge were satisfied on or about April 3, 1991, no conclusive evidence was presented to establish that the notice of discharge was actually sent to or received by Respondent. Respondent denies ever receiving that document. After Ms. Whitford was released from jail, the Indemnitor contacted Respondent's office several times in April and May of 1991 trying to arrange the return of his collateral. Respondent denies receiving any messages from the Indemnitor. The failure to receive the messages may have been due to office staff turnover. In any event, the evidence was sufficient to establish that the Indemnitor attempted to arrange for the return of his collateral on numerous occasions without success. On August 9, 1991, the Petitioner filed the Administrative Complaint which is the basis for this proceeding against Respondent alleging that he failed to return the Indemnitor's collateral. Upon receipt of the Administrative Complaint, Respondent contacted the Clerk of Court, in Clay County, Florida to determine the status of the bond. On August 30, 1991, the Clerk of Court, Clay County, Florida, sent Respondent a certified copy of the bond discharge. Respondent claims that he first became aware of the discharge of the Bond and the Indemnitor's right to the return of the collateral when he received the August 30 certification from Clay County. Because an Administrative Complaint had already been filed, Respondent did not immediately refund the collateral for fear that such action could be construed as an attempt to influence a witness in the case. In order to avoid the appearance of attempting to influence a witness, Respondent waited until the day of the hearing to arrange to make a refund of the collateral available to the Indemnitor. On January 14, 1992, Respondent sent a Western Union Money Transfer, control no. 7395574746, payable to the Indemnitor in the amount of $350.00 as return of the collateral. Although the Indemnitor did not receive the return of his collateral until approximately eight to nine months after it was due, the collateral was ultimately returned and there is no other evidence in this case of any other financial loss to any member of the public. On average, Respondent has between 100 to 150 active bond cases per month. Most of those bonds are written in Palm Beach County, where Respondent's business is located. In this case, Respondent arranged for a "teletype bond" whereby the arrangements for the bond were made in Palm Beach County and notification of the posting of the bond and authorization for the release of the prisoner were transmitted via teletype to Clay County. Respondent contends that he reviews his active cases on a quarterly basis to confirm the status of the bonds. Nevertheless, it took almost six months for Respondent to determine that the requirements of the Bond in this case had been fully satisfied. No justifiable excuse was given for this delay. However, in mitigation, it does appear that the long distance nature of the transaction, the change in Respondent's general agent and office staff turnover all contributed to the delay in refunding the Indemnitor's collateral. Respondent has had three Administrative Complaints filed against him since 1985. The first Administrative Complaint was filed on June 26, 1985 and alleged that Respondent failed to provide required documentation of his assets to the Department. Pursuant to a Consent Order entered on August 6, 1985, Respondent was fined $200 and placed on probation for one year as a result of this charge. The most serious and pertinent prior administrative proceeding against Respondent was commenced by an Administrative Complaint dated November 17, 1987. That complaint alleged, among other things, that Respondent failed to return collateral to at least two clients. In April of 1989, the parties entered into a settlement stipulation regarding these charges pursuant to which Respondent was suspended for one year and fined $1,000.00. He was also required to make resitution to several individuals who had not been identified in the Administrative Complaint in that case. No explanation has been provided regarding the "restitution" required to be made to those individuals. The third case involved an Emergency Suspension Order entered on March 16, 1988. That Order was dissolved on September 20, 1988 when the underlying criminal charges were nolle prosequi. Respondent has had several IRS liens filed against him and there is currently a foreclosure action pending against his house. However, no specific information was provided regarding the status of those cases. Respondent contends that he is vigorously contesting all of those matters and he believes they will be favorably resolved. The evidence in this case suggests that Respondent is currently involved in disputes with some other customers regarding the return of collateral. The evidence did not establish the exact number or the facts surrounding those disputes. Respondent contends that all of those disputes are related to problems with or caused by his prior General Agent. No conclusions as to the merits of those complaints can be drawn from the evidence presented in this case. Gerald Michael Sandy, a licensed bondsman in the State of Florida and the current president of the Florida Surety Agents Association, testified on behalf of the Respondent in this matter. He indicated that on approximately 40% of the bonds that are executed, the Courts do not provide written notice of the discharge. However, Mr. Sandy conceded that even if written notification from a court is not received, the bail bondsman is primarily responsible for determining whether a bond has been discharged and a bail bondsman must immediately respond to the inquiries of an indemnitor regarding the return of collateral.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is recommended that a Final Order be entered suspending Respondent's licenses for three months, placing him on probation for two years and assessing an administrative fine in the amount of $500. RECOMMENDED this 9th day of March, 1992, at Tallahassee, Florida. J. STEPHEN MENTON 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 9th day of March, 1992. APPENDIX TO RECOMMENDED ORDER, CASE NO. 91-6302 Both parties have submitted Proposed Recommended Orders. The following constitutes my rulings on the proposed findings of fact submitted by the parties. The Petitioner's Proposed Findings of Fact Proposed Finding Paragraph Number in the Findings of Fact of Fact Number in the Recommended Order Where Accepted or Reason for Rejection. 1. Adopted in substance in Findings of Fact 1. 2. Adopted in substance in Findings of Fact 1. 3. Adopted in substance in Findings of Fact 2. 4. Adopted in substance in Findings of Fact 3. Findings of Fact 5. 7. Adopted in substance in Findings of Fact 5. 8. Adopted in substance in Findings of Fact 7. Rejected as unnecessary. Adopted in substance in Subordinate to Findings of Fact 13 and 14 and addressed in the Preliminary Statement. Subordinate to Findings of Fact 6 and 10. Adopted in substance in Findings of Fact 8. Subordinate to Findings of Fact 18. Subordinate to Findings of Fact 19. Subordinate to Findings of Fact 20. The Respondents's Proposed Findings of Fact Proposed Finding Paragraph Number in the Findings of Fact of Fact Number in the Recommended Order Where Accepted or Reason for Rejection. 1. Adopted in substance in Findings of Fact 5. 2. Adopted in substance in Findings of Fact 5. 3. Adopted in substance in Findings of Fact 7. 4. Adopted in substance in Findings of Fact 10. 5. Adopted in substance in Findings of Fact 11. 6. Adopted in substance in Findings of Fact 11. 7. Adopted in substance in Findings of Fact 12. 8. Adopted in substance in Findings of Fact 14. 9. Addressed in the Preliminary Statement. 10a. Adopted in substance in Findings of Fact 10. 10b. Adopted in substance in Findings of Fact 9. 10c. Adopted in substance in Findings of Fact 10. 10d. Adopted in substance in Findings of Fact 10. 10e. Adopted in substance in Findings of Fact 13. 10f. Adopted in substance in Findings of Fact 13. 10e.[sic] Adopted in substance in Findings of Fact 17. 10f.[sic] Adopted in substance in Findings of Fact 16. 10g. Rejected as unnecesdsary. 11a. Adopted in substance in Findings of Fact 21. 11b. Adopted in substance in Findings of Fact 21. 11c. Adopted in substance in Findings of Fact 21. 12. Adopted in substance in Findings of Fact 4. COPIES FURNISHED: David D. Hershel, Esquire Department of Insurance and Treasury Larson Building, Room 412 Tallahassee, Florida 32399-0300 Franklin Prince, Esquire Northbridge Centre, Suite 300-P 515 N. Flagler Drive West Palm Beach, Florida 33401 Tom Gallagher State Treasurer and Insurance Commissioner Department of Insurance and Treasurer The Capitol, Plaza Level Tallahassee, Florida 32399-0300 Bill O'Neil Deputy General Counsel Department of Legal Affairs The Capitol, Plaza Level Tallahassee, Florida 32399-0300
The Issue The issue to be determined is the amount to be reimbursed to Respondent, Agency for Health Care Administration ("AHCA"), for medical expenses paid on behalf of Yisell Cabrera Rodriquez pursuant to section 409.910, Florida Statutes, from settlement proceeds received by Petitioner from third parties.
Findings Of Fact The Parties Petitioner, Julio Cesar Cabrera, is the duly-appointed Personal Representative of the Estate of Yisell Cabrera Rodriquez, his deceased daughter. Respondent is the state agency charged with administering the Florida Medicaid program, pursuant to chapter 409. The Events Giving Rise to this Proceeding On August 30, 2015, Petitioner's 23-year old daughter, Yisell, was severely injured in an automobile accident. She was a passenger in an automobile that was struck by another automobile that failed to yield the right-of-way at an intersection. The automobile in which Yisell was a passenger previously had been in an accident and had been determined a total loss. It subsequently was rebuilt by Unique Body Works in Miami. A sister company, Unique Automotive, sold the vehicle to the driver of the car in which Yisell was a passenger on August 30, 2015. When Unique Body Works rebuilt the automobile, it did not replace the passenger side airbags. When the automobile was struck in the accident, airbags on the passenger side were not available to deploy. As a result, Yisell was severely injured. She was transported to Jackson Memorial Hospital, where she received medical treatment in intensive care. Tragically, on August 31, 2015, Yisell died from the injuries she sustained in the accident. Petitioner instituted a wrongful death action against the at-fault driver ("Carlos Espinoza") and the owner of the automobile ("Ana Ramirez") that struck the automobile in which Yisell was a passenger, Unique Body Works, and Unique Automotive, to recover damages to Yisell's parents and to her estate. Espinoza/Ramirez were insured by Infinity Auto Insurance Company under a policy having a bodily injury limit of $10,000. Unique Body Works was insured by Grenada Insurance Company under a policy having a liability limit of $100,000. Unique Automotive was insured by Western Heritage Insurance Company under a policy having a liability limit of $30,000. All of the insurers tendered their respective policy limits for a total of $140,000. On July 14, 2017, Petitioner, on behalf of the Estate of Yisell Cabrera Rodriquez, entered into settlement agreements with Espinoza/Ramirez, Unique Body Works, and Unique Automotive, for a total of $140,000, which constitutes the total amount of the third-party benefits received.4/ Yisell's medical care related to her injury was paid by Medicaid.5/ The medical expenses paid by Medicaid totaled $86,491.86. Pursuant to section 409.910(6)(c)1., AHCA has a Medicaid lien for that amount. Petitioner's Challenge to the Repayment Amount Section 409.910(11)(f) establishes a formula for distributing the benefits that are recovered by a recipient or his or her legal representative in a tort action against a third party that results in a judgment, settlement, or award from that third party. Applying this formula to the $140,000 that Petitioner received in third-party benefits results in a lien repayment amount of $51,838.61.6/ In this proceeding, AHCA asserts that it is owed this amount. As noted above, Petitioner disputes that $51,838.61 is the amount of recovered medical expenses payable to Respondent, and instead asserts that $4,039.17 in medical expenses are payable to Respondent. In support of his position, Petitioner presented the testimony of Mrs. Maria Rodriquez, Yisell's mother. She testified, persuasively, that theirs was a very close-knit family who did everything together, and that the loss of Yisell has destroyed their family life. She also testified that as a result of the emotional trauma of losing Yisell, her health has suffered, and she has difficulty sleeping and has gastric reflux for which she is being treated. Petitioner also testified, persuasively, that the loss of Yisell changed his life and the lives of his family members. As he described it, "[her loss] has changed our life. It's all the sadness. It's all the pain, everything. Everything's changed. . . . We were happy. We were so happy. We were so close." Petitioner also presented the expert testimony of Oscar Ruiz7/ regarding the valuation of Petitioner's wrongful death claim. Mr. Ruiz testified that in his opinion, $3 million constituted a very conservative valuation of the damages suffered by Yisell's parents in this case. He based this opinion on having interviewed Yisell's parents regarding the impact of her loss on their family, and on his knowledge of jury verdicts and settlements in recent Florida cases involving awards of damages to parents for the loss of their children in automobile accidents or due to medical malpractice. He emphasized that his valuation was far more conservative than many comparable cases that yielded substantially higher verdicts or settlements. Petitioner asserts that Respondent is only entitled to recover $4,039.17 in medical expenses on the basis of the calculation method used in Arkansas Department of Health and Human Services v. Ahlborn, 547 U.S. 268 (2006). Specifically, Petitioner proposes to apply the same ratio that the settlement of $140,000 bore to the total monetary value of all damages ($3 million, according to Petitioner's expert) to determine the amount Respondent is owed for medical expenses. Petitioner contends that although Ahlborn did not establish a uniform calculation method applicable in all cases, it nonetheless has been accepted and applied by ALJs in other Medicaid third-party recovery cases to determine the amount of reimbursable medical expenses under section 409.910(17)(b), without challenge from AHCA regarding the accuracy of that method. Respondent did not present any evidence regarding the value of Petitioner's claim or propose a differing valuation of the damages. As more fully discussed below, Respondent contends that the opportunity to rebut the medical expense allocation provided under section 409.910(17)(b) is not available in cases such as this, where the Medicaid recipient dies before third- party benefits are recovered through settlement or other means.
The Issue Whether the Amended Notice and Order to Show Cause issued in DOAH Case Number 11-1150, with which this unadopted rule challenge is now consolidated, contains an agency statement that comes within the definition of a rule but has not been adopted through rulemaking procedures, in violation of section 120.54(1)(a), Florida Statutes, and if so, whether costs and attorney’s fees should be awarded.
Findings Of Fact The Financial Services Commission has responsibility over rules implementing provisions of the Florida Insurance Code conferring duties upon the Commission or its subunits. The Office of Insurance Regulation (the Office) is a subunit of the Financial Services Commission responsible for enforcing the provisions of the Florida Insurance Code with respect to licensees of the Office. Guarantee Trust Life Insurance Company (GTL) is a foreign insurer, domiciled in Illinois, which holds a certificate of authority to transact business as a life and health insurer in Florida. GTL offers insurance products nationwide, except for New York, including Medicare long-term care, supplemental, cancer, college student, accident, and sickness policies. GTL is subject to the jurisdiction of the Office under the Florida Insurance Code, including fines and disciplinary actions. It is substantially affected by the Office’s action and is entitled to a hearing to determine if the Administrative Complaint filed against it constitutes an unadopted rule. On or about May 5, 2010, GTL sent a Termination Letter to at least 216 Florida residents (Members) covered under an out-of-state group major medical policy (Policy), as well as to about 70 Florida residents who held individual policies offered by GTL.1/ The Termination Letter advised that major medical coverage would not be renewed and that GTL would no longer be offering major medical type coverage. On January 12, 2011, the Office served GTL with a Notice and Order to Show Cause alleging that GTL had violated the Florida Insurance Code by continuing to non-renew policies and failing to offer converted policies. A conversion policy is a form of replacement insurance coverage for which certificate holders in a group policy may be eligible when their coverage under a group policy is terminated. On January 28, 2011, GTL filed a Petition for Administrative Hearing with the Office. It amended that Petition on February 1, 2011, still maintaining that it was not required to offer conversion policies. On September 2, 2011, an Order was issued granting the Office’s Unopposed Motion to Amend Notice and Order to Show Cause. Counts I and II of the earlier complaint were amended. The earlier complaint had charged in these counts that “Guarantee Trust violated the Florida Insurance Code by failing to offer converted policies as required by Section 627.6675, Florida Statutes.” Amended counts I and II alleged that “Guarantee Trust violated the Florida Insurance Code by issuing the Termination Letter without offering converted policies required by the Florida Insurance Code and Section 627.6675, Florida Statutes.” On November 15, 2011, GTL filed a Petition to Challenge Unadopted Rule. The Petition was served on the Office more than 30 days before it was filed with the Division of Administrative Hearings, as stipulated at hearing. The Financial Services Commission has not adopted the statement that it was a violation of provisions of the Florida Insurance Code for GTL to “issue a termination letter without offering converted policies as required by Section 627.6675,” or any similar statement, by rulemaking procedures.
The Issue Whether a valid Medicaid lien exists, and, if so, what is the amount payable to Respondent pursuant to section 409.910(17), Florida Statutes, in satisfaction of the lien from a settlement received by Petitioners from a third-party.1/
Findings Of Fact Ethan Hunt (Ethan), was born on January 7, 2003, and died on May 31, 2006, from complications arising from his birth- related catastrophic neurological injury and severe disabilities. Petitioners, Elsa and Eric Hunt (the Hunts), individually, as parents of Ethan, and as the Co-Personal Representatives of the Estate of Ethan Hunt (Estate), brought a wrongful death lawsuit against the hospital where Ethan was born, a physician, and an Advanced Registered Nurse Practitioner (ARNP), to recover their individual damages as the surviving parents of Ethan, as well as the individual claim for damages of the Estate. In accordance with the limitation on damages recoverable in wrongful death actions contained in section 768.21, Florida Statutes, the Hunts' wrongful death lawsuit specifically sought the individual damages of each parent for their "mental pain and suffering and loss of companionship" of their deceased son. Further, the wrongful death action sought, on behalf of the Estate, recovery of "medical and funeral expenses." Ethan was a Medicaid recipient and a portion of his medical care was paid for by Medicaid. Respondent, Agency for Health Care Administration (AHCA), through the Medicaid program, paid $315,632.17 in benefits on behalf of Ethan for medical benefits related to the alleged negligent medical care received by Ethan. Ethan first received medical treatments for which Medicaid was obligated to make payments on June 11, 2003, and AHCA, through the Medicaid program, made its last payment for Ethan's medical care on May 29, 2006. As a condition of Ethan's eligibility for Medicaid, Ethan's right to recover from liable third-parties medical expenses paid by Medicaid was assigned to AHCA. See 42 U.S.C. § 1396a(a)(25)(H) and § 409.910(6)(b), Fla. Stat. Pursuant to section 409.910(6)(c), Florida Statutes, AHCA's Medicaid lien attached and was perfected on June 11, 2003, when Ethan first received medical care for which Medicaid was obligated to make payments. On May 25, 2005, AHCA recorded in the Miami-Dade County public record its Claim of Lien and Notice of Assignment and Other Statutory Rights (Lien), Book 23409, pages 2856-2858. By letter dated May 28, 2008, to an attorney representing the Hunts and the Estate, from AHCA’s contracted vendor, Health Management Systems (HMS), AHCA indicated that the Medicaid lien was in the amount of $315,632.17. On July 11, 2008, the Hunts, on behalf of themselves and Ethan's Estate, submitted to all defendants in the wrongful death action, Plaintiffs’ Proposal for Settlement to All Defendants (Proposal). The Proposal offered a settlement of $7,250,000.00 to be allocated as follows: Elsa Hunt $3,300,000.00 45.5% Eric Hunt $3,300,000.00 45.5% Estate of Ethan Hunt $650,000.00 9.0% The Hunts' July 11, 2008, Proposal was rejected, and a mediation of the wrongful death lawsuit was held on May 12, 2009. By letter dated May 4, 2009, to HMS, the attorney representing the Hunts in the wrongful death action notified AHCA's designated vendor of the May 12, 2009, mediation and provided a copy of the notice of mediation. AHCA did not attend or participate in the mediation. A global settlement was reached at the May 12, 2009, mediation for the total amount of $1,800,000.00. As part of the mediated settlement, the parties made an allocation of the settlement proceeds between individual claims of the surviving parents and the individual claim of the Estate. This allocation was memorialized in the Addendum to Mediation Settlement Agreement Allocation of Settlement (Addendum). Each parent was allocated a total amount of $819,000.00 "in satisfaction of their individual claims for mental pain and suffering and loss of companionship." The Estate was allocated a total of $162,000.00 "in satisfaction of its claims for medical expenses and funeral expenses." The parties allocated these amounts in accordance with the percentages as presented in the prior Proposal. By letter dated May 20, 2009, AHCA received notice that the case settled at the May 12, 2009, mediation and of the intent to issue a dismissal of the defendants in the case. On June 9, 2009, the court entered a Final Judgment of Dismissal with Prejudice. AHCA took no action to intervene in the wrongful death action or to seek relief from the settlement reached by the parties. Upon receipt of the settlement proceeds, the amount of $315,632.17 was placed into a trust account for the benefit of AHCA pending an administrative determination of AHCA's rights, and this constitutes "final agency action and notice thereof" for purposes of chapter 120, Florida Statutes, pursuant to section 409.910(17). Pursuant to 42 U.S.C. section 1396a(a)(25)(A), (B), and (H), section 1396k(a), and section 1396p(a), AHCA may only assert a lien against, and seek recovery from, the portion of a Medicaid recipient’s settlement representing the Medicaid recipient’s compensation for medical expenses paid by Medicaid. The Hunts requested that AHCA calculate the amount owed in satisfaction of the lien pursuant to the statutory formula set forth in section 409.910(11)(f).2/ The Hunts requested that this calculation be based on the Estate’s recovery of $162,000.00, minus the Estate's share of attorneys' fees and the Estate’s $15,559.01 share of the litigation costs (which represents the Estate’s 9% proportionate share of the gross $172,877.87 in litigation cost). AHCA refused to calculate the amount payable to AHCA in accordance with section 409.910(11)(f), Florida Statutes, and continues to seek payment of its full $315,632.17 Lien from the gross settlement award, including those funds allocated to the parents for their individual claims. Pursuant to section 409.910(6)(c)9., a Medicaid lien exists for seven years after it is recorded, and the lien may be extended for one additional period of seven years by AHCA recording a Claim of Lien within the 90-day period preceding the expiration of the original lien. In the instant case, AHCA recorded its Lien on May 25, 2005. By operation of law, this Lien ceased to exist on May 25, 2012 (seven years after it was recorded on May 25, 2005). AHCA did not extend the existence of the Lien by again recording it within the 90-day time period preceding its expiration on May 25, 2012. Accordingly, AHCA’s Lien no longer exists. In addition to the Lien, AHCA has subrogation and assignment rights to collect third-party benefits for the amount of medical assistance provided by Medicaid. § 409.910(6)(a) and (b), Fla. Stat. Actions to enforce the rights of AHCA must be commenced within five years after the date a cause of action accrues, with the period running from the later of the date of discovery by AHCA of the case filed by recipient or his or her legal representative, or of discovery of any judgment, award, or settlement contemplated in the section, or of discovery of facts giving rise to a cause of action. § 409.910(11)(h), Fla. Stat. By May 20, 2009, at the latest, AHCA was aware of the settlement between the Hunts and the Estate, with Ethan's physician, ARNP, and the hospital at which he was born. As of the date of the final hearing, May 13, 2014, AHCA had not exercised any subrogation or assignment rights. Accordingly, AHCA's ability to pursue subrogation and assignment rights has expired. Based on the undersigned's finding that no enforceable Lien exists, and that AHCA's subrogation and assignment rights are extinguished, as discussed more fully in the Conclusions of Law, there is no need to address any of the other factual contentions of the parties.3/
The Issue Whether one or more grounds exist for suspending, or imposing other discipline against, Respondent’s license, where Petitioner charges that Respondent engaged in fraudulent or dishonest practices in the conduct of business as a licensed health insurance agent.
Findings Of Fact The evidence presented at final hearing established the facts that follow. The Big Picture 1. Gonzalez is, and at all times material was, a Florida- licensed health insurance agent whose conduct qua licensee is subject to the regulatory jurisdiction of the Department. 2. From April 1997 until January 25, 1999, Gonzalez worked as a sales representative for Foundation Health, a Florida Health Plan, Inc. (“Foundation”) at its offices in Dade County, Florida. Foundation paid Gonzalez a base salary and car allowance plus commissions and bonuses tied to production. 3. As an agent of Foundation, Gonzalez’s job was to solicit applications from Medicare recipients for membership in Foundation’s Senior Value Medicare Plan, a health maintenance organization (“HMO”) that, through managed care, provided a broader spectrum of benefits than otherwise was available under traditional Medicare coverage. For each Medicare recipient enrolled in the Senior Value Medicare Plan, Foundation received a monthly payment from the federal Health Care Financing Administration (“HCFA”). 4. On January 14, 1999, Gonzalez, as Foundation’s representative, signed an application for enrollment in the Senior Value Medicare Plan that had been filled out for an applicant named “Doris Simpson.” Included in the application were numerous identifying data such as Ms. Simpson’s address, phone number, date of birth, social security number, and Medicare number. Gonzalez submitted Ms. Simpson’s January 14, 1999, application to Foundation, initiating the enrollment process. 5. The Doris Simpson who fit the application’s description had died on or around July 1, 1998. The fact of her death was discovered in short order by HCFA during the ordinary course of the enrollment process. HCFA naturally rejected the bogus application and notified Foundation of the problem on or around January 20, 1999. 6. On January 22, 1999, Foundation suspended Gonzalez for three days, effective immediately, pending the outcome of its investigation into the Doris Simpson matter. 7. Gonzalez resigned his employment with Foundation on January 25, 1999. Thereafter, on February 1, 1999, Gonzalez began working for Physicians Healthcare Plans, Inc. as a sales representative, a job he has held ever since. Mistake or Misconduct? 8. The foregoing facts are largely undisputed; those that follow mostly are, hotly. Getting to the bottom of whether Gonzalez made an honest mistake, as he maintains, or submitted a fraudulent application, as the Department has charged, is facilitated by a careful scrutiny of Gonzalez’s conflicting explanations of what happened. 9. Gonzalez’s most contemporaneous account of the Simpson affair appears to be contained in an undated handwritten document, entitled simply “Statement,” that Gonzalez himself indisputably prepared and signed. The full text of this paper follows: STATEMENT Prospect: Doris Simpson Ss# 075-22-6675 Agent: George J. Gonzalez Ss# 263-92-7916 To whom it may concern: To the best of my recollection I arrived at 20879 N.W. 9th Ct #107 (Walden Ponds Community) during the morning of (on or about) 11 a.m. 14th Jan.—through the gate system. Ms. Simpson agreed to my visit & let me in. Ms. Simpson opened [the] door and throughout my presentation produced a Medicare card and then proceeded to verification. Verification person was “DAWN.” Throughout the whole process everything proceeded to a normal sit down “application-to-verification” prospect call. P.S. She is blind, African-American. {Signed] George J. Gonzalez 10. Gonzalez’s manager at Foundation, Sergio Rumie, testified that sometime between January 20 and January 22, 1999, Gonzalez personally had handed him this Statement, which, according to Mr. Rumie, constituted Gonzalez’s written explanation of what had occurred with the Simpson application. Mr. Rumie recalled that in a discussion between the two of them, Gonzalez had told him that he (Gonzalez) had met with someone (obviously not Doris Simpson) in the Simpson household on January 14, 1999, who had held herself out as Ms. Simpson and signed the application. Mr. Rumie believed Gonzalez. 11. Although the Statement is not dated, two details in Gonzalez’s handwritten memorandum strongly suggest that the events of January 14, 1999, were its intended subject. The first of these telltale details is the date itself. The controversial Simpson application is dated January 14, 1999. The Statement refers to a meeting between Gonzalez and Doris Simpson on January 14. No imagination is required to connect one to the other. 12. The second common denominator linking the Statement to the phony Simpson application is the verifier’s name, Dawn. Before going on, however, some additional background must be provided, so that the significance of this datum may be understood. 13. At all times material, an independent contractor located in Utah performed application verification services for Foundation. The name of this contractor is not in evidence. For convenience’s sake, following the witnesses’ lead, the contractor will be referred to simply as “Utah.” 14. As part of the approved sales process, Foundation required its agents to place a telephone call to Utah, in the presence of the prospective enrollee, whenever an application had been completed. Once connected, the agent was supposed to introduce the applicant to the verifier, and then turn the phone over to the applicant. Using a script, the verifier would ask the applicant a series of questions, to confirm that he or she understood the transaction at hand. If the interview went well, the verifier would give the agent a verification number along with his or her name, both of which the agent would record on the face of the application. Foundation would not accept an _application unless it contained a verification number. 15. On the controversial Simpson application of January 14, 1999, Gonzalez wrote, by hand, a verification number and the verifier’s name, which happens to have been Dawn—the very name, recall, of the verifier who was so prominently identified (as “DAWN”) in the Statement. 16. If the story ended here, it would be difficult to find that Gonzalez had willfully submitted a false application. Rather, to this point, Gonzalez seems to have been the victim of a strange hoax, fooled by an imposter pretending (for reasons that admittedly are not readily apparent) to be the late Doris Simpson. Mr. Rumie, after all, who knew Gonzalez and was ina position to assess his character and credibility at the time of the incident, had believed this to be the case. 17. But there is more to the story. The exculpatory scenario just mentioned holds water only if Gonzalez were unacquainted with the real Doris Simpson, for if Gonzalez had known the decedent personally, then common sense would counsel that he could not have fallen for a poseur’s deceit. 18. Gonzalez testified that he had been to Ms. Simpson's home on three occasions before January 1999, and that he knew her well. Twice, he said, he had taken an application from Ms. Simpson in person, had submitted the application, which was accepted, and thereby had succeeded in enrolling her in Foundation’s HMO. Each time, however, Ms. Simpson had dis- enrolled before long. Corroborating Gonzalez’s account are two completed applications, dated March 31, 1997, and June 4, 1998, and the fact that Ms. Simpson had been a member of the Senior Value Medical Plan for brief periods following these dates. 19. Gonzalez claimed also to have taken an application from Ms. Simpson in January 1998 that was rejected. In contrast to the other two, however, no application from January 1998 was produced at hearing—indeed, no persuasive corroborating evidence of any kind was adduced in support of this supposed January 1998 application. 20. The reliability of Gonzalez's testimony that he knew Ms. Simpson personally from dealings between them that had occurred before January 1999 is high because the fact is against his interests; this much of Gonzalez's testimony, therefore, is accepted as true and adopted as a fact finding. 21. On the other hand, Gonzalez's testimony that he met with Ms. Simpson in January 1998 and took an application from her at that time is suspiciously self-serving (as will be seen) and, ultimately, not believable. Initially, Gonzalez’s failure to produce the purported application raises a skeptical eyebrow. But what sinks Gonzalez's story about meeting Ms. Simpson in January 1998 is that the tale was told in an incredible attempt to explain away the Statement (which, if intended to refer to events of January 14, 1999, cannot be squared with Gonzalez’s admission that he had by then known Ms. Simpson personally from prior dealings) as a memorandum regarding this purported January 1998 visit. Gonzalez maintained that, by coincidence, he had happened to meet with Ms. Simpson on January 14, 1998, and again on January 14, 1999, and that both times the verifier, as chance would have it, was Dawn. This contention is contrived and forced. 22. Taken as a whole, the evidence is convincing that Gonzalez wrote the Statement in January 1999 for his former employer and delivered it to Mr. Rumie between January 20 and January 22, 1999, with the intent that the Statement be understood as a description of the circumstances surrounding Gonzalez’s solicitation of the January 14, 1999, application from the putative Ms. Simpson. The contents of the Statement, 10 however, are false and misleading, as was Gonzalez's testimony at hearing about the Statement. 23. Gonzalez gave a different account of the Simpson application to the Department of Insurance in response to the Administrative Complaint in this matter. In an undated letter to the Department which the Department received on September 6, 2000, Gonzalez wrote: By recollection I believe this case involves a mail-in situation. I recall that I sent maybe two/three such invitation packages in the Spring of 1998 and one could have been for Mrs. Simpson. That practice is no longer tolerated after a new Vice-president of marketing (Medicare) was installed in the Sawgrass Headquarters late May of that same year. As 1998 was ending in December (late) I believe I received an application signed and (I believe) it was the Simpson one. I completed the data in those days that followed early in January 1999, before starting my new job did a phone verification (3 way) or gave this information to a verifying person (Utah) and the person was thus verified (I cannot be clear on this). Hearing no problems from Utah I recorded the authorization # on a call back from Utah or after the verification; if done by 3-way. I did not know of her death and in fact only found out when receiving your package of counts and allegations on August 21, 2000. I would only add that Mrs. Simpson had a family member there, perhaps her sister. During my first application for the plan with Mrs. Simpson in late 1997 I believe she helped in the signing and subsequent verification of her sister. Mrs. Simpson 11 could not sign any proper way the petitions. I believe she was blind in my recollections. 24. Ironically, one of the few unqualified representations in this letter of Gonzalez's to the Department—that he “in fact” had first learned of Ms. Simpson’s death upon receipt of the Administrative Complaint—was clearly untrue. In fact, Gonzalez undeniably had known of Ms. Simpson's death at the time of his resignation from Foundation on January 25, 1999, if not sooner, and certainly long before August 21, 2000, in any event. 25. As for the rest of this explanation, Gonzalez essentially stuck with it at hearing, although his memory apparently had improved by then, for he seemed far more confident of the details than he had as author of the above- quoted letter. 26. In a nutshell, Gonzalez claimed that, on his own initiative, he had mailed a partially filled-out application to Ms. Simpson in June or July 1998 with note asking her to sign and return the document if she wanted to re-enroll in Foundation's Medicare HMO. He claimed to have had no further contact with Ms. Simpson until, in late December 1998 or early January 1999, he received through the mail Ms. Simpson's signed- but-undated application. According to Gonzalez, despite the delay of some five months, Gonzalez failed to call Ms. Simpson to confirm her continued interest and instead signed the 12 application on January 14, 1999, inscribing the same date next to the purported signature of Ms. Simpson. He claimed to have contacted Utah, provided the necessary information to the verifier, and in due course to have received a verification number from Dawn, which signified to him that all was in order. 27. This story is facially unbelievable and is rejected as a fabrication. Moreover, there is an out-of-place detail on the January 14, 1999, application that exposes the chicanery; namely, the designated primary care physician, a Dr. Nidal Radwan, who is specifically identified therein as Ms. Simpson's current physician. When Gonzalez was asked at hearing to point out the parts of the application that he had filled out, Gonzalez replied, making reference to the top quarter of the first page where the primary care physician information appears, that [t]he part that's my handwriting is the name, the address, the phone number, and the date of birth, and doctor selected, which was her last doctor. I put it there, I said does she [sic] want this doctor again. Transcript of Final Hearing at 193 (emphasis added). 28. At the time Gonzalez supposedly prepared this application, in June or July 1998, he had not spoken with Ms. Simpson specifically about doing so; indeed, she may well already have passed away. He certainly did not speak with her about doctors after July 1, 1998. Yet on the previous 13 application that Gonzalez had taken from Ms. Simpson just a few weeks before her death, dated June 4, 1998 (Respondent's Exhibit 4), Ms. Simpson had chosen a Dr. [Illegible] -Nunez as her primary care physician—not Dr. Radwan. 29. It is commonly known that for a genuine insurance application, the sales representative or agent will endeavor to elicit truthful, complete, and current information from the applicant and rely upon the applicant's representations in preparing the paperwork. The fact that Gonzalez's selection of Dr. Radwan as Ms. Simpson's "current" primary care physician was not based on information obtained from Ms. Simpson—aindeed, his election deviated from her last (known) written expression of intent in this regard—-exposes the act as an arbitrary choice of Gonzalez's, which in turn underscores the counterfeit nature of the January 14, 1999, application. The Charges 30. In Count I of its Administrative Complaint, based on allegations that Gonzalez had signed and presented an application for insurance in the name Doris Simpson, who was at the time deceased, the Department accused Gonzalez of having submitted an enrollment form that he "knew or should have known" contained false or fraudulent information, in violation of Sections 626.611 and 626.621, Florida Statutes. Specifically, the Department alleged the following grounds for discipline: 14 (a) Willful misrepresentation of any insurance policy or annuity contract or willful deception with regard to any such policy or contract, done either in person or by any form of dissemination of information or advertising. [Section 626.611(5), Florida Statutes] ; (b) Demonstrated lack of fitness or trustworthiness to engage in the business of insurance. [Section 626.611(7}, Florida Statutes] ; (c) Fraudulent or dishonest practices in the conduct of business under the license or appointment. [Section 626.611(9), Florida Statutes] ; (d) Willful failure to comply with, or willful violation of, any proper order or rule of the department or willful violation of any provision of this code. [Section 626.611(13), Florida Statutes] ; (e) Violation of any provision of this code or of any other law applicable to the business of insurance in the course of dealing under the license or appointment. [Section 626.621(2), Florida Statutes] ; (£) In the conduct of business under the license or appointment, engaging in unfair methods of competition or in unfair or deceptive acts or practices, as prohibited under part X of this chapter, or having otherwise shown himself or herself to be a source of injury or loss to the public or detrimental to the public interest. [Section 626.621(6), Florida Statutes] ; [and] (g} UNFAIR METHODS OF COMPETITION AND UNFAIR OR DECEPTIVE ACTS.- The following are defined as unfair methods of competition and unfair or deceptive acts or practices: Misrepresentation in insurance applications.- Knowingly making a false or 15 fraudulent written or oral statement or representation on, or relative to, an application or negotiation for an insurance policy for the purpose of obtaining a fee, commission, money, or other benefit from any insurer, agent, broker, or individual. [Section 626.9541(1) (k), Florida Statutes] [.] Ultimate Factual Determinations 31. Because the evidence does not illuminate all the particulars of Gonzalez’s scheme, it is impossible to reconstruct completely the precise course of his misconduct. The evidence is sufficient, however, to establish, clearly and convincingly, that on or around January 14, 1999, Gonzalez: (a) signed an insurance application for Ms. Doris Simpson knowing that she had neither requested the sought-after coverage, nor supplied information for that application, nor executed the application herself; (b) placed a date next to the purported signature of Ms. Simpson (which he knew was not hers) intentionally to represent, falsely, that “she” and he had signed the instrument contemporaneously (and hence, implicitly, in one another’s presence); and (c) with intent to deceive, submitted this bogus application to his employer, Foundation, for the purpose of obtaining a commission or other benefit. 16
Conclusions For Petitioner: Anoush A. Arakalian, Esquire Department of Insurance Division of Legal Services 200 East Gaines Street Tallahassee, Florida 32399-0333 For Respondent: Ignacio Siberio, Esquire 525 Northwest 27th Avenue, Suite 100 Miami, Florida 33125
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department enter a final order suspending Gonzalez’s health insurance agent license for a period of one year. 21 DONE AND ENTERED this 10 day of July, 2001, in Tallahassee, Leon Count Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this lot day of July, 2001.
The Issue The issue in this case is the amount of the Petitioners' personal injury settlement required to be paid to the Agency for Health Care Administration (AHCA) to satisfy its Medicaid lien under section 409.910, Florida Statutes (2013).
Findings Of Fact The Petitioners are the grandparents and legal guardians of Taya Rose Savasuk-Maldonado, who is 11 years old. On October 2, 2010, Taya and six family members were involved in a horrific car crash. The driver of another car (the tortfeasor) failed to stop at an intersection and slammed into the family van, which rolled over, ejecting three passengers, including Taya and her great-grandparents. The great- grandparents died on the pavement next to Taya, and Taya suffered severe injuries, including a skull fracture, pancreatitis, bleeding in her abdomen, and severe road rash that required multiple skin graft surgeries and dressing changes so painful that anesthesia was required. Taya has significant, permanent scarring, which has left her self-conscious and unwilling to wear any clothing that exposes her scars, including bathing suits and some shorts. Taya's emotional injuries include nightmares and grief over the loss of both great-grandparents. Other family members also suffered injuries. Taya required emergency and subsequent medical care that has totaled $257,567 to date. It is not clear from the evidence how much, if any, of that total was reduced when providers accepted Medicaid. Future medical expenses are anticipated, but there was no evidence as to the amount of future medical expenses. The tortfeasor had a $100,000/$300,000 Hartford insurance liability policy on the car he was driving at the time of the accident. Hartford agreed to pay the policy limits. The injured family members agreed that $200,000 of the policy limits should be paid to Taya. On October 14, 2013, Hartford and the Petitioners agreed that the Petitioners would release Hartford, the tortfeasor and his wife (the other owner of the car) in return for payment of $200,000 to be held in trust by the Petitioners' attorneys for distribution as follows: $60,000 to be paid to the Prudential Assigned Settlement Services Corporation to fund future payments to Taya beginning in year 2020; up to $84,095 to lienholders in amounts to be determined; and the balance to the Petitioners' attorneys. The parties to that agreement, which did not include AHCA, agreed that $51,513 of the $200,000 should be allocated to payment of Taya's medical bills, with the rest allocated to claims other than medical expenses. There was no evidence that anything has been paid to AHCA towards its Medicaid lien, or that anything has been paid into an interest-bearing trust account for the benefit of AHCA pending the determination of the amount of its Medicaid lien, which at the time was claimed to be $55,944. The owner of the family van involved in the accident had a $10,000/$20,000 GEICO underinsured motorist policy, which also paid the policy limits. Although the evidence was not clear, the Petitioners appear to concede that all $20,000 was recovered by them for Taya's benefit. There was no evidence as to when the family's claim against the GEICO policy settled, or as to any agreement how the $20,000 should be allocated between medical expenses and other kinds of damages. There was no evidence that any of the $20,000 was paid to AHCA towards its Medicaid lien, or into an interest-bearing trust account for the benefit of AHCA pending the determination of the amount of its Medicaid lien. In addition to the insurance policy settlements, the owners of the other car paid the family approximately $250,000 from their own assets, which the family members agreed to apportion among themselves in a manner that was not disclosed by the evidence. There was no evidence as to when those funds were paid to the family, or when any of those funds was paid to Taya's benefit, if any. The evidence was not clear whether any of those funds was paid towards Taya's medical expenses that were not paid by Medicaid. The evidence suggested that some of the $250,000 was paid towards Taya's medical expenses to date, but it is possible that some of those expenses were reduced when providers accepted Medicaid. There was no evidence that any of those funds was paid to AHCA towards its Medicaid lien claim, or into an interest-bearing trust account for the benefit of AHCA, pending a determination of the amount of its Medicaid lien. A personal injury lawyer, who also was Taya's guardian ad litem, testified that the value Taya's claims against the owners of the other car was approximately $1.4 to $1.8 million. He did not testify as to the amount future medical expenses would contribute to the total value he estimated. AHCA has paid $55,710.98 in Medicaid benefits to treat Taya for her accident injuries. (The Petitioners stipulated to this amount.) Lee Memorial Hospital provided medical services for Taya and claims that it is owed $38,317.05, for which it appears to claim a statutory lien. The evidence was that Lee Memorial refused to accept Medicaid in payment for those services. If Medicaid were accepted, the amount of AHCA's lien would be more than $55,710.98, but probably not $38,317.05 more.
