Findings Of Fact Dr. Swerdzewski, a general dentist in practice in Tallahassee, has been Petitioner's family dentist since 1982. At some time in the latter part of 1983, he saw Petitioner's minor son, Rhett, whom he had seen on various dental problems since 1982 for some minor orthodontic problem. He referred Rhett to an orthodontist but the conclusion drawn was that any work done would be a matter of preference rather than necessity since the mouth was pretty well aligned and it was elective as to whether to do the cosmetic orthodonture or not. Consequently, no orthodontic work was accomplished or planned. On January 28, 1984, Rhett was riding his bicycle near Petitioner's home when he lost control and fell off the bike, over the handlebars, landing face first on the curb. A neighbor who saw the accident picked Rhett up and carried him to Petitioner's home. At this time, Rhett was bleeding heavily from the mouth. Fifteen to twenty minutes after the accident took place, Petitioner phoned the dentist. At that time, the dentist was out. When the call was returned an additional fifteen to twenty minutes later, the dentist instructed Petitioner to bring Rhett to the office immediately. Petitioner did not realize at that time that one tooth had been knocked out of Rhett's mouth. When they arrived at the dentist's office and the wound area was cleaned, it was first discovered that one of Rhett's teeth was missing and it was concluded that the tooth was probably still at the site of the accident. With that in mind, Petitioner went back to where Rhett had fallen and after a short period of time, located the tooth in the gravel near the side of the road. He returned the tooth to the dentist's office, where it was cleaned and reimplanted in Rhett's mouth. After this work was done, the dentist recommended that Petitioner bring Rhett back a week later and also recommended that Petitioner seek or consult with an orthodontist. This consult was held with Dr. Cummings on February 8, 1984. Dr. Cummings recommended orthodontic work to correct the problem and that the tooth in question be extracted because in his opinion, the long term prognosis for it was poor. Petitioner did not want to accept that diagnosis and sought a consultation with another orthodontist, Dr. Campbell, on February 21, 1984. This second orthodontist also recommended extraction and orthodonture indicating that in addition to the reimplanted tooth, the corresponding tooth on the opposite side of the mouth would also have to be extracted to maintain the mouth's midline balance. Petitioner was still reluctant to have this procedure followed. As a result, Dr. Campbell recommended that Petitioner also discuss the matter with Dr. King, Chairman of the Department of Orthodontics at the University of Florida Dental School. On April 3, 1984, the Petitioner saw Dr. King, who reviewed the case and recommended extraction of the bad tooth and its matching tooth and installation of an orthodontic device. After the meeting with Dr. King, Petitioner and his wife agreed that the orthodontic work was required and in order that the work could be done, requested an extension from the Blue Cross agency administering the state self health insurance plan in which Petitioner was enrolled. Blue Cross granted an additional 90 days for filing on May 17, 1984. Once that extension was granted, Petitioner decided to proceed with the treatment not expecting any problem with the insurance coverage. The work was accomplished after school was dismissed for the summer in June, 1984. The two teeth in question ware extracted upon the recommendation of all three orthodontists and braces were installed as appropriate. In August, 1984, the installing orthodontist and Petitioner were notified by Blue Cross/Blue Shield that the work being done would not be covered under the policy. Under paragraph VIII B of the Benefit Document, dental work "medically necessary" for the alleviation or repair of damage to an insured (including eligible dependents) is covered by the plan only if the work is (1) the result of an accident sustained while the insured is covered, and (2) rendered within 120 days of the accident unless a written explanation is submitted within that period stating extenuating circumstances. At the time of the accident and all times pertinent hereto, Petitioner was a bona fide member of the plan and Rhett was an eligible dependent. The term "medically necessary" means, in the opinion of the administrator of the program, the service received is required to identify or treat the illness or injury which a physician has diagnosed or reasonably suspects. The service must be (1) consistent with the diagnosis and treatment of the patient's condition, (2) in accordance with standards of good medical practice, and (3) required for reasons other than convenience of the patient or the physician. The fact that a service is prescribed by a practitioner does not necessarily mean that the service is medically necessary. A licensed dentist who performs a procedure covered by the plan is included in the definition of the term "physician." According to Dr. Swerdzewski, there were three accepted procedures for the treatment of Rhett's condition. The first would be to do nothing at all in which case the reimplanted tooth would ultimately be rejected by the body and lost from the mouth. In this case a space would remain on the gum where the lost tooth was that would allow the remaining teeth to spread to fill the void. In light of the fact that Rhett is still a child, whose jaw is still growing and developing, it would be impossible at this point to determine whether the remaining teeth would stay properly aligned or not. The second alternative would be to remove the tooth and replace it with a spacer to keep the void open until such time as the jaw was fully grown. At that point, the two teeth adjoining the hole on either side would be prepared for the affixing of a bridge consisting of a false tooth to be inserted in the vacant spot. Since a false tooth or bridge has an effective life span of from 15 to 20 years, given Rhett's current age, it is likely that the bridge would have to be replaced 2 or 3 times during his lifetime. The third alternative would be to follow that procedure followed here. The evulsed tooth, along with its symmetrical pairing on the other side of the mouth, would be removed and an orthodontic device (a brace) installed in the mouth to bring the remaining teeth together to fill the voids. Thereafter, the remaining canine teeth would be modified so that they would appear to be incisors from a cosmetic standpoint. Once this was done it is likely that no further treatment would be required throughout the course of the young man's life except to replace the cosmetic build attached to the modified incisors every so often. This replacement is not a major procedure. The tooth which was lost in the accident, tooth number 7, was subjected to a root canal by Dr. Swerdzewski prior to being reimplanted in Rhett's mouth. Since the root canal was done, this tooth would no longer discolor. However, subsequent examination of Rhett's mouth showed that tooth number 8 which is located immediately next to number 7, and which was loosened in the accident, shows some evidence of discoloration and may itself need some root canal work done on it. Though the evulsed tooth was treated and reimplanted, its prognosis at the time was poor. The longer a tooth is out of the mouth, the less chance of successful reimplantation there is when it is done. Dr. Swerdzewski reimplanted the tooth anyway because, in his opinion, individuals heal differently and he thought there was some chance this tooth would reaffix itself in the mouth and be satisfactory. In this case, however, the evulsed tooth was rejected. When the decision was made to follow the extraction/brace course of treatment and the evulsed tooth and its symmetrical match were pulled, the implanted tooth was seen not to have attached well. It had begun to deteriorate and was at that time in the process of rejection. In Dr. Swerdzewski's opinion, it would have had to come out anyway within the next year even if it did not break prior to that time. In fact, x-rays taken immediately before the tooth was pulled showed some loss of tooth structure and when the tooth was pulled and looked at clearly, the dentist was convinced it would not have stayed in. When Dr. Swerdzerdski took x-rays in March, 1984 there was no evidence of resorption. In discussing the two reasonable alternatives here, bridgework or orthodonture, Dr. Swerdzewski was of the opinion that while a bridge and caps could be done, this is not normally an acceptable treatment for a child of Rhett's age because of continued growth and mouth development. In addition, one of the adjacent teeth was loose, the area was traumatized, and it "'as likely that there could not be found a good base for attachment of the bridge. Consequently, over the long term, any bridge inserted would have to be replaced and the damage done to good teeth by the preparation for bridgework was not, in his opinion, justified in this case. The long term effect of the use of a bridge on this individual in these circumstances would be more traumatic than would be the course of treatment followed. It is, also, in the opinion of Dr. Swerdzewski, not good dental practice to do bridgework on patients under the age of 17 or 18 because even if the tooth to which the bridge is attached is fully erupted (grown out) the nerve and root structure of that tooth is not sufficiently developed to support the trauma of the preparation for bridgework. Consequently, Dr. Swerdzewski believes, while it would be dentally acceptable to utilize a space maintainer for the evulsed tooth area until the patient had matured sufficiently to support bridgework, it is not the most appropriate way. Instead, he chose, consistent with the recommendations of three orthodontists, to take out not only the injured tooth but also a perfectly good tooth which matched it symmetrically on the opposite side of the mouth in order to do the orthodonture. This was done to pull the tooth line together and in the opinion of all four experts, was the best result for the patient, Rhett. In the opinion of Dr. Swerdzewski, it is always better if possible to insert permanent artificialities in the mouth. Also, in Rhett's case, the teeth were pure and in his opinion it is too drastic a measure to damage pure teeth if not absolutely necessary. Dr. Swerdzewski's testimony is afforded great weight here because his practice includes the formulation and insertion of bridgework, not orthodonture. Having taken the position here that orthodonture was appropriate, he was referring business away from himself to his financial detriment. It was his confirmed opinion, and he acted in accord with it, that bridgework was not appropriate and dentally indicated for this case. No evidence to refute this was presented by Respondent.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore, RECOMMENDED that the Petitioner herein, ROBERT A. BRYMER, be afforded plan benefits under Respondent's Group Health Self Insurance Plan for treatment rendered his son as a result of the accident which took place on January 28, 1984. Recommended in Tallahassee, Florida, this 6th day of February, 1985. ARNOLD H. POLLOCK 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 6th day of February, 1985. COPIES FURNISHED: Dr. Robert A. Brymer 2805 Shamrock North Tallahassee, Florida 32308 Daniel C. Brown, Esquire General Counsel Department of Administration 435 Carlton Building Tallahassee, Florida 32301 Gilda Lambert, Secretary Department of Administration Carlton Building Tallahassee, Florida 32301
Recommendation Based on the foregoing Findings Of Fact and Conclusions Of Law, it is recommended that the Respondent, the Department of Administration, enter a final order denying coverage for the orthodontia recommended for Sandra Walsh. RECOMMENDED this 18th day of March, 1988, in Tallahassee, Florida. J. LAWRENCE JOHNSTON Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 18th day of March, 1988.
The Issue The issue is whether respondent's license as a health insurance agent should be disciplined for the reasons stated in the administrative complaint.
Findings Of Fact Based upon all of the evidence, the following findings of fact are determined: At all times relevant hereto, respondent, Michael Halloran, was licensed and eligible for licensure as a health insurance agent by petitioner, Department of Insurance and Treasurer (Department). When the events herein occurred, respondent was licensed to solicit health insurance on behalf of National States Life Insurance Company (NSLIC) and Transport Life Insurance Company (TLIC). He was also under contract with Diversified Health Services of St. Petersburg, Florida until that firm terminated his agency appointment on May 5, 1989. This proceeding involves the sale by respondent of various health insurance policies to four customers in January and February 1989. In 1987, Raymond H. Koester, a Largo resident, purchased from respondent a supplemental Medicare policy for both him and his wife. Their first policy was issued by American Integrity. A year later, respondent persuaded the Koesters to replace that policy with one issued by Garden State Insurance Company on the ground the latter policy represented an "improvement" over their existing policy. On January 10, 1989 respondent met with the Koesters for the purpose of selling them new health insurance coverage. During their meeting, respondent advised the Koesters that a new NSLIC policy would provide unlimited custodial and home health care, a type of coverage desired by the Koesters. Relying upon respondent's representation, the Koesters agreed to purchase two new policies. They filled out an application and paid Halloran $2,628 which was the premium for the first year. When the application was completed, respondent answered "no" to the question of whether the new policies were intended to replace existing coverage. This was a false representation. In June 1989 the Koesters learned that they had a problem with their new policies. This advice was conveyed to them by petitioner's investigator who advised them that the policies sold by Halloran loran did not provide any custodial or home health care benefits. Had the Koesters known this, they would not have purchased the insurance. On January 18, 1989 respondent visited Grace Miller, an elderly resident of Venice, Florida, for the purpose of selling her a health insurance policy. At that time Miller had an existing policy in force since 1983 which provided supplemental Medicare coverage. Respondent advised Miller that her existing coverage was inadequate and that more coverage was needed. More specifically, Halloran represented that a new NSLIC policy would supplement her basic Medicare coverage and increase her overall health insurance coverage. Based on that representation, Miller agreed to purchase a replacement policy issued by NSLIC. As it turned out, the policy sold to Miller was of little or no value to a Medicare recipient, such as Miller, and simply filled in the gaps on a major medical policy. Had Miller known this to begin with, she would not have purchased the policy. Respondent also persuaded Miller to purchase a long-term care policy from TLIC. She allowed respondent to fill out the application using information from her old policy. Without telling Miller, respondent misrepresented on the application her date of birth as December 2, 1921 when in fact she was born on December 2, 1911, or ten years earlier. By doing this, Halloran was able to reduce Miller's premium from $1,159.92 to $441.72. Had Miller known that she was responsible for paying a much higher premium, she would not have purchased the policy. On February 25, 1989 respondent accepted another check from Miller in the amount of $773.00 for an unknown reason. At about the same time, respondent submitted to NSLIC an application for a medical-surgical expense policy dated the same date purportedly executed by Miller In fact, Miller had not executed the policy and her signature was forged. NSLIC declined to issue a new policy to Miller since she already had a policy of that type in effect. On January 20, 1989 respondent visited Gertrude Simms, an elderly resident of Fort Myers. Simms desired to purchase a hospital expense insurance policy with a provision for dental insurance coverage. Simms desired such coverage because she had a medical condition that required her to have her teeth cleaned frequently to avoid an infection. Respondent was aware of this condition. Nonetheless, Halloran prepared an application with NSLIC for a limited medical-surgical expense insurance policy which did not provide any dental coverage. Respondent accepted a $1,100 check from Simms which he represented to her was the first year's premium. In fact, the first year's premium was only $506. Although respondent was supposed to return to Simms' home to explain the policy provisions, he never returned. At about this same time, TLIC received an application on behalf of Simms for a long-term care insurance policy bearing the signature of respondent as agent. However, Simms had no knowledge of the application and did not wish to purchase such a policy. The information contained in the TLIC application misrepresented Simms' age so that the premium was lower than it should have been. Although TLIC issued a policy and sent it to respondent, Halloran never delivered it to Simms. On February 1, 1989 respondent visited Velma Sonderman, who resided in Venice, Florida, for the purpose of selling her a health insurance policy. She had become acquainted with respondent through Grace Miller, who is referred to in finding of fact 4. Sonderman was then covered by a supplemental medicare insurance policy issued by United American Medicare. According to Sonderman, respondent gave a "snow job" and represented he could sell her better coverage through NSLIC. Sonderman agreed to purchase a new policy for supplemental medicare coverage to replace her existing policy and signed an application filled in by respondent. However, the application submitted by respondent was for a NSLIC limited benefit health insurance policy rather than the medicare supplement insurance policy Sonderman believed she was purchasing. Respondent also convinced Sonderman to purchase a long-term nursing home care policy issued by TLIC. When filling out the application on her behalf, but without telling Sonderman, respondent misrepresented Sonderman's birth date as July 11, 1915 instead of the correct date of July 11, 1911. By doing this, Sonderman's premium was reduced from $999.36 to $599.04 per year.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that respondent's license as a health insurance agent be REVOKED. DONE and ENTERED this 4 day of April, 1990, in Tallahassee, Florida. DONALD ALEXANDER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 4 day of April, 1990. APPENDIX Petitioner: 1-3. Substantially used in finding of fact 1. 4-17. Substantially used in findings of fact 4, 5 and 6. 18-29. Substantially used in findings of fact 9 and 10. 30-33. Substantially used in findings of fact 2 and 3. 34-45. Substantially used in findings of fact 7 and 8. 46. Substantially adopted in finding of fact l. Copies furnished to: Honorable Tom Gallagher Insurance Commissioner Plaza Level, The Capitol Tallahassee, FL 32399-0300 James A. Bossart, Jr., Esquire 412 Larson Building Tallahassee, FL 32399-0300 Mr. Michael Halloran 2519 McMullen Booth Road Clearwater, FL 34621 Donald A. Dowdell, Esquire Department of Insurance Plaza Level, The Capitol Tallahassee, FL 32399-0300
The Issue The issue in the case is whether the State of Florida Employees Group Health Self Insurance Plan Benefit Document provides coverage for a maxillary subperiosteal implant surgical procedure under the circumstances described below.
Findings Of Fact At all material times, Petitioner has been insured under the State of Florida Employees Group Health Self Insurance Plan Benefit Document, effective July 1, 1988 (the "Plan"). Dr. Clark F. Brown, Jr. is a dentist licensed to practice in the State of Florida. His specialty is dental implantology. The subperiosteal implant, which is the subject of this case, is a framework that rests on top of the bone underneath the tissue. Following the insertion of the framework, the tissue reattaches to the jawbone, thereby securing the framework to the bone. The implant procedure takes two days, but can be performed in Dr. Clark's office. On the first day, a direct bone impression is taken. In the process, the gum tissue is cut along the entire remaining ridge and lifted back almost to the base of the eye, floor of the nose, and palate. After the impression is taken, the incision is closed with sutures. On the next day, the stitches are removed, the implant is installed, and the incision again closed with sutures. On July 31, 1987, Petitioner visited Dr. Clark and complained of difficulties wearing his upper denture. Upon examination, Dr. Clark discovered that Petitioner lacked adequate bone to retain an upper denture. Lacking about 90% of the bone in the vicinity of the upper arch, Petitioner's upper denture was highly unstable. By letter dated August 8, 1987, Dr. Clark informed the Plan administrator of Petitioner's condition and proposed a full maxillary subperiosteal procedure for the installation of an orthopedic augmentation appliance. By letter dated December 11, 1987, the Plan administrator informed Dr. Clark that the proposed procedure was not covered under the Plan. The letter explains that dental services are a specific exclusion unless performed "as the result of an accident where a natural tooth has been damaged and the treatment is rendered within 120 days from the date of the accident." On December 17, 1987, Dr. Clark relined the denture that fit Petitioner the best. As he had warned Petitioner in advance, the procedure was unsuccessful. On June 26, 1988, Dr. Clark prepared a new upper denture in preparation for the installation of mucosal implants, which utilize the gum for support. Dr. Clark and Petitioner pursued this treatment largely because it was less expensive that the subperiosteal implant for which the Plan administrator had refused coverage. Dr. Clark later installed these implants, but they were unsuccessful due to the lack of bone. They were removed in November, 1988. At this point, the subperiosteal implant remained the only available treatment for Petitioner. On February 2, 1989, Dr. Thomas Priest, a physician licensed to practice in the State of Florida, examined Petitioner and found that his gums were severely receded, his alveolar ridge was absent, and his lower teeth were in poor shape. Considering the complaints of Petitioner concerning digestive disorders and weight loss, Dr. Priest determined that Petitioner would be a good candidate for, and might benefit from, the maxillary subperiosteal implant. Dr. Priest reached this conclusion based in part on the experience of other patients who had undergone similar procedures. Dr. Clark and the Plan administrator exchanged correspondence through the first half of 1989, at which time the administrator, in response to a threat of litigation, stated that "the preparation of the mouth for dentures is considered to be a dental procedure and non-covered." She then referred Dr. Clark to Respondent. The loss of bone was probably caused by Petitioner wearing loose upper dentures for an extended period of time. However, severe periodontal disease, which cannot be ruled out as a possible cause, could also result in the loss of bone. Another potential cause of the loss of bone is trauma from accidental injuries, such as those typically suffered in an automobile accident. However, this potential cause can be ruled out in Petitioner's case. No accident has necessitated the subject implant procedure, nor has any accident preceded the proposed procedure by 120 days. The Plan contains three coverage sections. Section II describes "Covered Hospital and Other Facility Services." Section III describes "Covered Medical--Surgical Benefits." Section IV describes "Other Covered Services." Section II deals with hospitals primarily and is not applicable to the present case. Subsections III.A. and D. provide coverage for "medically necessary inpatient/outpatient services provided to an insured by a . . . physician for the treatment of the insured as a result of a covered accident or illness." Section IV provides coverage for "medically necessary services when ordered by a physician for the treatment of an insured as a result of a covered accident or illness," including, at Subsection IV.D., "other medical supplies and prostheses . . . determined by the Administrator to be medically necessary for the treatment of an insured's condition." The phrase, "covered accident or illness," which is not defined in the Plan, apparently refers to accidents or illnesses that are not elsewhere excluded, such as in Section VII on Exclusions and Section VIII on Limitations. Section VII.A. excludes "services for cosmetic surgery or treatment unless the result of a covered accident as provided in Subsection VIII.A." However, Subsection VII.A. adds that cosmetic surgery is covered if it is: a medically necessary procedure in the correction of an abnormal bodily function; [or) for reconstruction to an area of the body which has been altered by the treatment of a disease, provided such alteration occurred while the insured was covered under the Plan. Subsection VII.G excludes: Services and supplies in connection with dental work, dental treatment, or dental examinations unless the result of a covered accident as provided in Subsection VIII.B., except that in no case shall orthodontia be covered. Subsection VIII.A. provides the following limitation upon coverage: Cosmetic surgery or treatment necessary for the repair or alleviation of damage to an insured covered by the Plan if such surgery or treatment is the result of an accident sustained while the insured is covered under the Plan and actually performed while the Plan is in force . . Subsection VIII.B. provides the following limitation upon coverage: Any dental work, dental treatment or dental examinations medically necessary for the repair or alleviation of damage to an insured is covered by the Plan only if such work, treatment or examination is (1) the result of an accident sustained while the insured is covered under this Plan and (2) rendered within . . . 120 days of the accident. . Subsection I.AX. defines a physician to include: a licensed dentist who performs specific surgical or non-dental procedures covered by the Plan, or who renders services due to injuries resulting from accidents, provided such procedures or services are within the scope of the dentist's professional license. Subsection I.AM(b). defines "medically necessary" to mean that: in the opinion of the Administrator the service received is required to identify or treat the illness or injury which a physician has diagnosed or reasonably suspects. The service must (1) be consistent with the diagnosis and treatment of the patient's condition (2) be in accordance with standards of good medical practice, and (3) be required for reasons other than convenience of the patient or his/her physician. The fact that a service is prescribed by a physician does not necessarily mean that such service is medically necessary. Subsection I.AE. defines "illness" as: physical sickness or disease, . . . bodily injury, [or] congenital anomaly . .
Recommendation Based on the foregoing, it is hereby RECOMMENDED that the Administration Commission enter a Final Order determining that the proposed procedure, under the facts of this case, is covered by the Plan. DONE and ORDERED this 21 day of March, 1989, in Tallahassee, Florida. ROBERT E. MEALE Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 21 day of March, 1990. COPIES FURNISHED: Augustus D. Aikens, Jr. General Counsel Department of Administration 435 Carlton Building Tallahassee, FL 32399-1550 William F. Lennan 740 Hunan St., N.E. Palm Bay, FL 32907 Aletta Shutes, Secretary Department of Administration 435 Carlton Building Tallahassee, FL 32399-1550
The Issue Whether Petitioner is entitled to a refund from the State of Florida Group Health Self Insurance Plan of pre-tax supplemental insurance premiums in the amount of $47.46 or $47.45 a month that were deducted from his pay for the 2007 and 2008 insurance plan years.
Findings Of Fact Petitioner, Detrick Murray ("Petitioner" or "Mr. Murray") was, at all times relevant to this proceeding, employed by the Florida Department of Corrections. As a state employee, he was given the option to participate in a pre-tax supplemental accident/disability insurance plan. Benefits, including insurance plans, are administered by a private contractor, Convergys, through a project called "People First," operated on behalf of Respondent, Department of Management Services, Division of State Group Insurance ("Respondent or the Division"). During the 2005 open enrollment period for the 2006 plan year, Mr. Murray elected to participate in a state- sponsored supplemental/accidental policy offered by Colonial Insurance Company ("Colonial"). The reverse side of the enrollment provided the following information and instructions: The enrollment form must be used to enroll in or change coverages. No changes will be accepted by e-mail or letter. Enrolling in a supplemental insurance plan, or changing options, does not automatically stop other coverages you currently have. To stop an existing coverage, you must place an "S" in the box provided for that Plan on the front of this form (Part 1). Only complete Part 2 on the front of this form if you wish to stop plans currently not offered. The Supplemental Enrollment Form must be submitted to the People First Service Center. Enrollment changes will not occur if forms and/or applications and the Supplemental Company Application are submitted directly to the supplemental insurance company. If you cancel or do not enroll in supplemental insurance, you will not be able to enroll again until the next annual open enrollment period, unless you experience a Qualifying Status Change. Supplemental premiums are deducted on a pre- tax basis. It is your responsibility to ensure that your enrollment selections are in effect. Check your payroll warrants to ensure that your deductions properly reflect your selections. Contact the People First Service Center immediately if these deductions are not correct. I understand my enrollment and/or changes will be effective the first of the month following a full payroll deduction. I also understand my elections are IRREVOCABLE until the next annual open enrollment period, unless I have a Qualifying Status Change as defined by the Federal Internal Revenue Code and/or the Florida Administrative Code. I understand that I must request such changes within thirty-one (31) calendar days of the Qualifying Status Change. The open enrollment period for the next year, the 2007 plan year, began on September 19, 2006, and ended on October 18, 2006. On October 14, 2006, Mr. Murray notified Colonial that he wanted to cancel the supplemental insurance for the 2007 plan year. He used a Colonial Request for Services form and sent it to the Colonial Processing Center in Columbia, South Carolina. In a letter dated February 14, 2007, Colonial acknowledged receiving Mr. Murray's request to cancel the insurance during the 2006 enrollment period, and informed him of its receipt of an "overpayment" of $47.46 monthly beginning January 1, 2007. Colonial directed Mr. Murray to contact his personnel officer "which will then work through the Division to issue your refund." After the open enrollment period ended, Mr. Murray had also contacted People First on November 14, 2006, and gave notice of his attempt to cancel with Colonial. He was informed that Colonial had not informed People First of the cancellation. Mr. Murray contacted People First again on January 29, 2007, questioning the continued payroll deductions and requesting a refund, as Colonial had suggested. He was told that he would have to cancel with People First during the open enrollment period, but he could send a letter of appeal to try to get a refund of premiums and try to cancel sooner. Despite repeated contacts, requests for refunds, and appeals to People First during 2007, Mr. Murray continued to have premiums for supplemental insurance deducted from his pay check. Ultimately, the Division denied his appeal. Although Mr. Murray was trying to get a refund for 2007 payroll deductions, he again failed to notify People First to cancel the insurance during the open enrollment period between September 17, 2007, and October 19, 2007, for the 2008 plan year. There is no evidence that Mr. Murray had a qualifying status change, as required by federal and state law, that would have permitted him to cancel the insurance at any time other than during open enrollment periods for the 2007 and 2008 plan years. The enrollment period for the 2009 plan year began on September 22, 2008, and ended on October 17, 2008. On September 24, 2008, Mr. Murray cancelled the supplemental insurance for the 2009 plan year by making a telephone call to a People First representative. In a late-filed exhibit produced by a manager for Convergys at the request of Petitioner, the Division showed that payments were made to Colonial to insure Mr. Murray through November 24, 2008. Sandi Wade, the Division's benefits administrator, noted that Colonial should not have canceled Mr. Murray's insurance policy. Colonial had no authority to send the letter of February 14, 2007, incorrectly telling Mr. Murray he was entitled to a refund. Ms. Wade's observations prompted Mr. Murray to question what, if any, remedies he might have with regard to Colonial's error. That issue is not and cannot be considered in this proceeding. In the absence of evidence that the Division or its agents were notified to cancel the supplemental insurance during open enrollment periods for 2007 and 2008, or based on a qualifying status change, Petitioner's request for a refund of premiums must be denied.
Recommendation Based on the foregoing, it is recommended that the Department of Management Services, Division of State Group Insurnace, enter a final order denying Petitioner, Detrick Murray, a refund of his accident/disability insurance coverage premiums paid in 2007 and 2008. DONE AND ENTERED this 12th day of May, 2010, in Tallahassee, Leon County, Florida. S ELEANOR M. HUNTER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 12th day of May, 2010. COPIES FURNISHED: Sonja P. Mathews, Esquire Department of Management Services Office of the General Counsel 4050 Esplanade Way, Suite 260 Tallahassee, Florida 32399 Detrick Murray 4370 Northwest 187th Street Miami, Florida 33055 John Brenneis, General Counsel Division of State Group Insurance Department of Management Services 4050 Esplanade Way Tallahassee, Florida 32399-0950
The Issue Whether Petitioner's claim for medical expenses from August 6, 1982 through February 27, 1983 should be approved, pursuant to the State of Florida Employees Group Health Self Insurance Plan. Petitioner appeared at the hearing accompanied by legal counsel. The Hearing Officer thereupon explained his rights and procedures to be followed in the administrative hearing. Petitioner acknowledged that he understood his rights and elected to represent himself. Petitioner testified in his own behalf at the hearing and the parties stipulated to the introduction of Respondent's Exhibits 1 and 2. A late filed exhibit, Respondent's Exhibit 3, was also admitted in evidence. Respondent presented the testimony of one witness, William R. Seaton, Benefit Analyst for the Respondent's Bureau of Insurance.
Findings Of Fact Petitioner Thomas J. Appleyard, III, is a former state employee who retired with disability in 1976 as a result of cardiac disease. At the time Petitioner retired, he maintained coverage in the state Employees Group Health Self Insurance Plan under which the Blue Cross/Blue Shield of Florida, Inc. serves as the administrator of the plan for the state. Petitioner also receives disability benefits under the Medicare program for medical expenses. (Testimony of Petitioner) The State Group Health Self Insurance Plan provides in Section X, COORDINATION OF BENEFITS, that if an insured has coverage under Medicare, the benefits payable under the state plan will be coordinated with similar benefits paid under the other coverage to the extent that the combination of benefits will not exceed 100 percent of the costs of services and supplies to the insured. Paragraph D of Section X provides that the state plan will be the secondary coverage in such situations and will pay benefits only to the extent that an insured's existing insurance coverage does not entitle him to receive benefits equal to 100 percent of the allowable covered expenses. This provision applies when the claim is on any insured person covered by Medicare. (Testimony of Seaton, Respondent's Exhibit 3) Petitioner was hospitalized at the Tallahassee Memorial Regional Medical Center on three occasions in 1982-33. His Medicare coverage paid all but $261.75 of the hospital expenses. In February 1983, Petitioner also incurred medical expenses to his cardiologist, Dr. J. Galt Allee, in the amount of $248.33. Petitioner was originally denied his remaining hospital expenses by the administrator of the state plan under the erroneous belief that he was receiving regular Medicare benefits for persons over the age of 65. In addition, Dr. Allee's bill was only partially paid by Medicare, subject to the receipt of additional information from the physician. Payment under the state plan was limited to an amount sufficient to reimburse petitioner 100 percent of the amount originally allowed by Medicare. (Testimony of Seaton, petitioner, Respondent's Exhibit 1, 3) Respondent does not receive information on claims filed under the state plan until contacted by an employee. In February 1984, Petitioner requested assistance from William R. Seaton, Benefit Analyst, of Respondent's Bureau of Insurance, regarding his difficulties in receiving proper claims payments. Seaton investigated the matter with the Insurance administrator for the state, Blue Cross/Blue Shield of Florida, and discovered that the latter had not coordinated the hospital expense balance with Medicare. They thereafter did so and as of the date of hearing, there was no longer a balance due to Tallahassee Memorial Regional Medical Center. Seaton also gave written instructions to Blue Cross to review all of Petitioner's claims and make sure that they were paid properly, and to install controls on his and his wife's records. (Testimony of Petitioner, Seaton, Respondent's Exhibit 1-2) The full claim of Dr. Allee had not been paid by Medicare since it had been awaiting requested additional in formation from the physician. Such information was provided after a personal visit had been made to Dr. Allee by Seaton and Medicare then recognized additional eligible expenses. However, a balance of $36.00 is still owed to the physician due to the fact that Blue Cross/Blue Shield had not received the necessary payment information from Medicare as of the day before the hearing. (Testimony of Seaton, Respondent's Exhibit 1) Section XVII of the state's Group Health Self Insurance Plan benefit document provides that an employee who wishes to contest decisions of the state administrator considering the employee's coverage under the plan may submit a petition for a hearing for consideration by the Secretary of Administration. (Respondent's Exhibit 3)
The Issue Whether Mr. Wills is entitled to reimbursement from the State Group Health Insurance Plan for health services provided by an otolaryngologist and a speech pathologist for vocal therapy.
Findings Of Fact The State of Florida makes available to employees several health insurance programs. One of the options available to employees is the State of Florida Employees Group Health Self Insurance Plan. Employees may also enroll in a number of different health maintenance organizations depending upon the county in which the employee resides. The Employees Group Health Self Insurance Plan was established by the Legislature, and its benefits are described in the Benefit Document. The Plan as a whole is administered by Blue Cross-Blue Shield, which did not write the terms of the Plan. When an employee chooses to participate in the Plan, the State contributes to the employee's insurance cost by paying a portion of the premium for the employee in order to be covered by the Plan. Mr. Wills is employed by the State of Florida as the Chief Assistant Public Defender for the Seventeenth Judicial Circuit in Broward County, Florida. Mr. Wills is a Senior Trial Attorney in the Public Defender's Office and a senior administrator who needs his voice to carry on his professional duties. He was a member of the Plan at all times relevant to this proceeding. The case revolves around whether Mr. Wills is entitled to reimbursement for expenses he incurred when he was diagnosed in June 1990 as having a vocal chord lesion, also known as a contact ulcer or granuloma of the vocal fold, and participated in a course of medical treatment for this condition. For example, Mr. Wills would attempt to speak, but portions of words could not be heard. Mr. Wills ultimately was treated by Dr. W. Jarrard Goodwin. Dr. Goodwin is a specialist in diseases of the ear, nose and throat (i.e., an otolaryngologist), and teaches at the University of Miami School of Medicine. Dr. Goodwin was of the view that the lesion was caused by the mechanical banging together of the vocal chords, and that surgery was not an appropriate treatment for him. Instead, he prescribed an antibiotic and three weeks vocal rest. He had a second consultation with Mr. Wills on August 14, 1990, at which time Dr. Goodwin referred Mr. Wills to Donna S. Lundy, a speech pathologist in the Department of Otolaryngology at the University of Miami Medical School, for voice therapy. A contact ulcer or granuloma can result from the pitch of the voice being too high or too low, from speaking too loudly, or from not breathing from the diaphragm. All of these can be treated with behavioral voice therapy through exercises, either to raise or lower the pitch of the voice, or to breathe from the diaphragm and relax the vocal chords in order to decrease effort and strain near the lesion. Mr. Wills saw Ms. Lundy for sessions of vocal therapy at Dr. Goodwin's office on August 11, September 13, October 5, November 11, and December 27, 1990, and Mr. Willis practiced the exercises he was given between appointments. Even if Mr. Wills had had surgery, i.e., a stripping of the vocal chords, an alternative treatment for the contact granuloma, he still would have had vocal therapy following that surgery to modify his vocal habits to prevent a recurrence of the lesion. As a result of the vocal therapy, Mr. Wills' condition has improved, and he no longer suffers from the contact granuloma. Speech therapy treats abnormalities of speech production, language formulation and processing, such as articulation disorders, stuttering, language delay, and disorders of neuromuscular control. It is not the same as voice therapy. Five claims for health services were submitted on behalf of Mr. Wills by Donna S. Lundy, under procedure code 92507. Code 92507 on the approved fee schedule covers "Speech, Language or Hearing Therapy, with Continuing Medical Supervision, Individual." Dr. Goodwin, also submitted one claim under procedure code 92507 for services provided to Mr. Wills on August 14, 1990. All such claims were rejected by the Department. The State of Florida, Employees' Group Health Self Insurance Plan benefit document contains exclusions. The applicable exclusion, according to the Department, is Section VII(Q): VII. Exclusions The following exclusions shall apply under the plan: * * * * Q. Occupational, recreational, edu-cational, or speech therapy, orthoptics, biofeedback, contra-ceptives, telephone consultation, cardiac rehabilitation exercise programs, or visits for the purpose of exercise by bicycle, ergometer or treadmill. Benefit Document, page 46. There is no further explanation of the term "speech therapy" found in exclusion VII(Q) in any other portion of the Benefit Document. The approved fee schedule for the Group Health Self-Insurance Plan has a procedure code for "speech, language or hearing therapy, with continuing medical supervision, individual." That the approved fee schedule has such an entry at all is an indication that there are circumstances where speech language or hearing therapy is covered. Otherwise, the entry would be wholly inconsistent with the Department's position that Section VII(Q) flatly prohibits any payment for "speech therapy". Ms. Lundy is licensed speech-language pathologist in the State of Florida. Unless a person qualifies for licensure as a speech-language pathologist, a person may not describe him or herself using a number of terms. Among these forbidden terms are "speech pathologist", "speech therapist", "language pathologist", "voice therapist" and "voice pathologist". Section 468.1285(1)(b), Florida Statutes, (1990 Supp.). The Department relies upon the definition for the practice of speech-language pathology in the Professional Practice Act, Chapter 468, Part I, Florida Statutes (1990 Supp.), to argue that any services provided by a licensed speech-language pathologist must necessarily fall within the exclusion found in Section VII(Q) of the Benefit Document. The Department's argument that because the term "speech therapy" is not defined in the Benefit Document, it should determine the meaning of the term by looking to see how the term "speech-language pathology" is defined in Section 468.1125(7)(a), Florida Statutes (1990 Supp.), the professional practice act for speech-language pathology, is unpersuasive. There was no testimony that the Benefit Document was written with all definitions found in various professional practice acts in mind. There is certainly no proof that the Legislature crafted the miscellaneous professional practice acts in Chapter 468 with an eye towards using the definitions in those acts for determinations under the Employees' Group Health Self Insurance Plan. The Benefit Document and the professional practice acts have little or nothing to do with each other, and neither shed light upon terms used in the other.
Recommendation It is recommended that the Secretary of the Department of Administration enter a Final Order requiring the Division of Employees' State Insurance to pay all claims submitted by Donna S. Lundy and the claim of Dr. Goodwin which have been denied. The Benefit Document does not clearly exclude voice therapy for a contact granuloma, and in the absence of a clear exclusion, the law requires that those claims be paid. RECOMMENDED this 24th day of December, 1991, in Tallahassee, Florida. WILLIAM R. DORSEY Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 24th day of December, 1991. APPENDIX TO RECOMMENDED ORDER, CASE NO. 91-5324 Rulings on findings proposed by the Department: Adopted in Finding 1. Adopted in Findings 2 and 3. Rejected as unnecessary. Adopted in Finding 3. Adopted in Finding 4. Discussed in Finding 5. Rejected as unnecessary. See, Conclusions of Law. Adopted in Finding 9. Adopted in Finding 10. Rejected. See, Conclusions of Law. Adopted in Finding 5. Rulings on findings proposed by Mr. Wills, treated as if the paragraphs had been numbered: Adopted in Finding 3. Adopted in Findings 3 and 4. Adopted in Finding 5. Adopted in Finding 7. Generally adopted in Finding 9. Generally adopted in Finding 5. Adopted in Findings 5 and 9. COPIES FURNISHED: Steven Michaelson, Esquire 9326 Northwest 18th Drive Plantation, FL 33322 John M. Carlson, Esquire Department of Administration 438 Carlton Building Tallahassee, FL 32399-1550 John A. Pieno Secretary Department of Administration 435 Carlton Building Tallahassee, FL 32399-1550 Augustus D. Aikens, Jr. General Counsel Department of Administration 435 Carlton Building Tallahassee, FL 32399-1550
The Issue The issue in this case is whether Petitioner is entitled to health insurance coverage for installation of temporary and permanent dental crowns under Florida’s State Employees’ Group Health Self Insurance Plan.
Findings Of Fact Petitioner claims to suffer from temporomandibular joint dysfunction ("TMJ"). Petitioner is a member of the State Employees’ Group Health Self Insurance Plan (the "Plan"). Respondent is responsible for administering the Plan. Blue Cross and Blue Shield ("Blue Cross") services the Plan for Respondent. The Plan covers medical expenses incurred for the treatment of TMJ. The Plan paid for treatment of Petitioner’s TMJ symptoms on March 25, 1996, and on December 2, 1997. That treatment did not include crowns. Dr. Michael Vallilo is one of Petitioner’s dentists. On May 28, 1998, Dr. Vallilo placed temporary crowns on 14 of Respondent’s teeth and bonded two of her teeth. On May 29, 1998, Dr. Vallilo wrote Blue Cross and requested payment for the temporary crowns. Dr. Vallilo also requested prior approval for permanent crowns at an approximate cost of $14,000 for both sets. Dr. Vallilo requested payment and prior approval based on his opinion that the crowns are reasonably necessary for the treatment of TMJ. The temporary and permanent crowns were necessary for the treatment of occlusion dysfunction. Occlusion dysfunction relates to the fit of the teeth when brought together. Occlusion dysfunction has no correlation to TMJ. Petitioner’s symptoms and medical records are not consistent with TMJ. The diagnosis in Petitioner’s medical records describes oral dyskinesia. Oral dyskinesia involves muscle spasm, limited muscle function, the body’s reaction to the way teeth fit together, and an inability to keep the jaws closed. The diagnosis did not state a cause for the symptoms. Even if oral dyskinesia were caused by TMJ, crowns are not covered by the Plan. Medical reimbursement under the Plan does not cover crowns, bridges, inlays, on-lays, fillings, equilibration of the teeth, or any other procedure that alters the tooth itself and can be performed only by a licensed dentist. The Plan covers only specified treatment for TMJ. Covered treatment includes X-rays, clinical exams, splint therapy, physical therapy, surgical procedures of the joint itself, and other procedures not performed on the teeth. The Plan covers repositioning devices necessary in the treatment of TMJ. Crowns are not repositioning devices. Petitioner had separate dental insurance at the time the crowns were installed in her mouth. Her dental insurance may, or may not, have covered the temporary and permanent crowns. Even if the Plan did not exclude crowns as dental treatment, the placement of crowns for TMJ or occlusion disorder is not covered. Such services are not consistent with applicable standards of good medical practice.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Respondent enter a final order denying Petitioner's claim. DONE AND ENTERED this 6th day of December 1999, in Tallahassee, Leon County, Florida. DANIEL MANRY Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 6th day of December, 1999. COPIES FURNISHED: Thomas D. McGurk, Secretary Department of Management Services 4050 Esplanade Way Tallahassee, Florida 32399-0950 Paul A. Rowell, General Counsel Department of Management Services 4050 Esplanade Way Tallahassee, Florida 32399-0950 Carole A. Clark 6325 Highland Gardens Court Lakeland, Florida 33813 Joan Van Arsdall, Esquire Department of Management Services 4050 Esplanade Way, Suite 260 Tallahassee, Florida 32399-0950
The Issue The issue is whether the Petitioner, Amjad Shamim, is eligible for continuation coverage of health insurance and reimbursement, under the State of Florida Employees Group Insurance Plan, for medical care expenses he incurred after he left state employment.
Findings Of Fact Mr. Shamim became a full-time employee of the Department of Health and Rehabilitative Services (HRS) in September, 1986, and worked at the Palm Beach County Health Department. Effective August 1, 1987, Mr. Shamim was insured with family coverage under the State of Florida, Employee Group Health Insurance Program. His enrollment continued until his insurance termination effective date of January 1, 1989. On November 15, 1988, Mr. Shamim met with Martina L. Walker, Personnel Technician I for HRS at the Palm Beach County Health Department, in connection with his decision to leave the Department's employ on November 18, 1988. At that meeting he executed the documents required by HRS to discontinue his health insurance coverage. As part of that November 15, 1988, conference, Martina Walker informed Mr. Shamim of his rights to continued health insurance coverage after his termination of employment. Mr. Shamim advised Ms. Walker that he no longer needed the State coverage because his new employer offered a health insurance plan to its employees. Ms. Walker, nonetheless, cautioned Mr. Shamim that any pre-existing conditions are usually not covered by new employer policies. Ms. Walker's notification of Mr. Shamim's right to continued health insurance coverage for up to 18 months was not in writing. Mrs. Walker never told Mr. Shamim orally the specifics of continuation coverage, i.e., that he had 60 days to elect continuation coverage from the coverage effective date of January 1, 1989, that his application and premium were required to be postmarked by March 1, 1989; or that he could continue his family coverage for 18 months at monthly premium of $273.01 per month. In addition to disclosures when an employee leaves, all employees of the Palm Beach County Health Department are advised of their opportunity to elect continuation coverage under the State Plan at the time of their employment, by means of a notice furnished by HRS. Mr. Shamim received a general notice of benefits, including the availability of post employment continuation coverage, at the time of his employment. The termination form completed by Ms. Walker was processed routinely, and caused the Division of State Employee Insurance to mail Mr. Shamim written notification by first class mail of the availability of continuation coverage in a letter dated December 1, 1988. Due to the appearance of the handwritten address on the notice mailed to Mr. Shamim, it is more likely than not that this notice failed to arrive at Mr. Shamim's home address. The portion of the address for the apartment number could be read as D201 or 2201, which would account for misdirection of the notice in the mail. Mr. Shamim's claim that he did not receive the notification is accepted. Had the notice been properly addressed and had he received it, Mr. Shamim would have had the opportunity to decide whether to exercise his legal right to continue his health insurance. On January 27, 1989, Mr. Shamim had surgery to his hand. He had been treated for that condition while he was employed with the Palm Beach County Health Department. Because it was deemed to be a pre-existing condition, the expense he incurred of almost $4,000 was not covered under the health insurance policy of his new employer. There is no evidence of the length of time the pre- existing condition exclusion in the policy offered by Mr. Shamim's new employer lasts. Mr. Shamim first notified HRS of his desire for post termination health insurance coverage on September 19, 1989. A second request was made on November 7, 1989. Finding no success with HRS, Mr. Shamim contacted the Respondent on December 29, 1989.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered accepting the request of Mr. Shamim for continuation coverage, accepting his premiums and processing his claim. DONE and ENTERED this 11th day of November, 1990, at Tallahassee, Florida. WILLIAM R. DORSEY, JR. 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 11th day of November, 1990.
