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
Findings Of Fact Dr. Roberts and His Background Dr. Steven Roberts is a dentist licensed to practice in the State of New York. He attended the United States Military Academy and received his undergraduate degree in 1970. He graduated from the New York University College of Dentistry in 1978, and practiced dentistry in New York, New York from 1978- 1987. To be licensed in New York, Dr. Roberts passed the national boards and the northeast regional board examination. During the course of his practice in New York, Dr. Roberts never received a complaint or had a claim for malpractice made or filed against him. Clinical Examinations Dr. Roberts took the Florida clinical dental examinations in June of 1986, January of 1987, and June of 1987. His grade on the June of 1987, examination is the subject of this proceeding. Dr. Roberts has successfully passed the written examination and the diagnostic examination required for licensure by Section 466.066(4)(a) and (c), Florida Statutes. Dr. Roberts' score for the June of 1987, clinical dental examination was 1.95; the minimum passing score is 3.00. The procedures tested during the June 1987, Clinical Dental Examination and Dr. Roberts' scores were as follows: The Procedure The Score The Revised Score Periodontal 1.67 Amalgam Cavity Preparation 1.67 Amalgam Cavity Restoration 3.00 Composite Preparation .67 Composite Restoration .33 Posterior Endodontics 2.00 3.66 Cast Preparation 2.67 3.00 Pin Amalgam Preparation 1.00 Pin Amalgam Restoration 1.67 Denture 3.63 Total Score 1.95 2.15 Dr. Roberts made a timely request to review his grade, and filed objections to his grades; a regrading procedure resulted in the regrading of his scores for posterior endodontics and cast restoration as set forth above. Each of the procedures tested in the clinical dental examination is scored by three different examiners. For each procedure examiners record their scores on separate 8 1/2" X 11" sheets. Each sheet has a matrix of circles which are blackened with a pencil so that they can be machine scored. On each sheet the candidate's identification number and the examiner's identification number are recorded along with the number for the procedure involved and the candidate's grade. On the sheet for each procedure the criteria for successful performance of the procedure are printed, along with preprinted comments which the examiners may use to explain the reason for the grade assigned. These comments relate to the criteria being examined. The following grades may be assigned by examiners: Complete failure Unacceptable dental procedure Below minimum acceptable dental procedure 3- Minimum acceptable dental procedure 4- Better than minimal acceptable dental procedure 5- Outstanding dental procedure An examiner is not required to mark a comment if the grade assigned is 5, a comment is marked for any grade below 5. Each procedure is graded in a holistic manner. Grades assigned by each of the three examiners for a procedure are averaged; the averaged scores for each procedure are then weighted and the weighted scores are summed to provide the overall clinical grade. By averaging the scores of three examiners for each procedure, variation from examiner to examiner is minimized. The examiners are experienced Florida dentists selected by the Board of Dentistry. An examiner must have at least five years of experience as a dentist and be an active practitioner. Potential examiners attend a standardization training exercise. This training is required by Section 466.006(4)(d), Florida Statutes. Its purpose is to instruct examiners in examination procedures and the criteria to be applied in grading. Through the training the examiner group as a whole arrives at a consensus opinion about the level of grading, so that candidates' scores on the examination will be valid and reliable. The training attempts to focus on each examiner's subjective, internalized evaluation criteria, so that they can be modified, as necessary, to reflect the consensus of all graders. A standardizer explains grading criteria to the potential examiners, and discusses various divisions among schools of thought and training on the procedures which will be the subject of the examination. The standardizer uses dental exhibits from prior dental exams as examples, and identifies grades and errors on the exhibits so that the graders learn and can adhere to uniform grading standards. The training focuses on three problems which professional literature has identified in evaluation: errors of central tendency, proximity errors, and bias a priori. Errors of central tendency result when graders are uncertain of criteria, hesitate to give extreme judgments, even in appropriate cases, and thus tend to improperly grade near the average. Proximity error is a type of halo effect which is applicable in grading of mannequin exhibits. The examiner grades all of the mannequin exhibits for each candidate at one time. If the first example of the candidate's work is especially good, and deserves a grade of 5, the grader may tend to transfer a generally positive attitude towards the next example of the candidate's work and assign a grade which may not be based solely upon the merits of that second piece of work. The same process can improperly depress the grades on subsequent mannequins if the first example of a candidate's work is poor. Bias a priori is the tendency to grade harshly or leniently based upon the examiner's knowledge of the use that will be made of the grade, rather than only on the quality of the work graded. After an 8 to 12 hour standardization training session, the Department administers an examination to those who have been trained. Those with the highest scores become the examiners, i.e., dentists who will grade candidates' work, while those with the lower scores in the training session become monitors, who supervise the candidates in their work on mannequins or on patients, but who do not actually grade student work. There is, however, no minimum score which a dentist who attends the standardization session must obtain in order to be an examiner rather than a monitor. This results, in part, from the limited pool of dentists who participate in the examination processes as monitors or examiners. For the 1987 clinical dental examination 31 dentists accepted selection by the Board and attended the standardization session, 20 were then selected as examiners and 11 became monitors for the examination. None of the dentists who attended the standardization session were dismissed by Department of Professional Regulation from further service at the examination session. The process by which the Department selected the examiners for the 1987 clinical dental exam was neither arbitrary nor capricious, but comports with Rule 21G- 2.020(4), Florida Administrative Code. The standardization training and examination of dentists to determine who will serve as examiners and monitors does not provide any bright line for distinguishing among potential examiners those who will make the most assiduous effort to apply the grading criteria explained in the training session versus those who retain an innate sense of a passing work based on what the examiner considers acceptable work in his own practice. The effort to convey to examiners the standard of "minimum competency" has imperfect success, but the Department's training is appropriate. Out-of-State Candidates' Scores 11. There is a substantial difference in the failure rates for out-of- state candidates and for in-state candidates on the clinical dental examinations. In the June of 1987, exam 82.5% of the candidates who graduated from the only in-state dental school, the University of Florida, passed the entire examination, while 54.2% of the out-of-state graduates passed, and only 37.8% of candidates from foreign schools were successful. Overall, 86.5% of the candidates passed the written portion of the examination, 93.5% the portion on oral diagnosis, but only 63.3% the clinical portion of the examination. Dr. Roberts has failed to prove that the lower pass rate for out-of- state candidates is the result of any sort of conscious effort on the part of examiners to be more stringent in grading out-of- state candidates. Dr. Kennedy's testimony indicated only that the data bear more analysis, not that they prove improper grading. Procedures Performed on Mannequins The Board of Dentistry tests between 600 and 700 dental candidates per year. It is extremely difficult for the candidates to find patients who have exactly the problem which is to be tested and bring them to the examination to work on. Some portions of the clinical dental examination, therefore, are not performed on patients, but on cast models of human teeth which resemble dentures, and which are known as mannequins. This is expressly authorized by Section 466.006(4)(a), Florida Statutes. The notice to appear which candidates receive approximately 30 days before the examination informs them of the types of mannequins which will be used in the examination. Before that time, however, dental supply companies obtain lists of those eligible to take the examination, and contact the candidates in an attempt to sell them the mannequins. Candidates must bring mannequins with them to the examination and can purchase additional mannequins for practice. Testing with mannequins is also more efficient because with live patients, the student must be graded at the time of the examination, while a model can be retained and graded a day or two later. The decision of the Board to have certain procedures performed on mannequins, so that each candidate would be graded on exactly the same procedure, is reasonable. The Board had also considered having students perform all test procedures on extracted human teeth, but there are not a sufficient number of all natural teeth available, given the number of students who are tested, both for the examination itself and for practice. The Board determined that it would be better to use mannequins for some of the procedures tested in the examination because they are readily available and students can purchase extra copies for practice. For certain procedures, such as endodontics, specific natural teeth (such as first bicuspids) are often extracted and so are generally available; for procedures performed on those teeth, it is possible to have candidates work on human teeth. By contrast, testing procedures performed on teeth such as incisors is not practicable. It is impossible to obtain enough incisors in good condition, without restorations and chips, for use during an examination. The statute governing the dental examination does require that one restoration performed by candidates must be done on a live patient, and for the June 1987, clinical dental examination that procedure was a class 2 amalgam restoration. The Board directed by rule that mannequins be utilized for five test procedures: the pin amalgam preparation and restoration, Rule 21G-2.013(3)(d), Florida Administrative Code; the endodontic procedure, Rule 21G-2.013(3)(e) Florida Administrative Code; the posterior tooth preparation for a cast restoration, Rule 21G-013(3)(f), Florida Administrative Code, the class III acid etch composite preparation and class IV acid etch composite restoration, Rule 21G-2.013(3)(g), Florida Administrative Code. Performing these procedures on mannequins is not exactly the same as performing procedures on human teeth in a patient. In view of the difficulty involved in finding patients whose teeth present virgin lesions, so that each candidate would be tested on exactly the same problem, the difficulty in grading a large number of procedures performed on live patients, and the difficulty in obtaining a large number of human teeth necessary for testing and for practice, the Board's decision to use the mannequins for these procedures is reasonable. The Legislature recognized this in Section 466.006(4)(b), Florida Statutes, which prescribes that the clinical dental examination shall include restorations "performed on mannequins, live patients, or both. At least one restoration shall be on a live patient." The Board was within its authority when it determined the procedures to be performed on mannequins. Violation of Blind Grading The dental examiners who grade the work of candidates grade blindly, i.e., they do not know which candidate's work they are grading. The Clinical Monitor and Examiner Instruction Manual for the June of 1987, examination makes this clear. At page 24 paragraph 3 the Manual states Examiners are requested to disqualify themselves at anytime they are presented with models or patients treated by a dentist who they know personally or with whom they have had professional contact. All examiners are requested to give department staff the name of any examination candidate who is personally known to them to be taking the exam. The department staff will assist the examiners in avoiding any work performed by the candidates they know. Rationale: Allegations have been made about examiners who knew candidates taking the exam even though the examiners only see candidate numbers. Monitors and Examiners are strongly urged to avoid discussion with candidates about the examination. Even conversation about non-examination related matters can be misinterpreted by other candidates as an unfair privileged communication. Despite this admonition, one of the examiners, Dr. Cohen, who knew Dr. Roberts, graded the work of Dr. Roberts. Dr. Cohen met Dr. Roberts the first time Dr. Roberts took the Florida Clinical Dental Examination in June of 1986. Dr. Roberts had with him a bag which would have identified him as a student from New York University, where Dr. Cohen had taught. Dr. Cohen came over to Dr. Roberts, introduced himself, gave Dr. Roberts his card, (exhibit 44) and invited Dr. Cohen to his hotel room where they discussed practicing dentistry in Florida. In 1986 Dr. Cohen was associated with another dentist, Gerald P. Gultz, who had recently moved to Florida from New York. Dr. Gultz had also been a part-time clinical assistant professor of dentistry at New York University College of Dentistry. After Dr. Cohen returned from the June 1986, administration of the clinical dental examination, he had a conversation with Dr. Gultz in which Dr. Cohen asked Gultz if he knew Dr. Roberts, and commented on Dr. Roberts performance on the clinical examination. Dr. Cohen said Dr. Roberts had done terribly, and Dr. Cohen believed that Dr. Roberts would never get his license to practice in Florida. (Tr. 5/26/88 at 73). Dr. Roberts saw Dr. Cohen at the January of 1987, clinical dental examination, but they did not speak. In June of 1987, Dr. Cohen also spoke briefly to the wife of Dr. Gerald Gultz, Lauren Gultz, saying that he would be seeing Dr. Roberts at the June of 1987, clinical dental examination, which was coming up. He told Mrs. Gultz that Dr. Roberts was a poor practitioner, and that he did not think he would pass the examination. At the June 1987, exam, Dr. Roberts' periodontal patient was his uncle, Mr. Finkelstein. Dr. Cohen was one of the examiners who reviewed Mr. Finkelstein to determine whether his condition was appropriate to serve as a patient for Dr. Roberts on the periodontal portion of the examination. Dr. Cohen had a conversation with Mr. Finkelstein in which he told him "tell your dentist to do a good job". Because Mr. Finkelstein had stated that his dentist was a graduate from N. Y. U. Dental School, Mr. Finkelstein was convinced that Dr. Cohen knew exactly who the dental candidate who would work on Dr. Finkelstein was -- Dr. Roberts. After accepting Mr. Finkelstein as an appropriate periodontal patient, Dr. Cohen also served as a grader on the periodontal procedure performed on Mr. Finkelstein. After grading the work which Dr. Roberts had done, Dr. Cohen told Mr. Finkelstein to tell his dentist that Dr. Cohen would see him later in the hotel where they were staying. At the hotel, Dr. Cohen talked to Dr. Roberts about the dental examination, that he himself had to take the examination three times, although he considered himself to be a superior dentist, and that Dr. Cohen could help Dr. Roberts with his grades but that he could never grade Dr. Roberts more that one grade higher than any of the other examiners. Dr. Cohen served as an examiner (i.e. grader) for Dr. Roberts on six of the nine procedures tested. There were: procedure number 1, the periodontal evaluation where he assigned a failing grade of 2; procedure number 4, the class III composite preparation, where he assigned a failing grade of 1; procedure number 5, the class IV composite restoration, where he assigned a failing grade of 1; procedure number 6, the endodontic evaluation, where he assigned a passing grade of 3; procedure number 7, the preparation for a cast restoration, where he assigned a passing grade of 3; and procedure number 8, the pin amalgam preparation, where he assigned a failing grade of 1. This failure of blind grading is a serious irregularity in the evaluation of Dr. Roberts' performance on the 1987 clinical dental examination, given his prior negative comments about Dr. Roberts before the examination. By ignoring those scores, Dr. Roberts would be evaluated only by two examiners, on all the procedures for which Dr. Cohen gave a grade. This would mean that his scores would not be comparable with those of any other candidate, for his grade on each procedure would not be the result of blind grading by three independent examiners. Dr. Roberts' Challenges to Grades Assigned by Other Examiners The full nine procedures evaluated in the 1987 dental clinical examination and Dr. Roberts' grades were: A periodontal exercise performed on a live patient, Mr. Finkelstein, which involved the scaling of five teeth both above and below the gum and stain removal. Dr. Roberts was assigned scores of 1, 2, and 2 by the examiners (one grade of 2 was assigned by Dr. Cohen) An amalgam cavity preparation, performed on a live patient, Elizabeth Cox, which is the preparation of a tooth for filling. When the preparation is completed a proctor escorts the patient to the three examiners who independently grade this part. After grading, the patient returns to the candidate who completes the filling of the tooth (the restoration) which is subsequently graded independently by three examiners. Dr. Roberts was assigned grades of 1, 1, and 3 for the preparation (none of these grades were assigned by Dr. Cohen). A final amalgam restoration, which is the filling of the tooth prepared in the prior procedure. Dr. Roberts received grades of 3, 3, and 3 on this procedure (none of the grades were assigned by Dr. Cohen). A class III composite preparation, which is preformed on a model, not a live patient. This involves removing decay and shaping a tooth to hold a class III filling, i.e., one located on the side surface of an incisor. Dr. Roberts received scores of 1, 0, and 1 (Dr. Cohen assigned one of the grades of 1) A class IV composite restoration, which is performed on a model, not a live patient. This involves restoring a fractured tooth with a composite restoration material. On this procedure Dr. Roberts received scores of 0, 0, and 1 (Dr. Cohen assigned the grade of 1). An endodontic evaluation performed on a posterior tooth, which is performed on a mannequin, and involves the opening of a molar, and identification of the canals in the tooth in preparation for a root canal procedure. Originally Dr. Roberts received grades of 3, 3, and 0 (one of the grades of 3 was assigned by Dr. Cohen). Dr. Roberts work was regraded by three new examiners and the grades of the original examiners were discarded. Dr. Roberts ultimately received a grade of 3.67 on the endodontic portion of the examination A preparation of a posterior tooth for a cast restoration, which is performed on a mannequin. It involves preparing a tooth to receive a crown. Dr. Roberts' original grades were 2, 3, and 3 (Dr. Cohen had assigned a grade of 3 on this procedure). On review, Dr. Roberts' was regraded by three new examiners, and the original grades were discarded. Dr. Roberts received a final grade of 3 on this portion of the examination. A pin amalgam preparation, which is performed on a model, not on a live patient. This involves the preparation of a tooth to hold an amalgam filling by inserting a pin into a portion of the tooth, which serves to anchor the filling. Dr. Roberts was assigned grades of 2, 0, and 1 on this procedure (Dr. Cohen assigned the grade of 1). Pin amalgam final restoration, which is performed on a model. It involves filling a tooth with amalgam filling material. Dr. Roberts was assigned grades of 2, 1, and 2 on this procedure (Dr. Cohen assigned one of the grades of 2). Due to the involvement of Dr. Cohen in so many of the procedures involved here, Dr. Roberts performance on the June of 1987, clinical dental examination was not fairly evaluated. A fair evaluation cannot be provided after the fact by merely dropping Dr. Cohen's grades, because Dr. Roberts' performance would not be subject to the independent evaluation of three examiners. Dr. Roberts relies, to a large extent, on the testimony of Dr. Gultz as the basis for regrading his procedures to a passing grade of 3, or better. The testimony of Dr. Gultz does not, however, show that he has ever participated in the standardization exercises for examiners at Florida clinical dental examinations. Dr. Gultz experience as a clinical professor of dentistry at New York University provides a substantial basis for his evaluation of dental procedures. The difficulty, however, is that as with any qualified examiner, his evaluations will be based on internalized standards which are personal to him. There is no way to know whether Dr. Gultz standards for adequate performance are equivalent to those which the standardization training produces among examiners at the standardization exercise before a clinical dental examination. The standardization process "attempts to bring all examiners to the same level of grading, so that each [examiner] is grading in a valid and reliable manner." Clinical Monitor and Examiner Instruction Manual, June of 1987, at page 42. The Florida dental clinical examination uses a holistic grading method. Each score sheet which an examiner fills out has on it the criteria to be applied in evaluating the candidates performance on that procedure. They all contain a statement which reads: It is the intent of the Board that each of the criteria are to be accorded equal importance in grading. Equal importance does not mean that each criteria has a numerical or point value, but means that any one of the criteria, if missed to a severe enough degree so as to render the completed procedure potentially useless or harmful to the patient in the judgment of the examiner, could result in a failing grade on the procedure. The criteria do not have any assigned numerical or point value, but are to be utilized in making a holistic evaluation of the procedure. Each grading sheet also points out to the examiner certain critical factors which, if present, require a grade of 0 for the procedure. The standardization in grading which the Board diligently attempts to achieve through the standardization training and the standardization testing of examiners done at the close of the training is elusive at best. Nonetheless, in the absence of showing that Dr. Gultz standards of evaluation are equivalent to those of an examiner trained at a standardization session, it is impossible to know whether his standards of evaluation are more rigorous or less rigorous than those reflected by the grades assigned to other candidates by the corps of examiners which evaluated the work of candidates at the June of 1987, clinical dental examination. The same is true with respect to the testimony of Dr. Simkins, the expert for the Board in this proceeding. No useful purpose would be served in attempting to choose between the testimony of Dr. Gultz, on the one hand, and the testimony of Dr. Simkins and of the other examiners who testified by deposition in this proceeding. If this were to be done, all the hearing officer would have determined is whose testimony about the appropriate grade to be assigned for each procedure is more believable. On this record it would be impossible to make a further finding about whether that more believable testimony reflects a scoring standard more stringent, less stringent or the same as that generally applied to all candidates by the corps of examiners in the June of 1987, clinical dental examination.
Recommendation It is recommended that the results of the clinical dental examination which Dr. Roberts took in June of 1987, be found invalid, and that he be permitted to take the next clinical dental examination offered by the Department of Professional Regulation at no cost to him. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 8th day of December, 1989. 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 8th day of December, 1989.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that all charges against Respondent be DISMISSED. DONE and ENTERED this 24th day of January, 1983, in Tallahassee, Florida. DONALD R. ALEXANDER 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 24th day of January, 1983.
The Issue Whether Petitioner’s disabled dependent child is entitled to have his dental benefits continued after he has reached the age of 26.
Findings Of Fact Respondent contracts with Humana/CompBenefits Company to provide dental benefits to employees of the State of Florida. In 2014, Petitioner, his spouse, and his dependent child were members of Humana/CompBenefits Company’s Network Plus Dental Plan (Humana Plan). The Humana Plan provides coverage for a subscriber’s dependent child through the calendar year in which the child reaches the maximum age of attainment. Respondent handles eligibility issues regarding the Humana Plan and allows dependent child coverage to continue through the end of the year in which the dependent turns 26 years of age (the maximum age of attainment). The dental coverage for Petitioner’s dependent terminated on January 1, 2015, due to the fact that the dependent turned 26 years of age in 2014. According to the Humana Plan, dental coverage for a dependent older than 26 years of age may, under certain circumstances, continue if the dependent is disabled. In order for dependent coverage to continue, proof of the dependent’s disability must be submitted within 31 days of the dependent’s maximum age of attainment, or by the end of the year in which the dependent turns 26 years of age. Petitioner did not submit any documentation regarding his dependent’s disability until August 2015, which was approximately 10 months after his child’s 26th birthday. Petitioner claims that he was unaware of the fact that his dependent’s coverage terminated on January 1, 2015, and if he had known of the termination, he would have timely provided to Respondent documentation demonstrating his son’s disability. Employee health insurance benefits are administered by a private contractor, Northgate/Arinso, through an online system called People First. The People First computer system automatically identifies which dependents will be ineligible for coverage during the upcoming policy year and mails notifications to members advising them that their benefits will be changing. From October through November 2014, Northgate/Arinso sent Petitioner the following three notifications that his dependent child would not be enrolled in dental insurance beginning January 1, 2015: the annual enrollment benefits statement; a COBRA package; and an annual enrollment confirmation. The annual enrollment benefits statement is mailed before Open Enrollment and informs members what benefits they will have beginning January 1 of the upcoming year should they not make any benefit changes during open enrollment. Northgate/Arinso mailed the annual enrollment benefits statement to Petitioner on October 4, 2014. A copy of the actual notice mailed to Petitioner was not produced, and Petitioner claimed he never received the annual enrollment benefits statement. Respondent offered no proof to the contrary. By correspondence dated October 3, 2014, and mailed to Petitioner at his address of record on November 8, 2014, Respondent provided Petitioner with his annual enrollment confirmation. The annual enrollment confirmation notice shows that only Petitioner’s wife, and not his dependent child, would be enrolled in dental coverage beginning January 1, 2015. On or about October 6, 2014, Northgate/Arinso also provided written notification to Petitioner of his rights to continue his dependent’s dental coverage pursuant to the federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). The COBRA package explains the process and costs associated with Petitioner’s dependent child continuing dental coverage through this option, and also informed Petitioner that his son’s dental benefits would terminate on January 1, 2015. Petitioner did not elect COBRA coverage for his dependent. The COBRA package was additional notice to Petitioner that there was a change happening to his existing dependent dental coverage. The People First system tracks all interaction with members, including notes of telephone conversations with members, any documents submitted by the member, and mail that has been returned as undeliverable. When mail is returned as undeliverable, an entry is made in the People First notes. Neither the annual enrollment benefits statement, nor the annual enrollment confirmation statement or the COBRA package, were returned as undeliverable. Respondent allows members to enroll in insurance benefits within 31 days of a QSC event and during open enrollment. At the time Petitioner sought to enroll his dependent child in August 2015, Petitioner did not experience a QSC event that would allow enrollment in the Humana Plan. Furthermore, because Petitioner’s dependent reached the age of attainment in 2014, dependent coverage was no longer available during periods of open enrollment.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Respondent, Department of Management Services, enter a final order denying Petitioner, Angel Ortiz's, request to have his dependent added to Petitioner’s dental plan. DONE AND ENTERED this 9th day of May, 2016, in Tallahassee, Leon County, Florida. S LINZIE F. BOGAN 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 9th day of May, 2016.
The Issue The issue in this case is whether the Florida Insurance Commissioner should discipline the Respondent, Brian Craig Parker, for alleged violations of the Insurance Code.
Findings Of Fact The Respondent, Brian Craig Parker, is a licensed health and life insurance agent. He had a contract with Denticare appointing him to act as Denticare's agent in selling prepaid dental insurance. On or about March 19, 1992, the Respondent, acting as an insurance agent, met with Christine Gamse and accepted her application for Denticare coverage and her check in the amount of $75, representing a $60 premium, plus a $15 "policy fee." The Respondent never submitted Gamse's Denticare application or premium to the insurer. In May, 1992, Gamse complained to Denticare that she still was not covered. Denticare confirmed that Gamse was not covered and offered to telephone the Respondent. When contacted by Denticare, the Respondent stated that he thought he had sent the application and premium to Denticare but that he had been very busy and that his recall was sketchy. Denticare had Gamse reapply directly to Denticare. On or about April 3, 1992, the Respondent, acting as an insurance agent, met with Donald Naegele for the purpose of presenting two dental insurance policies. Naegele decided to apply for Denticare dental insurance. The Respondent advised Naegele to write the Respondent a check in the amount of $104 to accompany Naegele's insurance application, representing a $89 premium, plus a $15 "policy fee." The Respondent told Naegele that he would submit the application by April 20 and that Naegele's coverage would be effective on May 1, 1992. The Respondent negotiated Naegele's check on or about April 7, 1992, but he never submitted Naegele's Denticare application or premium to the insurer. On or about May 1, 1992, Naegele attempted to use Denticare to pay for dental services and was informed that he was not covered by Denticare. He telephoned the Respondent several times and left messages on an answering machine but none were returned. He then telephoned Denticare, and it was confirmed that Naegele was not covered. Denticare offered to telephone the Respondent to resolve the matter. Soon after telephoning Denticare, Naegele got a telephone call from the Respondent, who offered to refund Naegele's $104. Within a few days, Naegele received the Respondent's check for the refund. Under the Respondent's agency contract with Denticare, the Respondent was not authorized to charge a policy fee. The Respondent's commission for Denticare policies was to be paid by Denticare out of the initial premium. Although the contract allowed the agent to ask for additional compensation, the Respondent did not do so, and Denticare would not have allowed him to charge a $15 policy fee. Under the Respondent's contract with Denticare, the Respondent was to promptly submit applications and premiums received from insureds. If Denticare received an application and premium by the 20th of the month, coverage would be effective on the 1st of the following month. If the Respondent had timely submitted their applications and premiums, both Gamse and Naegele would have had coverage by May 1, 1992.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Insurance Commissioner enter a final order revoking the license of the Respondent, Brian Craig Parker, to act as a health or life insurance agent in the State of Florida. RECOMMENDED this 23rd day of February, 1994, in Tallahassee, Florida. J. LAWRENCE JOHNSTON 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 23rd day of February, 1994. COPIES FURNISHED: Joseph D. Mandt, Esquire Division of Legal Services 612 Larson Building Tallahassee, Florida 32399-0300 Brian Craig Parker 4004 Bainwood Court Tampa, Florida 33614 Brian Craig Parker 15713 Woodcock Place Tampa, Florida 33624 Tom Gallagher State Treasurer & Insurance Commissioner The Capitol, Plaza Level Tallahassee, Florida 32399-0300 Bill O'Neil General Counsel Department of Insurance The Capitol, PL-11 Tallahassee, Florida 32399-0300
The Issue Whether the Petitioner should receive on the the clinical portion of the examination additional credit, which is sufficient to receive a passing grade on the December 1997 dental licensure examination.
Findings Of Fact Petitioner, Neda Raeisian, was a candidate for the dental licensure examination administered by the State of Florida in December 1997. The dental examination administered in December 1997 consisted of three parts: a "Florida Laws & Rules" part, an "Oral Diagnosis" part, and a "Clinical" part. The Petitioner received passing scores on the "Florida Laws & Rules" and "Oral Diagnosis" parts of the examination. Petitioner received a score of 2.95 on the Clinical part of the examination. A score of 3.00 was required on the Clinical part of the examination. The Petitioner failed the Clinical portion by .05 of a point, and, therefore, she failed the overall dental examination. Three examiners grade each candidate's clinical portion of the dental examination. Three examiners are used because by averaging the scores of the three examiners, the Respondent is more likely to capture the candidate's true score than by using one or two examiners. Before an examiner may be used for an examination, he or she must be recommended by an existing examiner or by a member of the Board of Dentistry. The proposed examiner may not have any complaints against his or her license and he or she must have been actively practicing and licensed for at least five years in the State of Florida. The examiner must complete an application that is sent to the Board of Dentistry examination committee, where it is then reviewed by the committee, and if approved, the examiner is entered into the pool of examiners. Before every examination, the Respondent conducts a standardization session, which is a process by which examiners are trained to grade using the same internal criteria. The Respondent uses assistant examiner supervisors who are appointed by the Board to train examiners on the different criteria that are used during the examination. The assistant examination supervisors go through and describe what a score of five would be, all the way down to a zero, the different criteria for each of those particular grades, and under what circumstances those grades should be given. After the examiners go through a verbal training, they are shown slides of teeth and told what the score on that procedure should be. After the standardization, there is a post- standardization exercise where the examiners are required to grade five mannequin models to make sure they have been able to internalize the criteria. After the post-standardization exercise, the Respondent evaluates the examiners to determine whether they are acceptable to use during the examination. There are also post-examination checks on the examiner, whereby the Respondent decides whether or not to use the examiners again. The Respondent runs the post-examination statistical checks to make sure that the examiners grade with consistency and reliability. There is generally a very high agreement rate between the examiners. Typically if there is an inconsistency in grading, it is usually the examiner who gives the higher grade that is incorrect because he or she missed an error; any error found by an examiner must be documented. The examiners grade the examination independently of each other; that is, they do not confer with each other while scoring the examination. The examination is also double-blind graded. Double- blind grading is the process through which examiners have no contact with the candidates. The examination is conducted in such a way that there is one clinic that is monitored by a licensed dentist in which the candidates actually perform the procedures. When the candidates are finished a proctor walks the patient over to another clinic where the examiners are located, and the examiners grade the examination. The candidates perform the patient portion of the examination on human beings that they are responsible for bringing in. If the patient has the necessary characteristics, the patient could serve for two different candidates or on two different examinations. The examination is a minimum competency examination. The grading system used during the clinical portion of the examination is as follows: A zero is a complete failure, a one is unacceptable dental procedure; a two is below minimally acceptable dental procedure; a three is minimally acceptable procedure, which is the minimum required to pass the clinical portion; a four is better than minimally acceptable dental procedure; and a five is outstanding dental procedure. An overall score is determine by averaging the three examiners' scores on the eight clinical procedures, putting different weights into a formula, and calculating the final grade. It is required in Board rule that the scores of the examiners be averaged. The Petitioner challenges the score given to her for her performance on Procedure 03, "Amalgam Final Restoration," of the Clinical portion of the examination. The Petitioner performed Procedure 03, the "Amalgam Final Restoration," on a live patient, Ms. Desiree Peacock. The Petitioner's performance on Procedure 03 was graded by three examiners: examiner number 290, identified as Dr. Richard Tomlin, of Pinellas Park, Florida; examiner number 299, identified as Dr. Haychell Saraydar, of Pinellas Park, Florida; and examiner number 176, identified as Dr. Leonard Britten, of Lutz, Florida. The Petitioner received a grade of 4 on a scale of 0-5 for her performance on Procedure 03 by examiner number 290; and a grade of 3 on a scale of 0-5 for her performance on Procedure 3 by examiner number 299. However, she received a grade of 0 on a scale of 0-5 for her performance on Procedure 03 by examiner number 176. The reason the Petitioner was given a score of 0 on procedure 03 by examiner number 176 was that the examiner felt that there was a lack of contact at the amalgam restoration site. The Respondent's dental expert, Jorge H. Miyares, D.D.S., testified that a score of 4 is given on Procedure 3 when, in the judgment of the examiner, there are only minor errors present which will not jeopardize the procedure; that a score of 3 is given on Procedure 03 when, in the judgment of the examiner, the procedure is completed at entry level; and that a score of 0 on Procedure 03 is mandatory if there is a total lack of contact. The examiners are taught and trained to check for contact when grading a candidate's performance on Procedure 03, as a lack of contact is a very significant error that jeopardizes the integrity of the amalgam restoration. There are two different types of contact involved in a Class II Restoration. The type of contact that was referenced by Examiner 176 in his grade documentation sheet is proximal contact. Proximal contact is when a tooth is restored, the proximal tooth next to it must be touching the tooth that has been prepared. Contact is something that either does or does not exist between two teeth. Contact is checked visually and by running a piece of dental floss between the teeth to see if there is resistance. Examiners 290 and 299 would have been required to give the Petitioner a grade of 0 on Procedure 03 if they had found a lack of contact. The findings of examiners 290 and 299 during their review of the Petitioner's performance on Procedure 03 were inconsistent with the findings of examiner 176 (lack of contact) during his review of the Petitioner's performance on Procedure 03. The inconsistency between the findings of examiners 290 and 299 and the findings of examiner 176 during their review of the Petitioner's performance on Procedure 03 were statistically unusual. Respondent performed Procedure 03 on the patient Desiree Peacock. Following the exam, Peacock used dental floss on the affected area and she believed she felt resistance. Although the grading on Procedure 03 of the clinical portion of the examination is inconsistent, the Respondent followed its standard testing procedures for the December 1997 dental examination. The evidence is insufficient to prove that the Respondent's examiner acted arbitrarily or capriciously or with an abuse of discretion in refusing to give the Petitioner a passing grade on procedure 03 of the clinical examination.
Recommendation Upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Board of Dentistry enter a Final Order dismissing the Petitioner's challenge to the grade assigned her for the clinical portion of the December 1997 dental licensure examination. DONE AND ENTERED this 22nd day of September, 1998, at Tallahassee, Leon County, Florida. DANIEL M. KILBRIDE Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 22nd day of September, 1998. COPIES FURNISHED: Anne Williamson, Esquire Department of Health Building 6, Room 102 1317 Winewood Boulevard Tallahassee, Florida 32399 Dr. Neda Raeisian 2161 Lake Debra Drive Apartment 1726 Orlando, Florida 32835 Pete Peterson, General Counsel Department of Health 2020 Capital Circle, Southeast Bin A 02 Tallahassee, Florida 32399-1703 Angela T. Hall, Agency Clerk Department of Health 2020 Capital Circle Southeast Bin A-02 Tallahassee, Florida 32399-1703
The Issue Respondent's alleged violation of Section 466.24(3)(a), Florida Statutes.
Findings Of Fact Dr. Albert Leo Vollmer is registered as a dentist with the Florida State Board of Dentistry, license no. 1437, and practices dentistry at Satellite Beach, Florida (Testimony of Mullins). On July 19, 1973, Allen M. Dingman made application to the Veterans Administration for medical benefits consisting of dental treatment (Petitioner's Exhibit 3). Authorization was given by the Veterans Administration for the requested treatment and Mr. Dingman sought the services of the Respondent. Respondent submitted a treatment plan to the Veterans Administration which was approved. Respondent thereafter provided dental services to Mr. Dingman and, in October, 1973, billed the Veterans Administration for the completed treatment. On October 18, 1973, payment in the amount of $503.00 was approved and paid to the Respondent by the Veterans Administration. This included payment for providing a 3/4 crown on tooth 20 in the amount of $115.00, a full gold crown on tooth 19 for $110.00, and a gold pontic on tooth number 18 for $90.00 (Petitioner's Exhibit 4). In April, 1974, Mr. Dingman visited Dr. Robert B. Downey, D.D.S., concerning a bridge which Respondent had provided him to replace the second molar (tooth number 18), which bridge Dingman had subsequently lost. He asked Dr. Downey what the cost would be to remedy his problem and informed him that the Veterans Administration had paid for the other work. Dr. Downey thereupon contacted the Veterans Administration concerning the prior treatment (Testimony of Dingman, Downey). Approximately a year later, Mr. Dingman was examined by Dr. Fred C. Nichols, D.D.S., of the Veterans Administration, who found that Dingman did not have gold crowns on teeth number 19 and 20, nor a gold pontic to replace tooth number 18. Mr. Dingman showed Dr. Nichols a cast metal frame work which had once been intended as a unilateral mandibular partial denture to replace tooth number 18 (Testimony of Nichols; Petitioner's Exhibit No. 5). The Veterans Administration, by letter of May 19, 1975, advised the Respondent that he would be billed for $315.00 representing the work which had not been performed. Respondent advised the VA that Mr. Dingman had objected to crown preparations and that he had therefore prepared a cantilever bridge which had been too bulky and thereafter another bridge was made at his expense which was apparently acceptable. The Veterans Administration reasserted its claim for $315.00 and Respondent, by letter of July 14, 1975, sought a credit for the work which he had performed, and by a further letter of August 12, 1975 advised that, although all of his records concerning Mr. Dingman could not be found, he estimated the cost of his actual work to be $207.90, and sought credit therefor (Petitioner's Composite Exhibit 6). Respondent testified that although his original plan was to provide fixed bridge work for Mr. Dingman, upon reflection and after noting that the patient was a hypersensitive person who objected to having the necessary preparatory work that would be required for crowns, he decided to attempt to preserve the natural teeth if possible and not to "abort" them. He further testified that although he had requested his office assistant to prepare an amended VA form for the patient to reflect his decision to do a different type of work, he did not follow-up to see if it was sent in to the Veterans Administration. He further maintained that his office assistant had done poor work, that he did not pay much attention to the paper work in the office and, although he usually reviewed applications for treatment such as Exhibit 4 by "implicit faith", he would usually "skip-read" these forms and sign them without completely checking the details thereon. He stated that his accounts were in a mess during this period and that this was the reason the dental laboratory records concerning Mr. Dingman were unavailable and why he had since hired accountants to do his bookkeeping work. His present assistant supported the fact that when she was first employed about a year and a half ago, Respondent's records were sloppy and that it was her custom to prepare various forms for the Respondent's signature. Mr. Dingman denied that he had ever told the Respondent that he was afraid to have his teeth cut into, or that he was hypersensitive in nature (Testimony of Vollmer, Mander, Person, Dingman) Dr. Daniel Beirne, a physician of Indian Harbor Beach, testified that he had common patients with the Respondent, and that the Respondent had an excellent reputation for truth and veracity in the community. Dr. Downey testified to the Respondent's bad reputation as a dentist, as did Dr. Carroll D. House, a member of the Brevard Dental Society Grievance Committee (Testimony of Burre, Downey, House). Respondent's license to practice dentistry was suspended in 1958 for a period of three months for an advertising violation with the proviso that the suspension was suspended for a period of one year upon certain conditions. His license was again suspended for a period of six months in 1960 for advertising violations (Petitioner's Exhibits 7 & 8)
