01-001804 Sarah C. Nuding vs. Department Of Management Services, Division Of State Group Insurance Status: Closed Recommended Order on Tuesday, August 14, 2001.

Summary: Petitioner contested Blue Cross Blue Shields` refusal to pay hospital bill resulting from Baker Act admission due to suicide attempt. State of Florida Employees Group Health Self Insurance Plan excluded self-inflicted injury and resulting treatment.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

SARAH C. NUDING, )

)

Petitioner, )

)

vs. ) Case No. 01-1804

)

DEPARTMENT OF MANAGEMENT )

SERVICES, DIVISION OF STATE )

GROUP INSURANCE, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice the Division of Administrative Hearings

through its duly-designated Administrative Law Judge, Fred L.

Buckine, conducted a video hearing in the above cause on

July 31, 2001, in Tallahassee and Tampa, Florida.

APPEARANCES

For Petitioner: Sarah C. Nuding, pro se

15501 Bruce B. Downs Boulevard

Apartment 3705

Tampa, Florida 33647

For Respondent: Julia P. Forrester, Esquire

Department of Management Services

4050 Esplanade Way, Suite 2 60

Tallahassee, Florida 32399-0950

STATEMENT OF THE ISSUE

The issue in this case is whether the expenses incurred by

Petitioner incident to admission to Town & Country Hospital on

December 11, 1999, resulted from an intentional self-inflicted

injury, to wit : attempted suicide, and are therefore excluded

from coverage under the State of Florida Employees Group Health

Self Insurance Plan.

PRELIMINARY STATEMENT

On December 11, 1999, Deputy Sheriff Midarst, Hillsborough

County Sheriff Department, delivered Petitioner to Town &

Country Hospital initiating involuntary examination pursuant to

Section 394.463, Florida Statutes. Petitioner had ingested an

overdose of prescription medication. Hospital admission listed

Petitioner's "chief complaint" as a suicide attempt.

On December 13, 1999, the hospital released Petitioner and

billed for medical services rendered. Petitioner's medical bill

was denied by Blue Cross Blue Shield of Florida ( BCBS). On

April 3, 2000, Petitioner sought and received review of the

initial denial. On April 11, 2000, Petitioner received from

BCBS notice of a second review denying hospitalization charges.

On May 10, 2000, Petitioner sought review by the Division of

State Group Insurance ( DSGI) of BCBS's denial of payment. On

June 6, 2000, DSGI advised Petitioner that BCBS's denial was

proper because Petitioner's PPO plan did not cover any services

and supplies received due to "an intentional self-inflicted

injury whether the participant was sane or insane."

On May 8, 2001 , DSGI referred Petitioner's request for an

administrative hearing, and the initial order was issued by the

Division of Administrative Hearings. On May 17, 2001, a

response to initial order was flied. On May 23, Notice of

Hearing scheduling the final hearing for July 13, 2001, was

issued. On July 5, 2001, Amended Notice of Video Hearing was

issued, scheduling the final hearing for July 13, 2001, via

video teleconference at sites in Tampa and Tallahassee, Florida.

At the final hearing, Petitioner testifi ed on her own

behalf. Respondent offered the testimony of Ms. Melody J.

Bartel who was qualified as an expert in the practice of nursing

and in reviewing of medical records. By stipulation of the

parties four joint exhibits were admitted into evidence. No

transcript of these proceedings was ordered. Respondent filed a

Proposed Recommended Order on August 3, 2001, which has been

considered. Petitioner did not file a Proposed Recommended

Order.

FINDINGS OF FACT

1. At all times pertinent hereto, Petitioner, Sarah

Nuding, was employed by the University of South Florida and was

a participant in the State of Florida Employees Group Health

Self Insurance Plan ( PPO).

2. Respondent, Department of Management Services, Division

of State Group Insurance ( DSGI), administers the state's self-

funded group insurance plan for employees and has secured the

services of BCBS as its third party administrator.

3. On December 11, 1999, Petitioner called the

Hillsborough County Sheriff's office after ingesting a handful

of Wellbutrin and four tablets of Neurontin. Deputy Sheriff

Midarst initiated involuntary examination pursuant to

Section 394.463, Florida Statutes, (Baker Act), and Petitioner

was admitted through the emergency room to Town & Country

Hospital, Tampa, Florida. Petitioner was placed in the

Hospital's Intensive Care Unit for observation of her seizure

activity and remained there under observation and treatment

until her release on December 13, 1999.

4. Upon admission and after examinations, Petitione r was

diagnosed with chronic anemia by the admitting physician who

ordered consultation with the treating physician before medical

services and treatment were provided.

5. The admitting and treating physician, after review of

Petitioner's hematocrit and hemoglobin levels which were above

that normally requiring hospitalization, determined that

Petitioner should be treated for the anemia condition before her

discharge on December 13, 1999.

6. Petitioner's State of Florida Employees Group Health

Self Insurance Plan Booklet and Benefit Document excludes

coverage for services rendered for treatment of self-inflicted

wounds, in pertinent part provides:

The following are not Covered Services and

Supplies under the Plan. The Participant is

solely responsible for the payment of

charges for all such services, supplies or

equipment excluded in this Section.

5. Any services and supplies received due

to the following circumstances:

(b ) Resulting from an intentional self-

inflicted injury whether the Participant was

sane or insane. An injury is intentionally

self-inflicted if the Participant intended

to perform the act that caused the injury

regardless of whether the Participant

intended to cause the injury.

7. On or about July 31, 2000, BCBS notified DSGI that of

the Hospital's statement totaling $8,244.00 for services and

supplies rendered December 11-13, 1999, only $1,030.25 were

directly related to a diagnosis of "anemia"; the remaining

charges are for the diagnosis of "drug overdose" and are not

covered expenses under the State PPO Plan.

8. The decision by both BCBS and DSGI , to pay those

charges related to Petitioner's diagnosis and treatment for

anemia and to not pay those charges related to the suicide

attempt, including two days intensive care unit cost of

$1,150.00 per day, are supported by preponderance of the

evidence, and is in accord with the terms and conditions of the

insurance plan exclusion provision.

9. Petitioner's position is that her prolonged hospital

stay, medical treatment and supplies were: (a) not at her

request and consent, (b) that her anemia condition was a pre-

existing, and therefore, a covered condition, and (c) intensive

care placement ($1,500.00 per day for two days) was not

necessary to treat her pre-existing anemic condition, therefore,

only her first day hospitalization expenses should have been

excluded. However, Petitioner's position ignores the fact that

her hospital admission was for a suicide attempt, and her stay

resulted from the requirements of the Section 394.463, Florida

Statutes, to wit : mandatory involuntary placement for

72 hours.

CONCLUSIONS OF LAW

10. The Division of Administrative Hearings has

jurisdiction over the parties and subject matter of this cause

pursuant to Sections 120.569 and 120.57, Florida Statutes.

11. Petitioner's State of Florida Employees Group Health

Insurance Plan clearly excluded coverage for any treatment of

self-inflicted injuries. Petitioner's intentional overdose of

medication with the intent to commit suicide which required

involuntary hospitalization was self-inflicted and therefore,

properly excluded from coverage.

12. Where, as here, proof is made of a loss within the

contract of insurance, the burden is on the insurer to

establish, by a preponderance of the evidence, that the loss

arose from a cause that is excepted from the policy.

Hudson v. Prudential Property and Casualty Insurance Company ,

450 So. 2d 565 (Fla. and 2nd DCA 1984) ; Stonewall Insurance

Company v. Emerald Fisheries, Inc. , 388 So. 2d 1089 (Fla. 3d DCA

1980) ; Mason v. Life & Casualty, Insurance Company , 41 So. 2d

153 (Fla. 1949). Here, the Department has met its burden of

proof by demonstrating that the excluded payment in question

arose as a consequence of an intentional self-inflicted injury;

to wit : attempted suicide by overdose of medication.

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions

of Law, it is

RECOMMENDED that the Department of Management Services,

Division of State Group Insurance, issue a final order

dismissing with prejudice the petition for administrative

review.

DONE AND ENTERED this 14th day of August, 2001, in

Tallahassee, Leon County, Florida.

___________________________________

FRED L. BUCKINE

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 [phone]

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 14th day of August, 2001.

COPIES FURNISHED :

Julia P. Forrester, Esquire

Department of Management Services

4050 Esplanade Way, Suite 260

Tallahassee, Florida 32399-0950

Sarah C. Nuding

15501 Bruce B. Downs Boulevard

Apartment 3705

Tampa, Florida 33647

Cynthia Henderson, Secretary

Department of Management Services

4050 Esplanade Way

Tallahassee, Florida 32399-0950

Mallory Roberts, General Counsel

Department of Management Services

4050 Esplanade Way

Tallahassee, Florida 32399-0950

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions

to this Recommended Order must be filed with the agency that

will issue the Final Order in this case.