16-000759 Angel Ortiz vs. Department Of Management Services, Division Of State Group Insurance Status: Closed Recommended Order on Monday, May 9, 2016.

Summary: Petitioner failed to prove that his adult disabled dependent child is entitled to continue benefits on Petitioner's dental plan.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

ANGEL ORTIZ,

Petitioner,

vs. Case No. 16 - 0759

DEPARTMENT OF MANAGEMENT

SERVICES, DIVISION OF STATE

GROUP INSURANCE,

Respondent.

_______________________________/

RECOMMENDED ORDER

Pursuant to notice, a final hearing in this cause was held

by video teleconference between sites in St. Peter s burg and

Tallahassee, Florida, on April 1 3 , 2016, before Linzie F. Bogan,

Administrative Law Judge of the Division of Administrative

Hearings.

A PPEARANCES

For Petitioner: Angel L. Ortiz , pro se

2361 Orangeside Road

Palm Harbor, Florida 34683

For Respondent: Gavin D. Burgess, Esquire

Department of Management Services

Suite 160

4050 Esplanade Way

Tallahassee, Florida 32399 - 0950

STATEMENT OF THE ISSUE

Whether PetitionerÓs disabled dependent child is entitled

to have his dental benefits continued after he has reached the

age of 26.

PRELIMINARY STATEMENT

This dispute involves the termination of dental coverage

for Angel OrtizÓs (Petitioner) child (dependent) who has reached

the age of 26. The Department of Management Services, Division

of State Group Insurance ( Respondent ) , terminated the

depen dentÓs dental coverage because Petitioner, prior to the

dependent reaching age 26, which is the maximum age for

dependent coverage, failed to submit to Respondent proof of his

dependentÓs disability. After the dependentÓs dental coverage

was terminated, P etitioner then sought to enroll his dependent

into coverage outside the open - enrollment period. Respondent

denied PetitionerÓs request for enrollment on the grounds that

there was not a qualified status change (QSC) 1/ event that wo uld

allow a mid - year enr ollment. On or about February 10, 2016,

Respondent referred the matter to the Division of Administrative

Hearings for a disputed - fact hearing.

At the hearing, Petitioner testified on his own behalf, and

his wife, Mary Ortiz, also testified. Respondent offered

testimony from Lindsay Lichti, Renee Webb, and Dewayne Purifoy .

PetitionerÓs Exhibit 1 was admitted into evidence.

RespondentÓs Exhibits 1 through 7 were also admitted into

evidence.

Neither party filed a transcript of the disputed - fact

hearing. The parties did, however, each file a Proposed

Recommended Order. The Proposed Recommended Orders have been

considered in the preparation of this Recommended Order.

FINDINGS OF FACT

1. Respondent contracts with Humana/CompBenefits Company

to provide dent al benefits to employees of the State of Florida .

2 . In 2014, Petitioner, his spouse, and his dependent

child were members of Humana/CompBenefits CompanyÓs Network Plus

Dental Plan (Humana Plan).

3 . The Humana Plan provides coverage for a subscriberÓs

de pendent child through the calendar year in which the child

reaches the maximum age of attainment.

4 . Respondent handles eligibility issues regarding the

Humana Plan and allows dependent child coverage to continue

through the end of the year in which the d ependent turns 26

years of age (the maximum age of attainment) . The dental

coverage for PetitionerÓs dependent t erminat ed on January 1,

2015, due to the fact that the dependent turned 26 years of age

in 2014.

5. According to the Humana Plan, dental cover age 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 dependentÓs

disability must be submitted within 31 days of the dependentÓs

ma ximum 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 dependentÓs disability until

August 2015, which was approximately 10 months after his childÓs

26th b irthday. Petitioner claims that he was unaware of the

fact that his dependent Ós coverage terminated on January 1,

2015, and if he had known of the termination , he would have

timely provided to Respondent documentation demonstrating his

sonÓs disability.

6 . Employee health insurance benefits are administered by

a private contractor, Northgate/ Arinso, through an online system

called People First.

7. The People First computer system automatically

identifies which dependents will be ineligible for coverage

d uring the upcoming policy year and mails notifications to

memb ers advising them that their benefits will be changing.

8. 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 a nnual e nrollment b enefits

s tatement; a COBRA package; and an a nnual e nrollment

c onfirmation.

9 . The a nnual e nrollment b enefits s tatement is mailed

before Open Enrollment and informs memb ers what benefits they

will have beginning January 1 of the upcoming year should they

not make any benefit changes during o pen e nrollment.

Northgate / Arinso mailed the a nnual e nrollment b enefits s tatement

to Petitioner on October 4, 2014. A copy of the ac tual 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.

10. 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 a nnual e nrollment c onfirmation notice show s

that only PetitionerÓs wife, and not his dependent child, would

be enrolled in dental coverage beginning January 1, 2015.

11. On or about October 6, 2014, Northgate / Arinso also

provide d written notification to Petitioner of his rights to

continue his dependentÓs dental coverage pursuant to the federal

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA ).

The COBRA package explains the process and costs associated with

PetitionerÓs dependent child continu ing dental coverage through

this option, and also informed Petitioner that his sonÓs dental

benefits would terminate on January 1, 2015. Petitioner did not

elect COBRA coverage for his dependent.

12. The COBRA package was additional notice to Petitioner

that there was a change happening to his existing dependent

dental coverage.

13. The People First system tracks all interaction with

me mbers, 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 t he a nnua l e nrollment b enefits s tatement , nor the a nnual

e nrollment c onfirmation statement or the COBRA package , were

returned as undeliverable.

14 . Respondent allows members to enroll in insurance

benefits within 31 days of a QSC eve nt 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 PetitionerÓs dependent reached the age of

attainment in 2014, depe ndent coverage was no longer available

during periods of open enrollment.

CONCLUSIONS OF LAW

15 . The Division of Administrative Hearings has

jurisdiction over the parties and subject matter of this

proceeding. §§ 120.569 and 120.57(1), Fla. Stat. (20 15 ) .

1 6 . Petitioner bears the burden of establishing by a

preponderance of the evidence h is entitlement to have h is

dependent reinstated to the dental plan. See Dep't of Banking &

Fin., Div. of Sec. & Investor Prot. v. Osborne Stern and Co. ,

670 So. 2d 932, 934 (Fla. 1996); Young v. Dep't of Cmty. Aff. ,

625 So. 2d 831, 834 (Fla. 1993); Espinoza v. Dep't of Bus. &

Prof'l Reg. , 739 So. 2d 1250, 1251 (Fla. 3d DCA 1999); Fla.

Dep't of Transp. v. J.W.C. Co. , 396 So. 2d 778, 788 (Fla. 1st

DCA 1981); and § 120.57(1 )(j) ("Findings of fact shall be based

upon a preponderance of the evidence, except in penal or

licensure disciplinary proceedings or except as otherwise

provided by statute . . . .").

1 7 . A preponderance of the evidence is defined as "the

greater weight of the evidence" or evidence that "more likely

than not" tends to prove a certain proposition. Gross v. Lyons ,

763 So. 2d 276, 280 n.1 (Fla. 2000).

18 . T he Humana Plan allows a dependent with a disability

to continue coverage provided the insured provide s timely

documentation that the dependent is disabled. § 636.022, Fla.

Stat. (2015) . Petitioner did not inform People First that his

child was disabled until August 25, 2015, which was

approximately 10 months after Petitioner Ós dependent turned the

maxim um age as allowed by Respondent, and nine months after

coverage terminated. PetitionerÓs notice to Respondent

regarding his dependentÓs disability was not timely submitted.

Furthermore, Petitioner received reasonable notice regarding the

changes to denta l coverage for his dependent , but failed to take

appropriate action with respect thereto.

19. Petitioner did not meet his burden of demonstrating

that dependent child coverage should continue.

RECOMMENDATION

Based on the foregoing Findings of Fact and C onclusions 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 PetitionerÓs 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 .

ENDNOTE

1/ A member may enroll in mid - year coverage if he experiences a

QSC event, which is defined in Florida Administrative Cod e Rule

60P - 1.003(17) as a Ðchange in employment status, for subscriber

or spouse, family status or significant change in health

coverage of the employee or spouse attributable to the spouseÓs

employment.Ñ

COPIES FURNISHED:

Gavin D. Burgess, Esquire

Depa rtment of Management Services

4050 Esplanade Way , Suite 160

Tallahassee, Florida 32399 - 0950

(eServed)

Angel L. Ortiz

2361 Orangeside Road

Palm Harbor, Florida 34683

J. Andrew Atkinson, General Counsel

Office of the General Counsel

Department of Manage ment Services

4050 Esplanade Way, S uite 160

Tallahassee, Florida 32399 - 0950

(eServed)

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 should be filed with the agency that

will issue the Final Order in this case.