Allen v. United States

• Decision Date: 05 October 1983
• Docket Number: No. 82-1350C(C).,82-1350C(C).
• Parties: Mary Lou ALLEN, Plaintiff, v. UNITED STATES of America, Defendant.
• Court: U.S. District Court — Eastern District of Missouri

572 F. Supp. 185

Mary Lou ALLEN, Plaintiff, v. UNITED STATES of America, Defendant.

No. 82-1350C(C).

United States District Court, E.D. Missouri, E.D.

October 5, 1983.

Laurence D. Mass, Clayton, Mo., for plaintiff.

Bruce D. White, Asst. U.S. Atty., St. Louis, Mo., for defendants.

MEMORANDUM OPINION

MEREDITH, District Judge.

This matter is before the Court on separate motions of the plaintiff and defendant for summary judgment. Plaintiff brings this action seeking the right to convert to non-group health coverage that is identical to the coverage she received under her federal employee group coverage.

The Federal Employees Health Benefits Act of 1959 ("FEHBA") created the Federal Employees Health Benefits Program. 5 U.S.C. §§ 8901-13. Pursuant to this program, federal employees and annuitants may purchase health insurance as a fringe benefit of their Government employment. The Government does not act as an insurer. Rather, in accordance with FEHBA, the Health Benefits Program consists of a group of "Health Benefits Plans". These plans are group insurance policies, contracts or similar group arrangements with non-governmental organizations, called "carriers", established for the purpose of "providing, paying for or reimbursing expenses for health services." 5 U.S.C. §§ 8901(6) and (7).

FEHBA authorized the Civil Service Commission (CSC) and now authorizes its successor, the Office of Personnel Management (OPM), to enter into contracts with carriers to make Health Benefits Plans available to Federal employees and annuitants. 5 U.S.C. §§ 8902(a). The benefits that an employee is entitled to under a particular Health Benefits Plan are defined by the contract between OPM and the carrier for the Plan. Each eligible employee is provided with a brochure summarizing those benefits. 5 U.S.C. § 8907. Each employee chooses the Health Benefits Plan that the employee wishes to subscribe to. The premiums or charges for the employee's coverage are paid in part by the employee subscribers to that Health Benefits Plan and in part by the Government. 5 U.S.C. § 8906.

FEHBA established rules governing continuation of enrollment in a Federal Employees Health Benefits Plan after a federal employee terminates employment. 5 U.S.C. § 8905.

Each Federal Employees Health Benefit Plan is required to offer the enrollee the opportunity to convert, without evidence of good health, to a non-group plan during a temporary extension period upon ending enrollment in the Federal Employees Health Benefits Plan. 5 U.S.C. § 8902(g). Upon leaving the government service, a former employee is covered under his or her federal employees health benefit plan for 31 days. During that period, the former employee is entitled to convert to a non-group plan offered by the carrier of the plan in which he or she was formerly enrolled. 5 C.F.R. § 890.401.

Plaintiff was an employee of the United States Postal Service for approximately fourteen (14) years before her retirement in July, 1981 as a result of her disability. She has emphysema and other pulmonary deficiencies which served as the basis for her retiring from government service and receiving disability benefits. Plaintiff also requires surgery on her ankle to remove metal screws which were inserted there to reduce and close a fracture. While an employee with the Post Office, plaintiff could have selected from among more than ten (10) health insurance coverage plans to obtain coverage. She, in fact, chose American Postal Workers Union Plan (APWU).

On July 10, 1981 the Postmaster of the United States Post Office for the City of St. Louis sent plaintiff a letter stating that her health benefits coverage had been transferred to the OPM. At the beginning of June, 1981 plaintiff moved from her address in St. Louis County, Missouri to her current address in Grandin, Missouri. She notified the OPM and Postal Service of this change of address and began receiving disability retirements benefits from OPM in June, 1981 at her Grandin, Missouri address. The OPM acknowledged receipt of the change of address before September 1, 1981.

On a form dated September 10, 1981, the OPM advised plaintiff that effective July 25, 1981 her health insurance coverage terminated. Plaintiff alleged and by affidavit stated that she never received this notice because it was sent to her former address in St. Louis, Missouri and not forwarded to her at her Grandin, Missouri address. It contained instructions on how plaintiff could automatically convert to a non-group health insurance coverage by notifying the insurance carrier of her desire to do so within thirty (30) days of the effective date of her termination from government coverage, or within fifteen (15) days from the date of the notice, but in no event later than seventy-five (75) days from the effective date of the termination.

At the beginning of October, 1981, plaintiff received a Civil Service Annuity Statement setting forth the amount of her monthly disability payments as "0". This statement was addressed to her at her residence in Grandin, Missouri. Plaintiff immediately wrote OPM and inquired as to why the Annuity Statement listed her health benefits as "0". The OPM responded in a letter dated November 30, 1981 and notified plaintiff that she has no health insurance coverage. The reason given for her non-coverage was that she had not been enrolled in a government program for five (5) consecutive years. More than seventy-five (75) days had elapsed from the effective date of termination of her coverage.

Plaintiff responded and explained...