Harris v. State, Dept. of Admin., Div. of State Employees' Ins.

• Decision Date: 03 April 1991
• Docket Number: No. 90-135,90-135
• Citation: 577 So.2d 1363,16 Fla. L. Weekly 930
• Parties: 16 Fla. L. Weekly 930 Annemarie HARRIS, Appellant, v. STATE of Florida, DEPARTMENT OF ADMINISTRATION, DIVISION OF STATE EMPLOYEES' INSURANCE, Appellee.
• Court: Florida District Court of Appeals

Page 1363

577 So.2d 1363

16 Fla. L. Weekly 930

Annemarie HARRIS, Appellant, v. STATE of Florida, DEPARTMENT OF ADMINISTRATION, DIVISION OF STATE EMPLOYEES' INSURANCE, Appellee.

No. 90-135.

District Court of Appeal of Florida,

First District.

April 3, 1991.

G. Bart Billbrough and Geoffrey B. Marks, of Walton, Lantaff, Schroeder & Carson, Miami, for appellant.

John M. Carlson, Senior Atty., Department of Admin., Tallahassee, for appellee.

ERVIN, Judge.

Appellant, Annemarie Harris, seeks review of an order denying her request for reimbursement from appellee, the State of Florida, Department of Administration, Division of State Employees' Insurance (division), under the state group health self-insurance plan (self-insurance plan or plan) for medical expenses incurred on behalf of her infant daughter. Appellant contends that the lower tribunal erred in failing to construe the ambiguous insurance document against its drafter, the division, and in failing to find that the state was estopped from denying coverage by virtue of a material misrepresentation made to appellant by an agent of appellee concerning the requirements for converting from individual to family coverage under the self-insurance plan. Upon review of the record, we conclude that the final order not only lacks factual findings necessary to determine the estoppel issue, but that certain conclusions therein are not supported by the evidence. Therefore, we reverse and remand with directions for the division to conduct additional proceedings.

Appellant is an attorney who, at all times pertinent to this appeal, was employed as an assistant public defender by the Dade County Public Defender's Office. Shortly after she began her state employment, she chose to enroll in one of the state-approved HMO plans for individual health insurance coverage. In December 1987 the contract between appellant's HMO and the state was terminated, and appellant was left with the option of selecting another HMO insurance plan or the self-insurance plan. To aid her in deciding which plan to apply for, appellant, who was then three months' pregnant, contacted Faith Quincoses, the administrative assistant in the public defender's office designated to advise employees of the benefits available to them under the various plans and to assist them in completing the paperwork necessary to secure such benefits. Although the record does not disclose the full extent of the conversations between Quincoses and appellant, it does reflect that Quincoses supplied appellant with the names of several fellow employees whom she could contact regarding their experiences with the health insurance plans they had selected. It appears that in addition to talking with these other employees, appellant discussed her choice of coverage with her husband, a former assistant state attorney who had been insured through the state insurance plan during his employment with the state. Following her discussions, appellant elected individual coverage through the state group health self-insurance plan.

The record next shows that in mid-April appellant again consulted Quincoses pertaining to the question of when she should convert from individual to family health insurance, so that her unborn child, who was due for delivery on June 23, 1988, would be covered. It is undisputed that Quincoses then erroneously told appellant that in order for her child to be included under the state plan, she must prepare and submit the necessary paperwork within 30 days from the child's birth. Quincoses considered that as long as the employee notified the division and did the paperwork within 30 days after the child's birth, the child would be covered as a family member. It is unclear from the record, however, whether this was the first time Quincoses had given such advice to appellant, and particularly whether Quincoses gave her the same advice at any time prior to mid-April.

Quincoses subsequently began work on the appropriate forms in order for appellant to complete her application for family coverage prior to June 1, the date scheduled for appellant's maternity leave. Before appellant signed the necessary papers, however, she experienced unexpected and severe complications with her pregnancy, resulting in an emergency premature birth by Caesarean section on April 24, 1988. Almost immediately following the delivery of the daughter, the child's condition worsened and she was transferred to another hospital with proper neonatal facilities. The infant remained in that hospital for approximately two months, incurring medical expenses of approximately $180,000. While the state health insurance plan covered appellant's expenses resulting from the birth, the state refused to pay any of the child's expenses, on the ground that appellant had only individual--not family--coverage at the time of her daughter's birth. Although the paperwork, which Quincoses signed on behalf of appellant, was submitted to the division on or about May 10, 1988, the division refused to provide the pertinent benefits available under family coverage, asserting that the child was not a named insured as of the date of her birth, and that once she became insured under the policy, her expenses related to a preexisting condition which was not covered under the policy.

In reaching its determination, the division relied on Florida Administrative Code Rule 22K-1.203, which provides:

(3) An employee or retiree may begin family coverage prior to acquiring any eligible dependents. Since such coverage is effective the first day of any given month, employees who will acquire eligible dependents during the month and are desirous of having immediate coverage of such dependents must make application in time for a complete month's premium to be deducted prior to the first day of the month during which the dependent will be acquired. Otherwise, coverage cannot be effective on the actual date the dependent is acquired.

(Emphasis added.) Under the division's interpretation of this rule, in order for the medical expenses of appellant's daughter to be covered, the premium for such coverage was required to have been paid before April 1, 1988. Because the first premium was not paid until sometime after May 10, 1988, or on a date following the child's birth, the division concluded that the child was not insured at the time of its birth; therefore none of the child's medical expenses could be paid under the coverage provided.

Turning to appellant's argument that the insurance plan was ambiguous and should be construed against the division, we consider it necessary first to set forth the applicable features of the plan. The self-insurance plan was established by the state and is administered by Blue Cross & Blue Shield. The plan is described in the "State of Florida Employees Group Health Self Insurance Plan Brochure." This benefit document is not, however, provided to individual employees, but rather is supplied to personnel officers of the various state agencies. It moreover expressly informs employees that it is not an insurance contract, and advises employees that if they wish to make any inquiries regarding the policy, they should direct them to "their agency personnel offices or the Office of State Employees' Insurance." Although the benefit document provides general information regarding the effective date of coverage, it says nothing about a...