Mojica v. State

• Decision Date: 19 December 2019
• Docket Number: No. 1D18-2105,1D18-2105
• Citation: 285 So.3d 393
• Parties: Angela MOJICA, a minor, BY AND THROUGH her mother and natural guardian, Glexys MOJICA, Appellant, v. State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, Appellee.
• Court: Florida District Court of Appeals

285 So.3d 393

Angela MOJICA, a minor, BY AND THROUGH her mother and natural guardian, Glexys MOJICA, Appellant,

v.State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, Appellee.

No. 1D18-2105

District Court of Appeal of Florida, First District.

December 19, 2019

Floyd B. Faglie of Staunton & Faglie, PL, Monticello, for Appellant.

Ashley Moody, Attorney General, and Elizabeth Teegan, Senior Assistant Attorney General, Tallahassee, for Appellee.

Ray, C.J.

This is an appeal from an amended final order entered by the Division of Administrative Hearings determining that the Agency for Healthcare Administration ("AHCA") has a right to full payment of its Medicaid lien from a medical malpractice settlement. Because the Administrative Law Judge ("ALJ") applied an incorrect standard for a Medicaid recipient to successfully challenge the amount payable to AHCA as reimbursement for past medical expenses and improperly rejected unrebutted expert testimony, we reverse.

I.

In November 2013, Angela Mojica, who was then eight years old, suffered catastrophic brain damage during a routine tonsillectomy. As a result, she cannot eat, speak, toilet, ambulate or care for herself. Her mother brought a medical malpractice action against the hospital and medical staff to recover her daughter's damages, as well as her own individual damages associated with her daughter's injuries. The lawsuit eventually settled for $8.8 million through a series of confidential settlements, and the settlement amount was approved by the court.

In the wake of Miss Mojica's medical tragedy, Medicaid paid $595,077.45 for her medical care, $322,048.83 of which was paid through AHCA. Although AHCA did not participate in the medical malpractice action or the settlement, Florida's Medicaid Third-Party Liability Act grants AHCA an automatic lien on any benefits a Medicaid recipient recovers, including a tort judgment or settlement. § 409.910(6)(c), Fla. Stat. (2016). Using the formula in paragraph (11)(f) of the statute for determining how much of Miss Mojica's recovery AHCA can claim in satisfaction of its Medicaid lien, AHCA calculated the presumptively appropriate amount of its lien at $322,048.83 and demanded payment of that amount from the settlement.

In response, Miss Mojica initiated an administrative proceeding under section 409.910(17)(b), Florida Statutes (2016), to contest the formula-based amount designated by AHCA to satisfy its Medicaid lien and to establish that a lesser portion of the total settlement should be allocated as reimbursement for past medical expenses. Miss Mojica contended that her and her mother's economic and noneconomic damages had a value in excess of $25 million, of which $595,077.45 represented the claim for past medical expenses. She argued that due to the inherent risks of litigation—e.g., disputed facts, causation, and insurance limits—she was unable to recover the full value of her damages in the settlement. And using the most conservative valuation of all damages of $25 million, the $8.8 million settlement represented a recovery of 35.2% of the total monetary value of all the damages. Miss Mojica thus submitted that she had only recovered 35.2% of her $595,077.45 claim for past medical expenses, or $209,467.26. She further contended that since the $322,048.83 in Medicaid benefits paid by AHCA only constitutes 54% of the $595,077.45 claim for past medical expenses, AHCA's lien should be limited to 54% of $209,467.26, or $113,112.33.

At the hearing, Miss Mojica presented the testimony of two experienced civil trial attorneys, both of whom the ALJ accepted as experts in the valuation of damages. They testified that based on Miss Mojica's life care plan and an economist report, valuing her damages at $25 million was very conservative. They agreed that the $8.8 million settlement did not fully compensate Miss Mojica and her mother for the full value of their damages and that the settlement amount represented a recovery of 35.2% of the value of their damages. They opined that the methodology of applying the same ratio the settlement bore to the total value of the damages to the $595,077.45 claim for past medical expenses would lead to a reasonable and conservative allocation of $209,467.26 of the settlement as reimbursement for past medical expenses.

AHCA likewise presented the testimony of an experienced civil trial attorney, although the ALJ accepted this attorney as an expert in the "settlement value" of a personal injury case. As the ALJ found, AHCA's expert did not provide an opinion on the value of Miss Mojica's damages. Instead, the expert testified that the settlement amount represents the value of the case "considering the limitations of liability, causation, the defendant's ability to pay, risk of trial, and other limiting factors."

After the final hearing, the ALJ entered an amended final order that is the subject of this appeal. The ALJ found that although Miss Mojica's experts had testified convincingly that the Mojicas' damages have a value far in excess of $25 million, Miss Mojica had not met her burden under section 409.910(17)(b) to establish the amount of damages "actually recovered" for past medical expenses. In pertinent part, the order states:

29. [Miss Mojica] did not establish the value of any element of damages other than past medical expenses. The record does not support a finding of the individual value of [her] damages for other economic damages (e.g., lost earning capacity, future medical expenses) or noneconomic damages (e.g., pain and suffering, loss of consortium).

...

31. Because the record contains no valuation of the damages other than past medical expenses, there is no evidence of the recovery for "each line item of damage" other than past medical expenses. The record does not support a finding of how the remaining $8.5 million of the recovery was allocated among the other elements of damages.

The ALJ determined that to rebut the (11)(f) formula, Miss Mojica had to prove by the preponderance of the evidence the settlement amount "actually recovered" for past medical expenses and that she fell short of this burden. Despite the ALJ's finding that the pro rata allocation of the 35.2% recovery ratio to the $595,077.45 claim for past medical expenses resulted in $209,467.26 of the settlement representing compensation for past medical expenses, the ALJ found that Miss Mojica's expert testimony was insufficient to support a finding that the amount allocated to past medical expenses is the amount she actually recovered for past medical expenses. The ALJ reasoned that "[w]ithout a breakout of the allocation of the settlement to other elements of damage, the undersigned cannot determine that the amount allocated to past medical expenses is reasonable." Thus, the ALJ ordered Miss Mojica to reimburse AHCA the full amount of its Medicaid lien.

II.

On appeal, Miss Mojica contends the ALJ applied an incorrect standard for a Medicaid recipient to successfully challenge the amount payable to AHCA as reimbursement for past medical expenses and then improperly rejected unrebutted testimony from her expert witnesses. We review an ALJ's findings of fact for competent, substantial evidence and review conclusions of law de novo. Moreland ex rel. Moreland v. Agency for Persons with Disabilities , 19 So. 3d 1009, 1011 (Fla. 1st DCA 2009).

Our analysis in this case is guided by the Florida Supreme Court's decision in Giraldo v. Agency for Health Care Administration , 248 So. 3d 53 (Fla. 2018), and our recent decision in Eady v. State , 279 So. 3d 1249 (Fla. 1st DCA 2019). We note that the ALJ did not have the benefit of either of these opinions when deciding this difficult case.

In Giraldo , Juan Villa, a Medicaid recipient, suffered a catastrophic spinal cord injury in an all-terrain vehicle accident. 248 So. 3d at 54. He sued those allegedly responsible for his injuries, claiming both economic and noneconomic damages, and the case eventually settled for $1 million. Id. Using the (11)(f) formula, AHCA asserted a $321,720.16 lien against the settlement for Mr. Villa's medical care. Id. Mr. Villa challenged the lien amount through the administrative forum where he presented uncontested expert testimony—applying the same pro rata methodology advanced in this case^* —that only $13,881.79 of the $1 million tort recovery represented compensation for his past medical expenses. Id. Mr. Villa argued that AHCA's lien should be limited accordingly while AHCA contended that it was entitled to recovery of Medicaid expenditures for both past medical expenses and reasonably anticipated...