Szewczyk v. Department of Social Services

• Decision Date: 27 May 2003
• Docket Number: No. 22134.,22134.
• Citation: 822 A.2d 957,77 Conn.App. 38
• Court: Connecticut Court of Appeals
• Parties: Zbigniew SZEWCZYK, v. DEPARTMENT OF SOCIAL SERVICES.

822 A.2d 957

77 Conn.App. 38

Zbigniew SZEWCZYK, v. DEPARTMENT OF SOCIAL SERVICES.

No. 22134.

Appellate Court of Connecticut.

Argued November 20, 2002.

Decided May 27, 2003.

COPYRIGHT MATERIAL OMITTED

LAVERY, C.J., and BISHOP and STOUGHTON, Js.

Thomas J. Riley, New London, with whom was Shawn L. Rutchick, for the appellant (plaintiff).

Tanya Feliciano, assistant attorney general, with whom, on the brief, were Richard Blumenthal, attorney general, and Richard J. Lynch, assistant attorney general, for the appellee (defendant).

BISHOP, J.

This appeal presents the question of whether hospital in-patient chemotherapy treatment of an undocumented alien who has been diagnosed with acute myelogenous leukemia constitutes treatment for an emergency medical condition so as to entitle the hospital to receive medicaid reimbursement for the cost of the treatment. Having provided treatment to the plaintiff, an undocumented alien, the hospital sought medicaid reimbursement from the department of social services (department).¹ Once the department rejected the plaintiff's reimbursement request, the plaintiff sought judicial review in the trial court where his appeal was dismissed. The two issues on appeal are (1) whether the court applied the proper legal standard for determining whether the plaintiff suffered from an "emergency medical condition" so as to qualify for medicaid benefits and (2) whether the court's conclusion that the plaintiff did not have an "emergency condition" was supported by substantial evidence. We affirm the judgment of the trial court.

To address the issues on appeal adequately, it is appropriate to provide a brief overview of the medicaid program as it relates to undocumented aliens.² "Medicaid is a federal program that provides health care funding for needy persons through cost-sharing with states electing to participate in the program." Greenery Rehabilitation Group, Inc. v. Hammon, 150 F.3d 226, 227 (2d Cir.1998). States, such as Connecticut, that elect to participate in the medicaid program are required to follow federal requirements. See Clark v. Commissioner, 209 Conn. 390, 394, 551 A.2d 729 (1988). The medicaid program is administered in Connecticut by the department pursuant to General Statutes § 17b-260. The department's Uniform Policy Manual (manual) sets forth the regulations in regard to medicaid, and has the full force and effect of law pursuant to General Statutes § 17b-10.

The department's regulations of the eligibility of undocumented aliens for medicaid assistance mirror its federal counterpart, which provides that "[u]ndocumented aliens or aliens not otherwise permanently residing in the United States under color of law generally are not entitled to full Medicaid coverage. See 42 U.S.C. § 1396b (v)(1) (`no payment may be made to a State under this section for medical assistance furnished to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law'); 42 C.F.R. § 435.406. The only exception to this exclusion is payment for medical assistance that is `necessary for the treatment of an emergency medical condition.' 42 U.S.C. § 1396b (v)(2)(A)." Greenery Rehabilitation Group, Inc. v. Hammon, supra, 150 F.3d 227-28.

Under federal law, an "emergency" is defined as "a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in — (A) placing the patient's health in serious jeopardy, (B) serious impairment to bodily functions, or (C) serious dysfunction of any bodily organ or part." 42 U.S.C. § 1396b (v)(3).

"The corresponding regulation ... found at 42 C.F.R. § 440.255 (b)(1) ... provides that aliens are entitled to Medicaid coverage for [e]mergency services required after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: (i) Placing the patient's health in serious jeopardy; (ii) Serious impairment to bodily functions; or (iii) Serious dysfunction of any bodily organ or part." Greenery Rehabilitation Group, Inc. v. Hammon, supra, 150 F.3d 227.

In Connecticut, consistent with the federal requirements, undocumented aliens are ineligible for medicaid coverage unless they have an emergency medical condition and are otherwise eligible for medicaid. See Department of Social Services, Uniform Policy Manual § 3005.05C. "A medical condition is considered an emergency when it is of such severity that the absence of immediate medical attention could result in placing the patient's health in serious jeopardy. This includes emergency labor and delivery, and emergencies related to pregnancy, but does not include care or services related to an organ transplant procedure." Id., at § 3000.01.³

Keeping the foregoing background in mind, we now turn to the facts and procedural history that are relevant to the plaintiff's claims. The plaintiff, a citizen of Poland, came to the United States on a tourist visa and remained illegally after his visa expired. On or about November 15, 1998, he began having symptoms relating to his current medical condition.

On November 19, 1998, he reported to his family physician that he was experiencing stomach pain, nausea and was having trouble walking. That same day, the plaintiff underwent blood tests and X rays. The test results became available on November 24, 1998, and on the basis of those results, his family physician referred him to Robert B. Erichson, an oncologist at Stamford Hospital (hospital).

Under the care of Erichson, on November 24, 1998, the plaintiff was diagnosed as having acute myelogenous leukemia, a disease that can be fatal if not treated aggressively with chemotherapy. As a result of the diagnosis, Erichson performed bone marrow biopsies and inserted a triple lumen Hickman catheter into the plaintiff so as to begin chemotherapy treatment. Following a course of chemotherapy, the plaintiff was discharged on December 26, 1998.

On February 26, 1999, the hospital filed an application for medicaid on behalf of the plaintiff. In its application, the hospital indicated that it was seeking payment for in-patient hospital care that the plaintiff had received that was "necessary for the treatment of his emergency medical condition" and which resulted in his hospitalization from November 24 to December 26, 1998. The plaintiff's application was sent for review to a third party, Colonial Cooperative Care, Inc. (Colonial), and to the department's medical review team (review team).

On April 24, 1999, Colonial found that the plaintiff met the criteria for disability as set forth in the department's regulations. Notwithstanding Colonial's findings, the review team found on May 11, 1999, that the plaintiff did not meet the criteria for having an emergency medical condition, and on May 17, 1999, the department denied the plaintiff's application for emergency medical assistance under medicaid.⁴

Subsequently, the plaintiff requested an administrative hearing to review the denial of his application for Medicaid assistance. A hearing was held on November 19, 1999, in which a department hearing officer adopted the review team's determination that the plaintiff did not have an "emergency medical condition" at the time he was admitted at the hospital on November 24, 1998. The hearing officer's conclusion was based, inter alia, on his findings that the medical procedures, bone marrow biopsies and the insertion of a Hickman catheter, performed at the hospital during the plaintiff's hospitalization, were not emergency medical events. Furthermore, the officer noted that the plaintiff would not have died if he did not receive treatment the day he was admitted. As a result, the plaintiff filed an administrative appeal with the Superior Court, which in turn was dismissed. This appeal followed. Additional facts will be set forth as necessary.

I

The first issue on appeal is whether the court applied the proper legal standard for determining whether the plaintiff suffered from an "emergency medical condition" so as to qualify him for medicaid benefits. Specifically, the plaintiff contends that the hearing officer construed the definition of "emergency medical condition" under § 3000.01 of the manual too narrowly by requiring the plaintiff to show that he "would ... have immediately died on November 24, 1998 [date of admittance] if he had not received the treatment administered to him on that date at Stamford Hospital." We disagree.

Before turning to the merits of the plaintiff's claim, we set forth our standard of review. "Judicial review of the conclusions of law reached administratively is ... limited. The court's ultimate duty is only to decide whether, in light of the evidence, the [agency] has acted unreasonably, arbitrarily, illegally, or in abuse of its discretion.... Although the interpretation of statutes is ultimately a question of law ... it is the well established practice of [the Supreme Court] to accord great deference to the construction given [a] statute by the agency charged with its enforcement.... Conclusions of law reached by the administrative agency must stand if the court determines that they resulted from a correct application of the law to the facts found and could reasonably and logically follow from such facts." (Citations omitted; internal quotation marks omitted.) Cadlerock Properties Joint Venture, L.P. v. Commissioner of Environmental Protection, 253 Conn. 661, 669, 757 A.2d 1 (2000), cert. denied, 531 U.S. 1148, 121 S.Ct. 1089, 148 L.Ed.2d 963 (2001).

In its definition of "emergency condition," § 3000.01 of the manual mirrors its federal counterpart, 42 U.S.C. § 1396b (v)(3). As stated previously, the manual provides...