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STATE OF NORTH CAROLINA IN THE OFFICE OF ADMINISTRATIVE HEARINGS 10 INS 8550 COUNTY OF GASTON Brenda A. Kincaid, Petitioner, v. North Carolina State Health Plan For Teachers And State Employees, Respondent. ) ) ) ) ) ) DECISION On April 6, 2011, the undersigned conducted an administrative hearing in this case in Charlotte, NC. At the conclusion of the hearing, the undersigned ruled in favor of the Respondent and directed Respondent to submit a proposed decision. Having received a hardcopy of Respondent’s proposed decision, the record in the case is now closed. APPEARANCES For the Petitioner: Brenda A. Kincaid 340 Eaker Road Bessemer City, NC 28016 For the Respondent: Heather H. Freeman Assistant Attorney General North Carolina Department of Justice Post Office Box 629 Raleigh, NC 27602-0629 ISSUES Did the Respondent act erroneously, arbitrarily or capriciously, or otherwise prejudice Petitioner’s rights when it denied the Petitioner’s claim for orthodontic treatment? RELEVANT STATUTES AND POLICIES N.C. Gen. Stat. §135, N.C. Gen. Stat. Chapter 150B, Article 3; and the State Health Plan PPO Benefit Booklet. EXHIBITS For Petitioner: Exhibits 1-9 For Respondent: Exhibits 1, 2 WITNESSES For Petitioner: Brenda. A. Kincaid, on her own behalf For Respondent: Donna Williams, Appeals Team Lead, Blue Cross Blue Shield of North Carolina FINDINGS OF FACT Based on a review of the witness testimony, exhibits and the record as a whole, it is found as a fact that: 1. Petitioner has been a member of the State Health Plan for thirty-seven (37) years. 2. Respondent is an agency of the State of North Carolina, and offers health care benefits to eligible active and retired employees and their enrolled dependants in accordance with the applicable North Carolina General Statutes, the benefit booklet for Respondent’s preferred provider organization (hereinafter “PPO”) plan, and Respondent’s health care policies. 3. At all times relevant to the issues in this contested case, Petitioner was a member of Respondent’s Standard PPO plan. 4. Blue Cross Blue Shield of North Carolina (BCBSNC) is the claims processing contractor for the State’s PPO plan. 5. On October 18, 2009, Petitioner had an accident where she fell down the stairs in her home and “knocked out a tooth.” 6. As a result of this injury, Petitioner consulted multiple providers. P Ex 1, 2, 3, 4, & 5 She received dental treatment, including wiring in her mouth, to manually reposition the tooth. P Ex 6, 7 & 8 7. Petitioner sought treatment from Dr. Macomson and received a full set of orthodontic braces on her upper and lower teeth on June 7, 2010. 8. Petitioner submitted claims for Dr. Macomson’s orthodontic treatment to Respondent for payment which were denied. P Ex 9 9. treatment. Petitioner timely appealed the denial of payment for the June 7, 2010 orthodontic 10. Petitioner’s appeal was denied and notice was provided by letter dated October 22, 2010. R Ex 1 The letter states the basis of the denial and quotes the State Health Plan benefits booklet. 11. Under the section titled “COVERED SERVICES” on page 13 of Respondent’s benefit booklet for the State Health Plan, is a subsection titled “Dental Treatment Covered Under Your Medical Benefit” which describes all dental treatment that is covered under the medical benefit pursuant to the Standard PPO Plan, to wit: Your health benefit plan provides benefits for diagnostic, therapeutic or surgical procedures, including oral surgery involving bones or joints of the jaw, when the procedure is related to one of the following conditions: Accidental injury of the natural teeth, jaw, cheeks, lips, tongue, roof and floor of the mouth. ... R Ex 2 12. Further within the subsection “COVERED SERVICES” on page 13 of Respondent’s benefit booklet for the State Health Plan is the following exclusionary paragraph: The Following Services Are Excluded From Coverage Under Your Medical Benefit Orthodontic braces R Ex 2 13. Under the section titled “WHAT IS NOT COVERED?” on page 29 of Respondent’s benefit booklet for the State Health Plan and continued on page 30, it states that: Exclusions that are specific to a type of service are stated along with the benefit description in “Covered Services.” Exclusions that apply to many services are listed in this section. To understand all of the exclusions that apply, read “Covered Services,” “Summary of Benefits” and “What Is Not Covered?” In addition, your health benefit plan does not cover services, supplies, drugs or charges that are: … For dental care, dentures, dental implants, oral orthotic devices, palatal expanders and orthodontics except as specifically covered by your health benefit plan … R Ex 2 14. According to the State Health Plan benefits booklet, orthodontic braces were excluded from coverage under Petitioner’s plan and, therefore, a non-covered service, regardless of the cause of Petitioner’s dental injuries. CONCLUSIONS OF LAW 1. The Office of Administrative Hearings has jurisdiction over this contested case and the parties thereto. 2. In N.C. Gen. Stat. Chapter 135, the General Assembly created a State Health Plan for the benefit of its state employees, retired employees and certain of their eligible dependants. Pursuant to N.C. Gen. Stat. Chapter 135, Respondent is to provide comprehensive medical coverage under a group plan and benefits are to be provided under contracts between the Plan and the claims processor. 3. Petitioner has the burden of proof in this matter by a preponderance of the evidence regarding the issues presented in this contested case. N.C. Gen. Stat. § 150B-34(a). 4. Respondent’s State Health Plan Benefit Booklet for the Standard PPO Plan sets forth the benefits available to members. 5. Petitioner did not meet her burden of proving by a preponderance of the evidence that Respondent acted erroneously, arbitrarily or capriciously, or otherwise prejudiced Petitioner’s rights by denying Petitioner’s claim for payment for orthodontic treatment. DECISION Based on the foregoing Findings of Fact and Conclusions of Law, the undersigned determines that the final decision maker should AFFIRM Respondent’s denial of Petitioner’s request for payment of claims related to orthodontic treatment. NOTICE AND ORDER The agency that will make the final decision in this contested case is the Board of Trustees of the North Carolina State Health Plan (hereinafter “Agency”). The Agency is required to give each party the opportunity to file exceptions to and written arguments concerning this Recommended Decision. The Agency is further required to serve a copy of the Final Agency Decision on all Parties or their attorneys of record and on the Office of Administrative Hearings. In accordance with N.C. Gen. Stat. §150B-36 the Agency shall adopt each finding of fact contained in the Administrative Law Judge’s decision unless the finding is clearly contrary to the preponderance of the admissible evidence. For each finding of fact not adopted by the Agency, the Agency shall set forth separately and in detail the reasons for not adopting the finding of fact and the evidence in the record relied upon by the Agency in not adopting the finding of fact. For each new finding of fact made by the agency that is not contained in the Administrative law Judge’s decision, the Agency shall set forth separately and in detail the evidence in the record relied upon by the agency in making the finding of fact. The party aggrieved by the Agency’s decision shall be entitled to immediate judicial review of the decision under Article 4 of this Chapter. This13th day of April, 2011. ______________________________ The Honorable Selina M. Brooks Administrative Law Judge