Download Published - North Carolina Office of Administrative Hearings

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.
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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