What Do You Mean It's Not Covered: The State Guidelines Limited Coverage

In reaching its determination, the State relied on Florida Administrative Code, which provided in relevant part: 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. Under the division's interpretation of this rule, in order for the medical expenses of Harris' daughter to be covered, the premium for such coverage was required to have been paid before April 1. Because the first premium was not paid until sometime after May 10, 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. Harris appealed the order denying her request for coverage for her infant daughter under the state group health self-insurance plan. She contended that the state hearing officer handling her case erred in failing to construe the ambiguous insurance document against its drafter, the State, and in failing to find that the state was prohibited from denying coverage by virtue of a material misrepresentation made to Harris by its agent, Quincoses. Considering Harris' first argument -- that the insurance plan was ambiguous -- the appeals court reviewed the applicable features of the plan. It was described in the "State of Florida Employees Group Health Self Insurance Plan Brochure." Although this benefit document provided general information regarding the effective date of coverage, it said nothing about a change from single to family coverage, or the effective date for doing that. However, the appeals court wrote, "While we consider that it would be far more informative for the state to provide a copy of the policy to each of its insureds, we cannot say that the benefit document is on its face ambiguous."