ADMINISTRATIVE HEARINGS
COUNTY OF WATAUGA / 06 INS 2302
Denise M Lovin, John Fulton Lovin & / )
Robert F Lovin / )
)
PETITIONERS, / )
) / DECISION
v. / ) / GRANTING
) / SUMMARY JUDGMENT
NC Teachers & State Employees Comprehensive / )
Major Medical Plan, Value Options Inc. / )
)
RESPONDENT. / )
)
This contested case came before the undersigned on Respondent’s Motion for Summary Judgment, and Petitioner’s Cross Motion for Summary Judgment. Having carefully considered the Motions, supporting briefs, affidavits, and applicable law, the undersigned finds as follows:
1. This contested case challenges the decision by Respondents to deny coverage to Petitioners under the N.C. Teachers & State Employees Comprehensive Major Medical Plan (State Health Plan) for Bobby Lovin’s treatment at Telos, a residential treatment center.
2. Respondent relied on N.C. Gen. Stat. § 135-40.7B in denying Petitioners’ request for coverage for Bobby’s treatment at Telos.
3. This statute upon which Respondents rely is titled “Special provisions for chemical dependency and mental health benefits.” The statute states in part (a) that benefits for the treatment of mental illness are covered by the plan and are generally treated the same as physical illnesses. In part (b), the statute lists the types of facilities in which treatment will be covered. N.C. Gen. Stat. § 135-40.7(b)(1)(c) states that the following types of facilities are covered:
Licensed residential treatment facilities that have 24-hour on-site care provided by a registered nurse and that hold current accreditation by a national accrediting body . . . .
N.C. Gen. Stat. § 135-40.7B(b)(1)(c)(emphasis added).
4. Respondents have taken the position that the language quoted above requires that a residential treatment facility must have a registered nurse physically on-site 24 hours per day. Respondents denied coverage to Petitioners on the uncontested fact that Telos does not have a registered nurse physically on-site 24 hours per day.
5. Petitioners respond that Telos does have RNs on staff, who provide care on-site at Telos, and provide that care 24 hours per day.
6. The primary question presented by the Motions for Summary Judgment, then, is the meaning of the statute. Does it require that care be available on-site 24 hours per day by an RN? Or does it require that an RN physically be on-site 24 hours per day? The parties agree that the answer to these questions resolves the case in its entirety.
7. The parties also agree that the plain meaning of the statute should control, and that no external factors need be brought to bear in interpreting this statute.
8. Simple grammatical analysis of the statutory clause shows as follows. The verb is “have.” The subject of the verb is “care.” Therefore, these facilities must “have care”. The word “care”additionally is modified by three modifiers: “24-hour”, “on-site”, and “provided by a registered nurse.” So, these facilities must have care that is 24-hour, on-site, and provided by a registered nurse.
9. The meaning of the statute is plain. There must be care provided on-site, 24 hours per day, and by a registered nurse. “[A] statute that is plain and free from ambiguity, and expresses a single, definite, and sensible meaning must be interpreted literally.” Abernathy v. Bd. of Commr’s of Pitt County, 169 N.C. 631, 83S.E. 577 (1915)
10. As established by the Affidavit of Janet Stodtmeister, and not controverted by Respondents, “With regard to nursing care, we [Telos] provide it 24 hours a day. We provide it on-site. It is provided by a registered nurse.” Affidavit of Stodtmeister,
11. Therefore, Telos provides what the statute requires.
12. Had the legislature wanted to require that residential treatment facilities have RNs on site 24 hours per day, it easily could have said so. Numerous wordings of the statute that would make this purpose clear come to mind, for example: “have a twenty-four hour on-site registered nurse” or “have a registered nurse on-site 24 hours per day” or “have a registered nurse in residence 24 hours per day.” The legislature said none of these things, but instead required that care be provided on-site, 24-hours, and by a registered nurse.
13. It is worth noting that there was no evidence presented that Bobby received inadequate care at Telos. In fact, the affidavits presented establish the opposite: that Bobby received exemplary, effective care at Telos, from a large staff of trained professionals. (seeAffidavits of Denise Lovin, Psy.D., Tony Mosier, Janet Stodtmeister, and Fulton Lovin). In other words, the issue before the undersigned was not whether coverage should be denied for treatment at a sub-par facility, but whether coverage should be denied for treatment at an excellent facility based upon Respondent’s erroneous reading of one sentence in a statute.
14. Were the plain meaning of the statute not clear, ambiguities in the statute should be resolved in favor of Petitioners, for the reasons set forth in Petitioners’ Response to Motion for Summary Judgment and Cross Motion for Summary Judgment, which hereby are adopted.
DECISION
The provider, Telos, meets the requirements of N.C. Gen. Stat. §135-40.7B(b)(1)(c). The Cross Motion for Summary Judgment hereby is granted in favor of Petitioners. As the referenced statute was the only reason for denial of coverage, Respondents shall pay the claim for Bobby Lovin’s treatment at Telos, subject to applicable deductibles and co-payments, if any. This grant of summary judgment disposes of all issues in the case. Respondent’s Motion for Summary Judgment is DENIED.
NOTICE
The Agency that will make the final decision in this contested case is the North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan.
The Agency is required to give each party an opportunity to file exceptions to the decision and to present written arguments to those in the Agency who will make the final decision. N.C.Gen. Stat. § 150-36(a). The Agency is required by N.C. Gen. Stat. § 150B-36(b) to serve a copy of the final decision on all parties and to furnish a copy to the parties' attorneys of record and to the Office of Administrative Hearings.
Under N.C. Gen. Stat. § 150-36(d), if the agency does not adopt the administrative law judge's decision, it shall set forth the basis for failing to adopt the decision and shall remand the case to the administrative law judge for hearing. The party aggrieved by the agency's decision shall be entitled to immediate judicial review of the decision under Article 4 of this Chapter.
This the 26th day of July, 2007.
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Beecher R. Gray
Administrative Law Judge
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