Appeal from the Order of the Department of Public Welfare, in case of William Martin, Case No. 0178677, dated June 6, 1984.
Jonathan E. Jones, Ogg, Jones & Desimone, for petitioner.
Jeffrey P. Schmoyer, Assistant Counsel, with him, John Kane and Jean E. Graybill, for respondent.
President Judge Crumlish, Jr., Judges Rogers and Colins, sitting as a panel of three. Opinion by Judge Colins.
[ 99 Pa. Commw. Page 346]
William Martin (petitioner) appeals from a final order of the Department of Public Welfare (DPW) dismissing an appeal from a denial of Medical Assistance (MA)*fn1 dated March 18, 1983. Because DPW erred in failing to afford the Martins proper notice of the grounds for the denial and in failing to make findings of fact regarding the timeliness of petitioner's appeal, we vacate in part and remand with specific instructions.
[ 99 Pa. Commw. Page 347]
In September of 1982, petitioner's wife, Louise Martin, became seriously ill and had to be hospitalized for major surgery. In December of 1982, petitioner's daughter, Theodora Martin, also became seriously ill and had to be hospitalized for major surgery in December of 1982 and again in April of 1983.
Petitioner and his family were named insureds under a policy of insurance issued by the New World Maintenance Association, Inc. (NWMA), an organization then purporting to operate as a licensed health and disability insurer under the laws of the State of California.*fn2 In February of 1983, petitioner received a notice from the California Department of Insurance (CADOI) stating that NWMA had lost its permission to operate in California as a consequence of a stipulation and order entered into by NWMA and CADOI stating that NWMA had never obtained proper licensing to operate as a California health insurer.*fn3 On August 24, 1983, NWMA and its constituent trading groups and corporations filed a petition for Chapter VII bankruptcy relief*fn4 in the United States Bankruptcy Court for the Central District of California.
On March 1, 1983, petitioner's wife, Louise Martin, went to the Westmoreland County Assistance Office (CAO) and requested Medical Assistance (MA) benefits for herself and her family. At the time, petitioner's family was faced with more than $6,500.00 in bills from the September, 1982, surgery on Louise Martin and nearly $6,000.00 in bills from the December, 1982, surgery on Theodora Martin. The amount due for the April, 1983, surgery would prove to be nearly $8,000.00, making for a total of approximately $20,500.00 in medical bills in
[ 99 Pa. Commw. Page 348]
just under seven months' time. The total amount of insurance ultimately recovered by the Martins from a reinsurer of NWMA was $2,500.00. The Martins' total income was such that they could qualify as medically needy and be eligible for MA.
Mrs. Martin was told by a CAO worker that her application could not be considered or processed, and her eligibility established, unless she first submitted the following items to the CAO:
(1) a 1982 profit-loss statement or a 1982 Federal tax return;
(2) verification of money spent on prescriptions;
(3) verification of payment of monthly hospital premiums.
On March 18, 1983, the CAO sent the Martins a notice of its decision to deny the application based upon the Martins' failure to provide "essential" information. The information was not specified on the denial form. The notice of denial contained no reference to any of the above-requested information or to a time limit for furnishing the information. The notice of denial was not preceded by either an oral or a written request for the furnishing of this information.
The testimony of Mrs. Martin before the hearing officer was that no definite time was assigned by which she had to submit the requested information, and that she had told the CAO worker it would take her family some time to gather the information together, as they had not yet filed a federal tax form for 1982. The CAO worker at the hearing testified that Mrs. Martin had been told to return the forms within fifteen (15) days. The hearing officer made no finding of fact regarding this issue. The denial form makes no mention of a fifteen (15) day deadline.
Subsequently, on April 7, 1983, the Martins reapplied for MA, this time providing sufficient information.
[ 99 Pa. Commw. Page 349]
This application was approved on May 9, 1983, the eligibility period running from 4/7/83 to 10/7/83, for full payment subject to client's liability of $2,877.68 over the six-month eligibility period.
The instant issue arose when the Martins discovered that DPW would not furnish MA reimbursement to cover the costs of daughter Theodora Martin's December, 1982, surgery or of wife Louise Martin's, September, 1982, surgery. On November 14, 1983, DPW received a letter from the Martins dated October 25, 1983, purporting to be an appeal of the March 18, 1983, denial of eligibility.
The hearing officer, after holding a hearing by telephone, proceeded to dismiss this appeal for want of timeliness pursuant to 55 Pa. Code § 275.3(b). The Office of Hearings and Appeals affirmed and the petitioner's request for ...