Opinion ID: 786208
Heading Depth: 2
Heading Rank: 3

Heading: Plaintiff Ooten's Application Process

Text: 32 On July 2, 1998, Ooten, then forty-nine years old, had a heart attack and was taken to Roane County Medical Center in Harriman, Tennessee. While in emergency care, Ooten's daughter completed a TennCare application for Ooten and submitted it to the hospital. After her release from the hospital, Ooten called the TennCare Bureau to inquire about her application. The TennCare Bureau informed Ooten that her application had been denied and advised her to submit a new application together with a denial letter from an insurance company. The TennCare Bureau later sent Ooten written notice, dated July 23, 1998, which provided in part: 33 THIS IS WHO IN YOUR FAMILY DOES NOT QUALIFY AND WHY WE THINK THEY DO NOT QUALIFY: Betty S. Ooten 34 ___________[Social Security Number] 35 This person(s) denied for the reason listed below. 36 Your application was received during a period of closed enrollment. 37 . . . . YOU HAVE THE RIGHT TO REQUEST A REASSESSMENT 38 Do you think we are wrong for turning you down for TennCare? 39 You have the right to ask for a reassessment to tell us why. 40 (J.A. at 499.) 41 On July 21, 1998, Ooten filed another application with a denial letter from a private insurance company. This application was received by the TennCare Bureau on July 24, 1998. The TennCare Bureau enrolled Ooten in the program effective July 24, 1998. On July 28, 1998, Ooten requested a reassessment of her original application and informed the TennCare Bureau that she could not get medical insurance because she had a preexisting medical condition; a 70% blockage in her arteries. Ooten's request for reassessment was referred to a formal hearing. 42 At a hearing held on February 3, 1999, Dena Bost, an officer of the TennCare Bureau, testified as follows on direct examination: 43 Q. Can you explain why TennCare denied the July 2nd application? 44 A. The July 2nd application did not indicate that Ms. Ooten had been turned down for other insurance, and there was no attachment indicating that either. 45 Q. Why did TennCare approve the July 24th application? 46 A. A denial letter from an insurance company denying her coverage on the basis of her medical condition was attached to that application, and she indicated that she had been denied. 47 (J.A. at 609.) On cross-examination, Bost conceded that a person can have an existing medical condition that they know makes them uninsurable and cited personal circumstances. Bost also conceded that applicants are not asked if they are unable, because of an existing condition, to obtain health insurance. Bost testified that applicants may respond differently to the question have you been denied insurance? if they were asked about existing medical conditions. 48 The ALJ issued an order on May 3, 1999, denying Ooten's request that her date of eligibility relate back to the date of her original application. Ooten filed a petition for appeal. As of the date of this appeal, Defendants had not yet ruled on Ooten's administrative appeal.