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Gatica v. Dept. of Public Aid





APPEAL from the Circuit Court of Cook County; the Hon. JAMES C. MURRAY, Judge, presiding.


Vincente Gatica was admitted as a patient to the Illinois Masonic Medical Center (hereinafter IMMC) on February 10, 1979. He thereafter applied for medical aid from the Illinois Department of Public Aid (hereinafter IDPA) under article V of the Illinois Public Aid Code (Ill. Rev. Stat. 1979, ch. 23, par. 5-1 et seq.) (hereinafter Public Aid Code). At the time, he was not a public aid recipient; he had no health or hospitalization insurance; and he had no funds with which to pay the hospital bills. After his death, IDPA denied Gatica's application for aid. He was alleged to have empowered an IMMC employee, Noemy Martinez, who was in charge of medical assistance applications, to be his authorized representative in all matters relating to his application for medical aid. After the denial of Gatica's application, IMMC sought to contest IDPA's decision at a departmental hearing which IMMC requested. At the conclusion of the IDPA hearing, the hearing officer held that IMMC had not been properly authorized to represent Gatica at the hearing; dismissed the claim solely on that basis; and refused to consider the merits of the claim. IMMC filed a complaint in the circuit court for administrative review. The trial court, after appointing IMMC special administrator, affirmed on the ground that medical benefits under the Public Aid Code abate at death.

The issues presented to this court by IMMC are whether potential rights to medical aid benefits under article V, which have been applied for but not yet approved or denied, abate upon the death of an applicant; and whether IDPA improperly denied IMMC the opportunity to present the merits of Gatica's claim at the departmental hearing. For the following reasons, we reverse the decision of the trial court and remand this cause to IDPA for further proceedings consistent with our decision.

The stated purpose of article V of the Public Aid Code is to establish a program of essential medical care for persons who, because of inadequate financial resources, are unable to meet their essential medical needs. For persons who are medically indigent, but are otherwise able to support themselves with a livelihood, it is of special importance to maintain their incentives for continued independence, among other objectives. (Ill. Rev. Stat. 1979, ch. 23, par. 5-1.) Toward this end, the legislature created the program outlined in article V setting forth the procedures by which application can be made by an indigent for aid, and by the vendors of medical services for subsequent reimbursement. Implicit in this legislative action was the recognition that a necessary and practical incentive was needed to motivate vendors of medical services to promptly and willingly treat the indigent population by assuring the reimbursement of expenses advanced by such providers.

IMMC is a private, not-for-profit hospital located in Chicago which serves, inter alia, a large Hispanic community. Approximately 57 percent of all IMMC's patients receive medical services funded by State or Federal programs. *fn1 When Gatica was admitted to IMMC for a lung disorder and indicated that he had no health insurance or savings, he was examined, treatment was begun and he completed an IDPA standard form application for medical assistance. That form was forwarded to and received by IDPA within five days, on February 15, 1979. Gatica died while a patient at IMMC on March 1, 1979, after receiving over $13,000 in medical treatment. At this time, his application had not been completely processed by IDPA. On June 4, 1979, IDPA sent a notice to the deceased Gatica's home and to IMMC stating that the application was denied because "applicant could not be located" for further inquiry concerning the application.

On June 20, 1979, IMMC sent a notice to IDPA seeking a departmental hearing in order to contest the denial of the application. On July 13, 1979, a hearing was conducted before an IDPA hearing officer. Noemy Martinez, the representative of IMMC, stated that she was "authorized" by Gatica to request this administrative hearing. As Gatica had no living relatives to represent him, she completed the hearing application form on June 20, 1979, and signed it "patient unable to sign." The hearing officer asked if she had any written authorization signed by Gatica and she responded only that Gatica had signed the "applications" for aid. She stated that IMMC had informed IDPA on March 27, 1979, of Gatica's death and it was after his death that IDPA denied the application.

Lewis Cornwall, a representative of IDPA, then advised the hearing officer that on May 27 and 30, 1979, inquiries were sent to Gatica's home address but were returned to IDPA by the post office. If an applicant dies before the application is processed, the department continues to evaluate the application. If IDPA is unaware that an applicant has died, however, it simply awaits a response to the inquiries. Gatica's application was denied because there was no reply to the inquiries sent to his home.

The hearing officer elicited no testimony concerning the merits of Gatica's application. Martinez asked for a hearing continuance in order to submit additional documents, which the officer denied. Several times during the hearing Martinez indicated that more than one "application" had been completed by Gatica. *fn2 On August 10, 1979, the officer's written findings and IDPA's final decision were sent to Martinez, dismissing the appeal for "want of jurisdiction" because IMMC's authorization to contest the denial had not been demonstrated. The cover letter directed that this administrative decision could be reviewed only through the circuit court.

On September 13, 1979, a complaint was filed by IMMC in the circuit court of Cook County, seeking administrative review of IDPA's ruling (Ill. Rev. Stat. 1979, ch. 23, par. 11-8.7) "on the behalf of" Gatica, the captioned plaintiff. The complaint, alleged, inter alia, that the ruling of the IDPA hearing officer was against the manifest weight of the evidence. IDPA answered by filing a copy of the July 13, 1979, hearing transcript.

Before the trial court, IMMC argued that Gatica's right to aid did not terminate at his death and that IMMC was authorized to represent him. IMMC stated that a blank authorization form had been signed by Gatica. Because the form required the date of denial, this information had not been filled in since Gatica expired before the denial. IMMC asserted that the signed form had not been brought to the department hearing because it was incomplete. IDPA objected that the blank authorization form could not be considered by the trial court because it had not been introduced at the administrative hearing. IMMC moved to be appointed as special administrator by the court for Gatica under section 54(2) of the Civil Practice Act (Ill. Rev. Stat. 1979, ch. 110, par. 54(2)) which the trial court allowed. The trial court then requested briefs concerning whether any potential rights of Gatica to medical benefits abated at his death. On March 27, 1980, the trial court announced its decision to affirm "for the sole reason that the entitlement of medical assistance abates at death."

• 1 The trial court's ruling, that an applicant's potential entitlement to benefits abates solely because death occurs before a final decision, was in error. IDPA has so conceded on appeal. That the legislative intent is clearly contrary to such a ruling is apparent from a reading of sections 5-2, 5-6, and 1-15(2) of the Public Aid Code (Ill. Rev. Stat. 1979, ch. 23, pars. 5-2, 5-6, and 11-15(2)). Section 5-2 provides that medical assistance shall be available to "persons * * * who fall sick, are injured, or die, not having sufficient money, property or other resources to meet the costs of necessary medical care or funeral and burial expenses." (Emphasis added.) Section 5-6 provides that obligations incurred but not paid for at the time of a recipient's death, for authorized services, may be paid "* * * after the death of the recipient." (Emphasis added.) Section 11-15(2) provides that an application for medical aid may be filed on behalf of a person who "* * * died before an application was filed." (Emphasis added.) This legislative language must be given its plain and ordinary meaning. (Western National Bank v. Village of Kildeer (1960), 19 Ill.2d 342, 350, 167 N.E.2d 169), and it clearly demonstrates its intention that such claims are not to abate upon the death of an applicant who has received medical assistance by a provider such as IMMC. This conclusion is one reached by IDPA itself as reflected in its own written policies implementing the foregoing statutory provisions, and others. (See IDPA General Assistance Manual (1977), policies 235.1; 310.2; 310.3; IDPA Handbook for Hospitals (1979), H-281(3); H-282.) We therefore reverse the trial court's ruling concerning abatement, and find that such an action survives an applicant's demise.

• 2 While conceding that Gatica's potential entitlement to benefits did not abate, IDPA argues that Gatica's legal right to administrative review abated because it is not listed in the survival section of the Probate Act (Ill. Rev. Stat. 1979, ch. 110 1/2, par. 27-6). IMMC correctly responds that the Administrative Review Act does not create a new cause of action or an independent remedy, but instead provides merely a method of review, a view supported by Illinois case law. (Roosevelt-Wabash Currency Exchange, Inc. v. Fornelli (1977), 49 Ill. App.3d 896, 900, 364 N.E.2d 449.) It would be logically inconsistent to create the right of an applicant to have his application evaluated subsequent to his death, yet deny the procedural right to review that evaluation. There is no question but that administrative decisions made under article V of the Public Aid Code are amenable to administrative review in the circuit court. Ill. Rev. Stat. 1979, ch. 23, par. 11-8.7.

Turning to the question of whether IMMC should have been allowed to present the merits of Gatica's claim at the IDPA hearing, we begin our analysis with a review of the relevant sections of the Public Aid Code and IDPA rules concerning the application and appeals procedure within the department. Under section 11-15 of the Public Aid Code (Ill. Rev. Stat. 1979, ch. 23, par. 11-15), an applicant must file a written request for aid with IDPA. Under section 11-15(2), an application for a minor, incompetent, or decedent may be filed "on behalf" of such persons. Applications "on behalf" of a decedent under this section are to be filed by the next of kin or a person "acceptable under the rules" of IDPA. IDPA policy 310.2 provides that in the case of a decedent, application can be made by "someone acting responsibly for him." Under IDPA policy 235.1, where an application has been denied, an appeal to an IDPA hearing officer can be made by the applicant, or an "authorized" representative. Rule 9.13 of the IDPA Rules and Regulations provides that in the case of a hospital seeking to pursue the appeal of an application denial, the hospital must have a "written, signed authorization designating the representative to act in this capacity." None of these rules, however, specifically provide for the circumstances which arose here, where the applicant made the initial application and died before the application was denied and therefore before authorization to appeal could have been given.

• 3 At the departmental hearing, the hearing officer dismissed IMMC's appeal on the ground that written authorization had not been presented. IDPA claims on appeal that its ruling was not against the weight of the evidence and that, in any event, IMMC was not a proper party to represent Gatica in the review of this ruling before the trial court. IMMC claims that the administrative procedure it employed before the department in the present case had been previously acceptable; the refusal of the department to hear the merits of the claim was a departure from custom; and, the ruling was therefore arbitrary, unreasonable and capricious. Deference is generally to be accorded the decision of an agency on administrative review, yet the courts> do not hesitate to intervene when the decision is against the manifest weight of the evidence or is arbitrary, unreasonable or capricious. (Southern Illinois Asphalt Co. v. Pollution Control Board (1975), 60 Ill.2d 204, 326 N.E.2d 406; People ex rel. Stephens v. Collins (1966), 35 Ill.2d 499, 221 N.E.2d 254; Environmental Protection Agency v. Pollution Control Board (1976), 37 Ill. App.3d 519, 346 N.E.2d 427.) An agency which has changed a previously existing construction, or application of a rule, or an informal practice, may be bound thereby as a result of the previous custom. (Holland v. Quinn (1978), 67 Ill. App.3d 571, 574-75, 385 N.E.2d 92; Olin Corp. v. Pollution Control Board (1977), 54 ...

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