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`Lynn M. Allen, State Bar Number 012612
`lallen@tysonmendes.com
`TYSON & MENDES, LLP
`7910 East Thompson Peak Parkway, Suite 101
`Scottsdale, Arizona 85255
`Telephone: (480) 571-5031
`Facsimile: (480) 245-5424
`Attorneys for Plaintiff
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`UNITED STATES DISTRICT COURT
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`DISTRICT OF ARIZONA
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`Allied World Specialty Insurance Company
`f/k/a Darwin National Assurance Company,
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` Plaintiff,
`vs.
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`Blue Cross Blue Shield Of Arizona, Inc.,
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` Defendants.
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`No.
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`COMPLAINT FOR DECLARATORY
`JUDGMENT
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`Plaintiff, Allied World Specialty Insurance Company f/k/a Darwin National Assurance
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`Company (“Allied World”), brings this action seeking declaratory relief against the Defendant,
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`Blue Cross & Blue Shield of Arizona, Inc. (“BCBS-AZ”), and alleges the following:
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`Parties, Jurisdiction and Venue
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`1.
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`This is a diversity action for declaratory relief pursuant to 28 U.S.C. § 2201 to
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`declare the rights and other legal relations of the parties regarding an insurance policy issued by
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`Allied World.
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`2.
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`Allied World is a corporation organized and existing under the laws of the State
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`of Delaware with its principal place of business in the State of New York.
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`3.
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`BCBS-AZ is a corporation organized and existing under the laws of the State of
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`Arizona with its principal place of business in the State of Arizona.
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 2 of 16
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`TYSON & MENDES, LLP
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`4.
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`This Court has subject matter jurisdiction over this case pursuant to 28 U.S.C. §
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`1332(a). There is complete diversity of citizenship between Allied World and BCBS-AZ. The
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`amount in controversy exceeds $75,000.00, exclusive of interest and costs.
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`5.
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`This Court has personal jurisdiction over BCBS-AZ, and venue is proper in this
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`District under 28 U.S.C. § 1391.
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`6.
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`This action is brought pursuant to 28 U.S.C. § 2201, which provides that the
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`Court may declare the rights and other legal relations of the parties. Allied World and BCBS-
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`AZ are both parties having an interest in the insurance policy referenced herein.
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`BACKGROUND FACTS
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`The MDL Action
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`7.
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`Beginning in 2012, numerous class action lawsuits were filed against multiple
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`Blue Cross Blue Shield entities or member plans (“Blues”) and the Blue Cross Blue Shield
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`Association (“BCBSA”) alleging violations of federal antitrust laws. One set of cases was filed
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`by “Providers” (physicians and other healthcare providers who render services to persons
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`insured under Blue Plans), and another set of cases was filed by “Subscribers” (persons and
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`businesses that have Blue Plan healthcare insurance policies)
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`8. While brought by different groups of plaintiffs, the lawsuits each allege
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`generally that the Blues and the BCBSA conspired to leverage their economic power and market
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`dominance to under-compensate healthcare providers for their services and to increase
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`healthcare costs to subscribers by coordinating their operations and limiting their activities
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`through restrictions in their trademark licenses.
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 3 of 16
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`TYSON & MENDES, LLP
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`9.
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`On December 12, 2012, the Judicial Panel on Multidistrict Litigation
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`consolidated both the Provider and Subscriber lawsuits and transferred them to the United States
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`District Court for the Northern District of Alabama, thus creating the MDL litigation referred to
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`as In Re: Blue Cross Blue Shield Antitrust Litigation, Master File No 2:13-cv-20000-RDP (the
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`“MDL Action”). A copy of the December 12, 2012 MDL Transfer Order is attached hereto as
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`Exhibit 1.
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`10.
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`In consolidating the Providers’ and the Subscribers’ actions, the MDL Panel
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`found: “Here, the actions involve substantial common questions of fact relating to the state
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`BCBS entities’ relationship with the national association, BCBSA, and the licensing agreements
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`that limit the Blue Plans’ activity to exclusive service areas, among other restrictions.” MDL
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`Transfer Order at 2.
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`11.
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`Pursuant to an Order issued by the MDL Court, two consolidated complaints
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`were filed in the MDL Action on July 1, 2013, one for the “provider track” (the “Provider
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`Complaint”) and one for the “subscriber track” (the “Subscriber Complaint”), both of which
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`have been amended several times. A copy of the Consolidated Fourth Amended Provider
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`Complaint is attached hereto as Exhibit 2; a copy of the Subscriber Track Fourth Amended
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`Consolidated Class Action Complaint is attached hereto as Exhibit 3.
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`12. BCBS-AZ was first named as a defendant in each the Provider Complaint and in
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`the Subscriber Complaint when the consolidated complaints were filed on July 1, 2013.
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`13.
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`The Provider Complaint alleges that the Blues have been engaged for many
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`years in an agreement not to compete against one another, but instead to cooperate and
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 4 of 16
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`TYSON & MENDES, LLP
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`coordinate their activities on a nationwide basis in order to maximize their profits. The
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`Complaint claims that the Blues agreed to cease competing and to impose operational uniformity
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`on themselves decades ago by carving out exclusive service areas, setting up their national
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`programs (including Blue Card), and establishing BCBSA’s uniform rules and regulations. The
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`Blues allegedly formalized their cooperation agreement through restrictions in their trademark
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`licenses, such as the requirement of mandatory participation in the national programs.
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`14.
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`The alleged conspiracy has perpetuated and strengthened the dominant market
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`position each Blue enjoys in its specifically defined geographic market which, in turn, has
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`enabled the Blues to force healthcare providers to accept anticompetitive rates and terms. The
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`Provider Complaint alleges that healthcare providers have been subjected to lower rates and less
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`favorable terms than would have been the case in the absence of the conspiracy.
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`15.
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`The Provider Complaint seeks injunctive relief prohibiting the Blues, including
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`BCBS-AZ, from entering into, honoring, or enforcing any agreements that restrict territories or
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`geographic areas, enjoining the Blues from utilizing the Blue Card Program to pay healthcare
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`providers, and enjoining the Blues from developing any other program or structure that is
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`intended to fix, or has the effect of fixing, prices paid to healthcare providers. The Provider
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`Complaint also seeks money damages in the form of treble damages.
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`16.
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`The Subscriber Complaint similarly alleges that the Blues have been engaged for
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`many years in an agreement not to compete against one another, but instead to cooperate and
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`coordinate their activities on a nationwide basis in order to maximize their profits. The
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`Subscriber Complaint alleges that the Blues agreed to cease competing and to impose
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 5 of 16
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`operational uniformity on themselves decades ago by carving out exclusive service areas and
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`establishing BCBSA’s uniform rules and regulations, including BCBSA’s Membership
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`Standards and Guidelines. The Blues allegedly formalized their cooperation agreement in their
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`trademark licenses.
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`17.
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`The Subscriber Complaint seeks injunctive relief prohibiting the Blues, including
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`BCBS-AZ, from entering into, honoring, or enforcing any agreements that restrict territories or
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`geographic areas, and it also seeks to eliminate restrictions on the Blues’ activities. The
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`Complaint further seeks money damages in the form of treble damages of the amount by which
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`the plaintiffs allege premiums were artificially inflated above their competitive levels.
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`18. On November 30, 2020, the Court in the MDL Action preliminarily approved a
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`settlement of the Subscribers’ claims, pursuant to which the Blues agreed to pay $2.67 billion. A
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`copy of the Court’s Memorandum Opinion and Order Preliminarily Approving Settlement, Plan
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`of Distribution, and Notice Plan, and Directing Notice to the Class is attached as Exhibit 4.
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`19.
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`The Provider Complaint and the Subscriber Complaint are based upon the same
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`or related conduct of the Blues relating to the Blues’ “relationship with the national association,
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`BCBSA, and the licensing agreements that limit the Blue Plans’ activity . . . .” MDL Transfer
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`Order at 2. The Complaints differ only with respect to the alleged harm to the Providers and to
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`the Subscribers. Both Complaints seek damages in excess of this Court’s jurisdictional limit and
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`invoke federal question jurisdiction.
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`Prior Related Litigation – Love
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`20. BCBS-AZ was also a defendant in a prior class action litigation styled Love v.
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 6 of 16
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`TYSON & MENDES, LLP
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`Blue Cross Blue Shield Assoc., No. 03-21296 (S.D. Fla.) (originally titled Thomas v. Blue Cross
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`Blue Shield Assoc.) (“Love”). Love was part of the MDL proceeding created in April 2000, and
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`styled In re Managed Care Litigation, No. 1:00-MDL-1334. A copy of Plaintiffs’ Sixth (and
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`final) Amended Class Action Complaint is attached as Exhibit 5.
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`21.
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`Like the MDL Action, Love was based on the theory that the Blues for many
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`years have not competed against one another, but instead have engaged in an agreement to
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`cooperate and coordinate their activities on a nationwide basis in order to maximize their profits.
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`22.
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`The Love plaintiffs alleged that the Blues are not competitors, but instead
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`Blues have market power in their respective regions. The plaintiffs further alleged that the Blues
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`use their market power to harm providers by forcing them to accept unfavorable
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`reimbursements.
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`23.
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`The Blues allegedly agreed to cease competing and to impose operational
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`uniformity on themselves decades ago by agreeing to operate in distinct geographic regions,
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`setting up their national programs (including Blue Card), and establishing BCBSA’s uniform
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`rules and regulations.
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`The Blues formalized their alleged cooperation agreement in their trademark
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`licenses. The Complaint cites the absence of Blue-on-Blue competition – and the resulting
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`market dominance each Blue has acquired as a result – as well as the operational uniformity
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`among the Blues required by their trademark licenses (including the requirement of mandatory
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`participation in the Blue Card Program) as evidence that the Blues have conspired.
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 7 of 16
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`TYSON & MENDES, LLP
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`25.
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`The plaintiffs in Love alleged that the Blues engaged in a common scheme to
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`systematically deny, delay, and diminish payments to providers. Similar to the Provider and
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`Subscriber Complaints, the Love litigation was based on the restrictions in the Blues’ trademark
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`licenses, on the Blues’ relationship with BCBSA, and on the Blues’ long history and practice of
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`national coordination and cooperation.
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`26. Many of the Blues settled the Love litigation through three settlement
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`agreements that became effective on September 26, 2008, October 3, 2008, and June 19, 2009,
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`respectively.
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`27. BCBS-AZ did not enter a settlement, and, in 2009, the Love court dismissed the
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`Plaintiffs’ Sixth Amended Complaint with prejudice, issuing a Final Judgment in favor of
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`BCBS-AZ and eight other Blues.
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`Three Federal Courts Have Held the MDL Action is Related to the Love Litigation
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`The Blues who had settled in the Love were named as defendants in a subsequent
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`28.
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`action styled Musselman v. Blue Cross Blue Shield of Ala., et al., no. 13-20050 (S.D. Fla.), in
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`which Provider plaintiffs in the MDL Action sought a declaration that the claims in the MDL
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`Action were not released by the settlement agreements with the Blues in the Love litigation.
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`29.
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`The Blues in Musselman moved to dismiss the complaint, arguing that the MDL
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`Action Provider Complaint (the only complaint at issue in Musselman) “arises out of and relates
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`to the ‘facts, acts, events … or other matters’ in Love.”
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`30.
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`The District Court agreed with the Blues and granted their motion to dismiss,
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`holding that:
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 8 of 16
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`[The Provider Complaint] arises out of and relates to the “facts, acts, events .
`. . or other matters” in Love. [The Provider Complaint] is based on Plaintiffs’
`allegation that Defendants conspired to “suppress competition and to increase
`their profits . . . by decreasing the rates paid to healthcare providers . . . .”
`Love was based on the similar allegation that the defendants had engaged in a
`common scheme to systematically deny, delay, and diminish the payments due
`to doctors. In short, both complaints are based on allegations that Defendants,
`acting through [the BCBS Association], conspired to reduce provider
`reimbursement.
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`Musselman v. Blue Cross & Blue Shield of Alabama, No. 13-20050-CV-MORENO, 2013 WL
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`4496509, at *5 (S.D. Fla. Aug. 20, 2013), aff'd, 684 F. App’x 824 (11th Cir. 2017) (citations
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`omitted).
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`31.
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`The Musselman plaintiffs appealed to the Eleventh Circuit, and the Eleventh
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`Circuit “affirm[ed] the District Court’s dismissal of the plaintiff-appellants’ complaint under
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`Federal Rule of Civil Procedure 12(b)(6) on the basis of the District Court’s thorough and well-
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`reasoned order.” Musselman v. Blue Cross & Blue Shield of Alabama, 684 F. App’x 824, 825
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`(11th Cir. 2017).
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`32.
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`In the MDL Action, the Provider plaintiffs sought a partial summary judgment
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`ruling barring Blue defendants, like BCBS-AZ, that were not signatories to the Love settlement
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`agreements, from asserting any affirmative defenses related to the Love settlement agreements,
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`such as res judicata, collateral estoppel, release and waiver.
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`33. BCBS-AZ and other Blues that did not settle in the Love litigation have argued
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`that they can benefit from the Musselman ruling that the claims in the Antitrust Litigation were
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`“Released Claims” within the meaning of the Love settlement agreement.
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`34.
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`Judge Proctor in the MDL Action agreed, citing Musselman and holding that
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 9 of 16
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`TYSON & MENDES, LLP
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`“Providers’ claims in this MDL fall squarely within the scope of the Love releases because they
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`arise from, or are based on, conduct by the Released Parties,” and stating that “The court agrees
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`with [the Musselman court] ‘that the [Provider] claims are Released Claims’ under the Love
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`Settlement Agreement.” In re Blue Cross Blue Shield Antitrust Litigation (MDL No. 2406), No.
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`2:13-CV-20000-RDP, 2018 WL 6333563, at * 7-8 (N.D. Ala. Oct. 17, 2018).
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`The Excess Policy
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`35. Allied World issued Excess Insurance Policy No. 0307-1532 to BCBS-AZ for
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`the policy period January 1, 2013 through January 1, 2014, that provided certain coverage to the
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`insured in excess of this Court’s jurisdictional threshold pursuant to the policy’s terms,
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`conditions, and exclusions (the “Excess Policy”). A copy of the Excess Policy is attached hereto
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`as Exhibit 6.
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`36.
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`The Insuring Agreement in the Excess Policy provides:
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`The Insurer will provide the Insured with insurance excess of
`the Underlying Insurance specified in ITEM 4 of the
`Declarations for claims first made against the Insured during
`the Policy Period. Except as otherwise provided in this Policy,
`coverage under this Policy will apply in conformance with the
`terms and conditions of, and endorsements to, the Primary
`Policy and any other Underlying Insurance. In no event will
`the coverage under this Policy be broader than the coverage
`under any Underlying Insurance. Coverage under this Policy
`will attach only after all Underlying Insurance has been
`exhausted by the actual payment of loss by the Underlying
`Insurers and/or the Insured.
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`(Excess Policy, § I.)
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`37.
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`Policy Number 1055376365 issued by Travelers Casualty and Surety Company
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`of America is listed as the Primary Policy in Item 4 of the Excess Policy’s Declarations. A copy
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`of the Primary Policy is attached hereto as Exhibit 7.
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 10 of 16
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`TYSON & MENDES, LLP
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`38.
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`The Private Company Directors and Officers Liability Coverage Section
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`Insuring Agreement (“D&O Coverage Section”) in the Primary Policy provides insurance as
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`follows:
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`The Company will pay on behalf of:
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`***
`C. the Insured Organization, Loss for Wrongful Acts,
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`resulting from any Claim first made during the Policy Period,
`or if exercised, during the Extended Reporting Period or Run-
`Off Extended Reporting Period.
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`(Primary Policy, D&O Coverage Section § I, Insuring Agreement (C).)
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`39.
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`The Primary Policy defines the term “Claim,” in relevant part, as “any civil
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`proceeding commenced by service of a complaint or similar pleading . . . against an Insured for
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`a Wrongful Act, provided that Claim does not include any labor or grievance arbitration or
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`other proceeding pursuant to a collective bargaining agreement.” (Primary Policy, D&O
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`Coverage Section § III, Definition (A).)
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`40.
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`The term “Wrongful Act” is defined, in relevant part, as “any actual or alleged
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`act, error, omission, misstatement, misleading statement or breach of duty or neglect by, or any
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`matter asserted against, the Insured Organization.” (Primary Policy, § III, Definition (M).)
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`41.
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`Pursuant to the Terms and Conditions of the Primary Policy:
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`All Claims . . . for Related Wrongful Acts will be considered
`as a single Claim . . . for purposes of this Liability Policy. All
`Claims . . . will be deemed to have been made at the time the
`first of such Claims . . . for Related Wrongful Acts was made
`whether prior to or during the Policy Period . . .
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`(Primary Policy, Terms and Conditions § III, Condition (H).)
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`42.
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`The Primary Policy defines a “Related Wrongful Act” as “all Wrongful Acts
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`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 11 of 16
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`that have as a common nexus, or are causally connected by reason of, any fact, circumstance,
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`situation, event or decision.” (Primary Policy, Terms and Conditions § II, Definition (X).)
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`43.
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`The D&O Policy defines “Loss” as:
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`Defense Expenses and money which an Insured is legally
`obligated to pay as a result of a Claim, including settlements,
`judgments, back and front pay, compensatory damages, punitive
`or exemplary damages or the multiple portion of any multiplied
`damage award if insurable under the applicable law most
`favorable to the insurability of punitive, exemplary, or
`multiplied damages, prejudgment and postjudgment interest,
`and legal fees and expenses awarded pursuant to a court order
`or judgment. Loss does not include:
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`1. civil or criminal fines, sanctions, liquidated damages other
`than
`liquidated damages awarded under
`the Age
`Discrimination in Employment Act or the Equal Pay Act,
`payroll or other taxes, or damages, penalties or types of relief
`deemed uninsurable under applicable law; or
`2. any amount allocated to non-covered loss pursuant to
`Section III. CONDITIONS. P. ALLOCATION of the
`Liability Coverage Terms and Conditions.
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`(Primary Policy, D&O Coverage Section § II, Definition (G).)
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`44.
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`Insurance afforded by the D&O Coverage Section of the Primary Policy is
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`subject to the following exclusion: “The Company will not be liable for Loss for any Claim
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`based upon or arising out of the performance of or failure to perform any Managed Care
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`Activity” (the “Managed Care Activity Exclusion.”) (Primary Policy, Endorsement No. PDO-
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`19008 Ed. 06-12.)
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`45.
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`The term “Managed Care Activity,” is defined in the Primary Policy as:
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`[A]ny of the following services or activities performed by or on
`behalf of the Insured for or under any . . . health care plan:
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`1. Provider Selection;
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`2. Utilization Review;
`3. advertising, marketing, selling, enrollment, administration
`or management;
`4. Claims Services;
`5. establishing or maintaining health care provider networks;
`6. reviewing, profiling or tiering quality or costs of, or
`providing quality assurance of, any provider of Medical
`Services;
`7. design or implementation of benefit plans or financial
`incentive plans, including pay for performance programs,
`that compensate providers of Medical Services;
`8. Disease Management;
`9. Health Care Plan Consulting;
`10. risk management services to any provider of Medical
`Services;
`11. Wellness Services;
`12. development or implementation of clinical guidelines,
`practice parameters or protocols; or
`13. triage for payment of Medical Services.
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`(Primary Policy, Endorsement No. PDO-19008 Ed. 06-12.)
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`46.
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`Further, Exclusion (B)(1) of the D&O Coverage Section provides that the
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`Primary Policy shall not cover any Loss, other than Defense Expenses, for any Claim based on
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`or arising out of any Insured:
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`a. committing any intentionally dishonest or fraudulent act or
`omission;
`b. committing any willful violation of any statute, rule, or law;
`or
`c. gaining any profit, remuneration or advantage to which such
`Insured was not legally entitled;
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`provided that this exclusion will not apply unless a judgment or
`other final adjudication in the underlying action establishes that
`such Insured committed such intentionally dishonest or
`fraudulent act or omission, or willful violation of any statute,
`rule or law, or gained such profit, remuneration or advantage to
`which such Insured was not legally entitled.
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`(Primary Policy, D&O Coverage Section § III, Exclusion (B)(1), as amended by Endorsement
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`LIA-7335.)
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`The Parties’ Dispute
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`47.
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`In July 2013, when the consolidated complaints in the MDL Action were filed,
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`BCBS-AZ provided notice to its insurers, including Allied World, requesting coverage under
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`managed care errors and omissions liability policies, as well as under the D&O policies issued
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`by Travelers and Allied World.
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`48. By letter dated April 14, 2014, Allied World noted that all claims submitted for
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`Subscriber and Provider lawsuits consolidated in the MDL Action were being handled as a
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`single claim, and reserved its rights given that coverage under the Excess Policy only attaches if
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`all of the underlying insurance is exhausted by payment of covered losses. A copy of Allied
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`World’s April 14, 2014 letter, is attached hereto as Exhibit 8.
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`49.
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`In a letter dated August 27, 2019, after three Federal courts held that the MDL
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`Action is related to the Love litigation, Allied World denied coverage for the MDL Action under
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`the Excess Policy due to the applicability of the Managed Care Activity Exclusion. A copy of
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`Allied World’s August 27, 2019 letter, is attached hereto as Exhibit 9.
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`50. Upon information and belief, the managed care activities alleged in the MDL
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`Action are covered under the terms and conditions of the managed care errors and omissions
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`liability policies issued by other insurers.
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`51.
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`In addition, in its August 27, 2019 correspondence, Allied World notified BCBS-
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`AZ that the Love litigation and the MDL Action constitute Claims for Related Wrongful Acts
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`and, as such, would be deemed a single Claim made prior to the Policy Period. Allied World
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`specifically reserved its rights with respect to all exclusions, conditions and terms of the Excess
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`Policy.
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`52.
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`There is a bona fide present dispute between Allied World and BCBS-AZ
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`regarding whether Allied World’s Excess Policy provides coverage to BCBS-AZ for the MDL
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`Action.
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`53. Allied World is entitled to a declaratory judgment construing the Excess Policy
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`issued to BCBS-AZ, resolving the dispute between the parties, and declaring that Allied World
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`has no liability to BCBS-AZ for any claims, losses, or other damages or liabilities asserted by
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`claimants in the MDL Action under the Excess Policy.
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`COUNT I
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`Declaration of No Coverage under Excess Policy
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`54. Allied World hereby incorporates by reference and re-alleges, as if fully stated
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`herein, each and every allegation of Paragraphs 1 through 53 of this Complaint.
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`55.
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`There is no coverage for the MDL Action and the cases consolidated therein
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`under the Excess Policy for the following reasons:
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`(a)
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`The MDL Action alleges acts done by BCBS-AZ in the performance
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`of Managed Care Activities. (Primary Policy, Endorsement No.
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`PDO-19008 Ed. 06-12);
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`(b)
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`The MDL Action and the Love litigation are Claims for Related
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`Wrongful Acts, which are considered a single Claim deemed made
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`prior to the Policy Period. (Primary Policy, Terms and Conditions §
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`III, Condition (H));
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`(c)
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`plaintiffs in the MDL Action seek relief, and any settlement or
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`judgment in the MDL Action would grant relief, that does not
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`constitute Loss and/or is uninsurable as a matter of law. (Primary
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`Policy, D&O Coverage Section § II, Definition (G)); and
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`(d)
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`the Claim is not covered under the Policy and Allied World has no
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`obligation to pay any amount under the Policy.
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`56. Allied World is entitled to a declaratory judgment in its favor, stating that it has
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`no liability under the Excess Policy issued to BCBS-AZ for any loss or other damage of any
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`kind as alleged in the MDL Action (or the separate actions consolidated therein) because the
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`MDL Action alleges acts done by BCBS-AZ in the performance of Managed Care Activities,
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`the Claim alleges Related Wrongful Acts to the Love litigation, first made prior to the
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`inception of the Excess Policy, and because the Claim is excluded under Exclusion (B)(1).
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`Moreover, Allied World has no obligation to pay any amounts under the Excess Policy because
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`the relief sought by the plaintiffs in the MDL Action does not constitute Loss, is uninsurable as a
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`matter of law, or is otherwise not covered under the Excess Policy.
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`WHEREFORE, Allied World prays that the Court declare the rights of the parties and
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`declare that Allied World has no liability to BCBS-AZ under the Excess Policy for any Loss,
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`including Defense Expenses, that are the subject of the MDL Action (or the separate actions
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`consolidated therein) and for such other and further relief as the Court may deem just and
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`proper.
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`DATED this 28th day of May, 2021.
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`TYSON & MENDES, LLP
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`By: /s/ Lynn M. Allen
`Lynn M. Allen
`Attorneys for Plaintiff
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