Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 1 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 1 of 14
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`EXHIBIT A‐4 
`
`EXHIBIT A-4
`
`

`

`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 2 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 2 of 14
`
`E-FILED
`
`41'11'2021 3:09 PM
`
`Clerk of Court
`Superior Court of CA.
`County '5’“ Santa 0'“
`2103881551.
`Reviewed By. Y. Chavez
`
`(SBNll3755)
`(SBN 113472}
`(SBN 265467)
`
`LAw OFFICES OF STEPHENSON,
`ACQUISTO a COLMAN, INC.
`JOY STEPHENSON-LAWS, ESQ.
`
`RICHARD A. LOVICH, ESQ.
`SHADI SHAYAN
`303 N. Glenoaks Blvd., Suite 700
`
`Burbank, CA 91502
`
`Telephone:
`Facsimile:
`
`(818) 559-4477
`(818) 559-5484
`
`Attorneys for Plaintiff
`STANFORD HEALTH CARE
`
`SUPERIOR COURT OF CALIFORNIA
`
`FOR THE COUNTY OF SANTA CLARA
`
`UNLIMITED JURISDICTION
`
`STANFORD HEALTH CARE, a
`
`Case No.:
`
`21CV38‘I561
`
`COMPLAINT FOR DAMAGES FOR:
`
`1. BREACH OF IMPLIED-IN—
`FACT CONTRACT; and,
`T
`T
`T
`2- QUANTUM MERLE
`
`California nonprofit corporation,
`
`Plaintiff,
`
`VS.
`
`BLUE CROSS AND BLUE SHIELD
`OF NORTH CAROLINA, a North
`Carolina Corporation, and DOES 1
`THROUGH 25, INCLUSIVE,
`
`Defendants.
`
`
`
`
`
`_ l _
`
`COMPLAINT FOR DAMAGES FOR:[|] BREACH OF
`IMPLIED-IN-FACT CONTRACT; and [2‘] QUAA-TUM‘
`MERUJ'T.
`
`\DDOHJGNU'I-b-DJN
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`

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`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 3 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 3 of 14
`
`PARTIES
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`1.
`
`Plaintiff Stanford Health Care ("STANFORD") is a nonprofit
`
`corporation organized and existing pursuant to the laws ofthe State of California.
`
`STANFORD has its principal place of business in the City of Stanford, County of
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`Santa Clara, State of California. STANFORD renders medically necessary care to
`
`patients.
`
`2.
`
`Defendant Blue Cross and Blue Shield of North Carolina
`
`(“BCBS") is a North Carolina corporation and is organized and existing pursuant
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`to the laws ofthe United States of America, specifically 26 U.S.C. § 501(c)(9).
`
`BCBS of North Carolina has its principal place of business in the City of Durham,
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`County of Durham, State of North Carolina. Blue Cross and Blue Shield ofNorth
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`Carolina is health plan providing health care benefits to its members.
`
`3.
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`STANFORD is unaware ofthe true names and capacities,
`
`whether corporate, associate, individual, partnership or otherwise of defendant
`
`Does 1 through 25, inclusive, and therefore sues such defendant by such fictitious
`
`names. STANFORD will seek leave of the Court to amend this complaint to alleg
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`their true names and capacities when ascertained.
`
`4.
`
`BCBS and Does 1 through 25 shall be collectively referred to as
`
`“BCBS" and “Defendant."
`
`5.
`
`Defendant, and each of them, at all relevant times, have
`
`transacted business in the State of California. The violations alleged within this
`
`complaint have been and are being carried out in the State of California.
`
`
`
`_ 2 _
`
`COMPLAINT FOR DAMAGES FOR:[L] BREACH OF
`IMPLIED-IN-FACT CONTRACT; and [2‘] QUAA-TUi'Id‘
`MERUJ'I
`
`

`

`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 4 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 4 of 14
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`woouowmgmw
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`6.
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`At all relevant times each of the defendant, including the
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`defendant named "Doe," was and is the agent, employee, employer, joint venturer,
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`representative, alter ego, subsidiary andfor partner of one or more of the other
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`defendant, and was, in performing the acts complained of herein, acting within the
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`scope of such agency, employment, joint venture, or partnership authority andfor is
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`in some other way responsible for the acts of one or more of the other defendant.
`
`COMMON FACTUAL BACKGROUND
`
`’1'".
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`STANFORD is informed and believes and thereon alleges that
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`at all relevant times the patients identified on the spreadsheet‘ attached as Exhibit
`
`A to this complaint (and which is incorporated herein by this reference as though
`
`set forth in full} (the “Patients") were members of a health plan sponsored,
`
`administered andfor financed by Defendant.
`
`8.
`
`At all relevant times, STANFORD entered into an agreement
`
`with Anthem Blue Cross (“Blue Cross of California"), as a provider ofmedically
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`necessary care for the benefit of all members, enrollees and/or beneficiaries of
`
`health plans that were or would be registered with Blue Cross as Payer, such as
`
`Defendant (the “Blue Cross Agreement"). Thus, under the Blue Cross Agreement,
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`STANFORD agreed to render medically necessary care to the members, enrollees
`
`andfor beneficiaries of Defendant’s health plan; in exchange, Defendant (being s
`
`Payor} agreed to pay STANFORD the discounted rates negotiated in the Blue
`
`Shield Agreement.
`
`In general, the discounted rates under the Blue Cross
`
`Agreement provide for medically necessary care to be paid at a discount of
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`Stanford Hospital’s usual and customary total billed charges (the “Blue Cross
`
`L Stanford has limited discloSurc of palicnl idcnlificalion pursuanl lo the privaCy provisions ol'lhc Hcallh lnSurancc
`Porlabilily & Accounlabilily Acl [“HIPAA‘"), 42 U_S_C §§ |320d er seq, and the California Conslilulion, art.
`I
`It}
`|_
`
`
`_ 3 _
`
`COMPLAINT FOR DAMAGES FOR:(l] BREACH OF
`IMPLIED-IN-FACT CONTRACT; and [2‘] QL".4A-'TU.-'|.r‘
`11.1'ERU1'I'".
`
`

`

`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 5 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 5 of 14
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`Rates").
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`9.
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`At all relevant times, BCBS had an agreement with Blue Cross
`
`of California so as to gain access to the Blue Cross of California Rates as a Payer.
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`In also agreed that Blue |Cross of California would act as an administrator for
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`BCBS. Thus, BCBS agreed to pay STANFORD for medically necessary care
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`rendered to the members, enrollees and/or beneficiaries of Defendant’s health plan.
`
`10.
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`At all relevant times, agents and/or representatives of
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`Defendant verified that Patients were enrolled in Defendant’s health plan and thus,
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`Defendant was responsible for arranging for delivery of health care services to
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`Patients.
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`1 l.
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`STANFORD is informed and believes and thereon alleges that
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`at all relevant times, Defendant provided, arranged andfor paid for healthcare
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`services for its beneficiaries and/or members, including the Patients.
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`12.
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`During the dates of service as set forth in Exhibit A,
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`STANFORD admitted the Patients into its facility and rendered medically
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`necessary services, supplies and/or equipment to the Patients.
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`13.
`
`BCBS andfor its agent authorized that medical services be
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`rendered to the Patients by STANFORD during the various dates of service as set
`
`forth in Exhibit A.
`
`14.
`
`STANFORD’s usual and customary charges for the medically
`
`necessary services, supplies and/or equipment rendered to the Patients amounted to
`
`$526,645.58.
`
`_ 4 _
`
`COMPLAINT FOR DAMAGES FOR:[|] BREACH OF
`IMPLIED-IN-FACT CONTRACT; and [2‘] QUAA-TUr'Irr‘
`MERUJ'I
`
`

`

`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 6 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 6 of 14
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`15.
`
`STANFORD timely and properly billed Defendant and/or its
`
`agent for the medically necessary services, supplies andfor equipment it rendered
`
`to the Patients for payment by Defendants.
`
`16.
`
`Rather than properly paying STANFORD for the medically
`
`necessary services, supplies andfor equipment STANFORD rendered to the
`
`Patients, Defendant failed to properly pay, paying only $16,608.43.
`
`17.
`
`As a result of Defendant’s refusal to properly pay STANFORD
`
`for the medically necessary services, supplies and/or equipment STANFORD
`
`rendered to the Patients, STANFORD suffered damages in the amount to be
`
`proven at trial but not less than the sum of $510,037.15, exclusive of interest,
`
`which represents STANFORD’s usual and customary total billed charges less the
`
`previously received payments.
`
`FIRST CAUSE OF ACTION
`
`(Breach of Implied-In-Fact Contract)
`
`(Against Defendant, and Does 1 through 25)
`
`18.
`
`STANFORD incorporates by reference and re-alleges
`
`paragraphs 1 through 17 here as though set forth in full.
`
`19.
`
`As is custom and practice in the health care industry,
`
`sometimes hospitals and health plans form contracts through their conduct even
`
`though they do not exchange express promises, contracts under which a hospital
`
`agrees to render medically necessary services, including emergency services,
`
`supplies and/or equipment to a member of a health plan; and in return, the health
`
`_ 5 _
`
`COMPLAINT FOR DAMAGES FOR:[1] BREACH OF
`IMPLIED-IN-FACT CONTRACT; and [2‘] QUrL-VTL’1'LJI
`MERUJ'T.
`
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`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 7 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 7 of 14
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`plan agrees to pay for such health care at the hospital's usual and customary
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`charges in place at the time of service. Such implied-in-fact contracts can arise
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`from a variety of manifested conduct which includes, among other things, when a
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`hospital calls up the health plan: (a) to ask for authorization of care for a particular
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`member of that health plan and the plan does not deny andfor does not coordinate
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`the transfer of its members, (b) to provide concurrent review during the hospital
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`stay and the plan does not deny and/or does not coordinate the transfer of its
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`members, or (c) when a hospital renders medical care to a health plan's members in
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`an emergency situation.
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`20.
`
`Prior to the treatment rendered by STANFORD to the
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`Patients, through custom and practice, STANFORD and BCBS impliedly agreed
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`and understood that STANFORD would render medically necessary services,
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`including emergency services, supplies andfor equipment to BCBS members,
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`submit its claims for such services to BCBS, and that BCBS would pay
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`STANFORD at the Blue Cross Rates.
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`21.
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`At all relevant time, by its words and/or conduct, BCBS
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`requested that STANFORD provides the Patients set forth in Exhibit A with
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`medically necessary services, including emergency services, supplies andfor
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`equipment. In other words, BCBS, andfor its agents, acknowledged the need for
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`the medically necessary services, including emergency services, for the Patients
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`and requested that STANFORD provide medically necessary services, including
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`emergency services, supplies and/or equipment to the Patients by authorizing and
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`not denying and/or not coordinating the transfer ofits members to different
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`hospitals. By such conduct, it was understood between STANFORD and BCBS
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`that, in exchange for STANFORD providing medically necessary services,
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`including emergency services, supplies andfor equipment to the Patients, BCBS
`
`_ 6 _
`
`COMPLAINT FOR DAMAGES FOR:[l] BREACH OF
`IMPLIED-IN-FACT CONTRACT; and [2‘] QL".4A-'TU.-'|.r‘
`11.1'ERU1'I'".
`
`

`

`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 8 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 8 of 14
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`would pay STANFORD at the Blue Cross Rates.
`
`22.
`
`At no time did BCBS instruct STANFORD to stop the
`
`medical services or coordinate with UABT to transfer the Patients to another
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`facility.
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`23.
`
`At all relevant time, STANFORD and BCBS had entered into
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`an implied-in-fact contract as demonstrated by custom and practice, as well as, the
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`actions and conduct of BCBS.
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`24.
`
`STANFORD performed all conditions required on its part to be
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`performed in accordance with the terms and conditions of that implied-in-fact
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`contract.
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`25.
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`BCBS breached that implied-in-fact contract by not paying
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`STANFORD according to the Blue Cross Rates in the amount due of $191,245.72,
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`for the medically necessary services, including emergency services, supplies and/o
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`equipment rendered to the Patients.
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`26.
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`As a result of BCBS breach of the implied contract,
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`STANFORD suffered damages in an amount to be proven at trial but not less than
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`the sum of$191,245.72, exclusive of interest.
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`SECOND CAUSE OF ACTION
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`(Quantum 1Mertrir)
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`(Against Defendant, and Does 1 through 25)
`
`
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`27. STANFORD incorporates by reference and re-alleges
`
`_ 7 _
`
`COMPLAINT FOR DAMAGES FOR:[l] BREACH OF
`IMPLIED-IN-FACT CONTRACT; and [2‘] QUAA-TUi'Ia‘
`MERUJ'I
`
`

`

`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 9 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 9 of 14
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`paragraphs 1 through 26 here as though set forth in full.
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`28.
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`Based upon Defendant” agent's representations and
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`authorization for medical treatments and based on the custom and practice of the
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`health care industty, which STANFORD reasonably relied, STANFORD rendered
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`medically necessary care to the Patients identified in Exhibit A.
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`29.
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`Because the Defendant not only confirmed coverage, but also
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`the treatment was deemed authorized, such conduct is tantamount to a request by
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`Defendant to confer the benefit oftreatment provided by STANFORD to Patients.
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`30.
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`Acting pursuant to Defendant’ implied and/or express request,
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`STANFORD provided Patients with medically necessary services, supplies andfor
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`equipment.
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`31.
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`The aforementioned assurances and representations by
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`Defendant, obstructed STANFORD from pursuing other avenues of reimbursemen
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`before rendering treatment to Defendant health plan’s Patients.
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`32.
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`As a member of the Defendant health plan, who pays premiums
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`for such medical coverage, Patients benefited from the medically necessary
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`services rendered to it by STANFORD. Defendant benefited, as well as its
`
`member, when Patients received the medically necessary care and treatment he
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`expected as a member of the Defendant health plan.
`
`33.
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`STANFORD requested payment from Defendant for its usual
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`and customary value of $526,645.58 for rendering medically necessary care to
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`Patients, but Defendant failed to pay that amount.
`
`_ 8 _
`
`COMPLAINT FOR DAMAGES FOR:[L] BREACH OF
`IMPLIED-IN-FACT CONTRACT; and [2‘] QUAA-TUi'Id‘
`MERUJ'I
`
`

`

`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 10 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 10 of 14
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`34.
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`As a direct and proximate result ofthe aforementioned
`
`misrepresentations by Defendant, STANFORD was induced to render medical care
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`and has suffered substantial detrimental damages in the amount to be proven at
`
`trial but not less than the sum of $510,037.15, exclusive of interest, which
`
`represents STANFORD’s usual and customary total billed charges less the
`
`previously received payments.
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`PRAYER FOR RELIEF
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`WHEREFORE, STANFORD prays forjudgment as follows:
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`For the First Cause of Action stated herein:
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`1.
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`for the principal sum of $191,245.72;
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`2.
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`for interest on such principal sum at the rate of 15% per annum,
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`pursuant to Cal. Health & Safety Code § 1371; or, in the altenrative, for interest on
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`such principal sum at the rate of 10% per annum, pursuant to Cal. Civ. Code §
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`3289;
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`For the Second Cause of Action stated herein:
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`3.
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`for the principal sum of $510,037.15;
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`4.
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`for interest on such principal sum at the rate of 15% per annum,
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`pursuant to Cal. Health & Safety Code § 1371; or, in the alternative, for interest on
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`such principal sum at the rate of 10% per annum, pursuant to Cal. Civ. Code §
`
`_ 9 _
`
`COMPLAINT FOR DAMAGES FOR:[|] BREACH OF
`1M PLIED-IN-FACT CONTRACT; and [2‘] QUAA-TU1'P1‘
`MERUJ'T.
`
`

`

`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 11 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 11 of 14
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`3289;
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`For All Causes of Action stated herein:
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`5.
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`for all costs of suit incurred herein; and,
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`6.
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`for such other and further relief as the Court deemsjust and
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`proper.
`
`Dated: April 1, 2021
`
`LAW OFFICES OF STEPHENSON,
`
`ACQUISTO & COLMAN, INC.
`
`Zs/ Shae? Shayan
`
`SHADI SHAYAN, ESQ.
`
`Attorneys for
`STANFORD HEALTH CENTER
`
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`_ 10 _ COMPLAINT FOR DAMAGES FOR:[|] BREACH OF
`IMPLIED-IN-FACT CONTRACT; and [2‘] QUAA-TUr'Irf
`MERUJI
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`

`

`21CV381561
`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 12 of 14
`Santa Clara – Civil
`
`
`
`R. Nguyen
`
`Electronically Filed
`
`by Superior Court of CA,
`County of Santa Clara,
`on 5/10/2021 4:44 PM
`Reviewed By: R. Nguyen
`Case #21CV381561
`Envelope: 6413810
`
`LAW OFFICES OF STEPHENSON,
`ACQUISTO & COLMAN, INC.
`JOY STEPHENSON-LAWS, ESQ.
`
`(SBN 113755)
`(SBN 113472)
`RICHARD A. LOVICH, ESQ.
`SHADI SHAYAN (SBN 265467)
`303 N. Glenoaks Blvd., Suite 700
`Burbank, CA 91502
`
`Telephone: (818) 559-4477
`Facsimile:
`(818) 559-5484
`
`Attorneys for Plaintiff
`STANFORD HEALTH CARE
`
`SUPERIOR COURT OF CALIFORNIA
`
`FOR THE COUNTY OF SANTA CLARA
`
`UNLIMITED JURISDICTION
`
`STANFORD HEALTH CARE, a
`California nonprofit corporation,
`
`21CV381561
`Case No.:
`
`
`EXHIBIT A TO COMPLAINT
`
`Plaintiff,
`
`vs.
`
`
`
`BLUE CROSS AND BLUE SHIELD
`OF NORTH CAROLINA, a North
`Carolina Corporation, and DOES 1
`THROUGH 25, INCLUSIVE,
`
`Defendants.
`
`
`
`1
`
`2
`
`3
`
`4
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`5
`
`6
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`7
`
`8
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`9
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`10
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`11
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`12
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`- 1 - EXHIBIT A TO COMPLAINT
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`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 13 of 14
`Case 5:21-cv-04598—VKD Document 1-4 Filed 06/15/21 Page 13 of 14
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`EXHIBIT A
`EXHIBIT A
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`Case 5:21-cv-04598-VKD Document 1-4 Filed 06/15/21 Page 14 of 14
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`STANFORD HEALTH CARE V. BLUE CROSS BLUE SHIELD OF NORTH CAROLINA
`
`FC 27731
`No. File Number Admit Date Discharge
`
`Patient ID
`
`Total Charges
`
`Expected
`
`Total Paid Underpaid
`
`000064441331
`000066828449
`000064056644
`000066563631
`000066111368
`000066111370
`000066111372
`000066111375
`000066111376
`10 000066111387
`11 000066042686
`12 000066111363
`13 000066111364
`14 000066111399
`15 000066111401
`
`3
`
`2
`
`1
`
`9
`
`8
`
`7
`
`6
`
`5
`
`4
`
`4/15/2019
`6/10/2020
`3/7/2019
`2/9/2020
`12/16/2019
`12/18/2019
`12/19/2019
`12/23/2019
`12/24/2019
`1/8/2020
`12/9/2019
`12/10/2019
`12/11/2019
`1/17/2020
`1/22/2020
`
`Date
`
`4/15/2019
`6/12/2020
`3/7/2019
`2/9/2020
`12/16/2019
`12/18/2019
`12/19/2019
`12/23/2019
`12/24/2019
`1/8/2020
`12/9/2019
`12/10/2019
`12/11/2019
`1/17/2020
`1/22/2020
`
`CGQW1729607901
`MNUW1413046904
`YPYW1242919001
`YPS10288323603
`CRXW1718728801
`CRXW1718728801
`CRXW1718728801
`CRXW1718728801
`CRXW1718728801
`CRXW1718728801
`CRXW1718728801
`CRXW1718728801
`CRXW1718728801
`CRXW17187288
`CRXW17187288
`
`$19,846.50
`$297,085.08
`$25,210.00
`$47,708.00
`$12,436.00
`$12,436.00
`$12,436.00
`$12,436.00
`$12,436.00
`$12,436.00
`$12,436.00
`$12,436.00
`$12,436.00
`$12,436.00
`$12,436.00
`$526,645.58
`
`$11,728.93
`$57,138.74
`$25,210.00
`$33,901.31
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$207,854.16
`
`$0.00
`$0.00
`$0.00
`$16,608.43
`$0.00
`$0.00
`$0.00
`$0.00
`$0.00
`$0.00
`$0.00
`$0.00
`$0.00
`$0.00
`$0.00
`$16,608.43
`
`$11,728.93
`$57,138.74
`$25,210.00
`$17,292.88
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.38
`$7,261.37
`$191,245.72
`
`