Case 3:21-cv-01172-VAB Document 1-1 Filed 09/01/21 Page 1 of 20
`Case 3:21-cv-01172-VAB Document1-1 Filed 09/01/21 Page 1 of 20
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`EXHIBIT A
`EXHIBIT A
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`

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`RETURN DATE: August 174 2021
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`NORTHEAST EMERGENCY MEDICINE
`SPECIALISTS, LLC,
`
`Plaintiff,
`
`Vs.
`
`: SUPERIOR COURT
`: JUDICIAL DISTRICT OF NEW
`: NEW HAVEN
`
`: AT NEW HAVEN
`
`HARVARD PILGRIM HEALTH CARE OF
`CONNECTICUT, INC.,and HEALTH PLAN
`HOLDINGS, INC. n/k/a POINT32HEALTH, Inc., :
`
`Defendants.
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`COMPLAINT
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`Plaintiff Northeast Emergency Medicine Specialists, LLC ("Plaintiff Doctors") by and through
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`undersigned counsel, as and for its Complaint against Defendants Harvard Pilgrim Health Care of
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`Connecticut, Inc. and Health Plan Holdings, Inc. k/n/a Point32Health, Inc. (collectively the "Insurance
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`Company"), alleges as follows:
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`PARTIES
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`1.
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`Plaintiff Northeast Emergency Medicine Specialists, LLC is a Connecticut limited
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`liability company that staffs the emergency departments at Windham Hospital, Johnson Memorial
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`Hospital, and the Hospital of Central Connecticut, Bradley Memorial Campus (collectively the
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`"Hospital") with emergency medicine physicians and advance practice providers. The plaintiff also
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`has a place of business in New Haven, Connecticut.
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`2.
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`Defendant Harvard Pilgrim Health Care of Connecticut, Inc. is a corporation organized
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`under the laws of the State of Connecticut. Upon information and belief, its principal place of
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`business in Connecticut is 185 Asylum Street, Hartford, Connecticut.
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`3.
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`Upon information and belief, Harvard Pilgrim Health Care of Connecticut, Inc. merged
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`with Health Plan Holdings, Inc. and the merged entity is about to be or has been renamed Point32Health,
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`Inc. Health Plan Holdings, Inc. n/k/a Point32Health, Inc.is located at 705 Mt. Auburn Street in
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`Watertown Massachusetts.
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`4.
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`The Insurance Company provides health insurance to Connecticut residents.
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`BACKGROUND
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`5.
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`Plaintiff Doctors provide emergency care to tens of thousands of Connecticut and
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`American citizens each year. Unlike most physicians, who can choose the patients they treat, these
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`doctors cannot. Under compulsion of federal law (The Emergency Medical Treatment and Labor
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`Act, 42 U.S.C. § 1395dd ("EMTALA")), Plaintiff Doctors are obligated to treat all patients who
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`present to their emergency departments. See also, Conn. Agency Regs., § 19-13-D3(j).
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`6.
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`Plaintiff Doctors provide high-quality emergency services, every day and night, on
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`every weekend, on Christmas and other holidays, during long shifts, and under stressful conditions.
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`7.
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`Patients come to a hospital's emergency department because they need immediate
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`help to treat an emergent medical condition. Patients put their lives and their trust in the hands of
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`Plaintiff Doctors.
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`8.
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`In recognition of the nature and critical importance of these services, and to protect
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`patients from surprise bills, the legislature enacted a surprise billing law that creates a legal duty
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`independent of ERISA and ERISA plans, and that law compels the Insurance Company to pay
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`Plaintiff Doctors the amount specified by statute (for the care provided, the greatest of (i) the in
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`network fee; (2) the usual, customary and reasonable rate as set forth in the Fair Health database; or
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`(3) the Medicare rate).' This portion of the statute only applies to emergency department services
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`where there is no contractually agreed upon rate for such services. See Conn. Gen. Stat. Ann. § 38a-
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`In circumstances applicable to this case, the FAIR Health database has the highest rate of the three specified in the
`statute for the Current Procedural Terminology ("CPT") codes at issue.
`2
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`477aa (the "Surprise Billing Law"). The Insurance Company violated the Surprise Billing Law and
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`illegally failed to pay Plaintiff Doctors.
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`9.
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`Similarly, the Patient Protection and Affordable Care Act requires group health plans
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`and managed care companies that provide or cover benefits with respect to services in an emergency
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`department of a hospital, to cover all emergency services without the need for prior authorization,
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`without regard to the provider's status as an out-of-network provider, and in a manner that ensures
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`that the patient's cost-sharing requirement is the same requirement that would apply if such services
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`were provided in-network. See 42 U. S .0 . § 300gg-19a(b)(1).
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`10.
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`Typically, physician groups enter into provider agreements with insurers that specify
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`the amount the insurer is supposed to pay the provider for each CPT code billed. Physician services
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`are summarized using CPT codes for billing purposes. There are seven common CPT codes for
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`emergency department care, 99281-99285 and 99291 and 99292 (critical care). In addition, there are
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`observation codes for observation status and codes for procedures performed in the emergency
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`department.
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`11.
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`Generally, when a physician group provides medical services to a patient, and the
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`physician group has signed a provider contract with the patient's insurer or an affiliate, the services
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`are considered in-network and are paid by the insurer or patient (if there is a deductible or co-
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`insurance) at the contracted rate. Conversely, when there is no applicable provider agreement and
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`therefore no contracted rate for the applicable CPT code(s), the medical services are out of network.
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`12. While Plaintiff Doctors are under contract, directly or indirectly, with most payors,
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`including, for example, Anthem, United, Cigna, Aetna (either directly or through Multiplan), they have
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`elected not to participate with the Insurance Company. From Plaintiff Doctors' perspective, the
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`Insurance Company offered to pay Plaintiff Doctors below market rates and its subscribers have
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`comparatively high deductibles. Many patients do not pay their deductibles and they can be difficult,
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`even costly, to try to collect. Plaintiff Doctors are unable to collect a substantial percentage of unpaid
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`deductibles. As a result of these problems, Plaintiff Doctors elected not to participate in the Insurance
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`Company's network of healthcare providers.
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`13.
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`One purpose of the Surprise Billing Law is to protect patients from the cost of
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`uninsured care. Another purpose of the statute is to protect emergency medicine providers. For the
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`reasons described below, absent the Surprise Billing Law, they would not necessarily be paid
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`anything by the Insurance Company for the mandatory and lifesaving services Plaintiff Doctors
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`provide.
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`The Treatment and Billing Process
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`14.
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`Every day and night, Plaintiff Doctors provide emergency medical services at the
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`Hospital.
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`15.
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`Plaintiff Doctors provide their patients with a wide variety of emergency medical
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`services (in many instances, life-saving services), including treatment of conditions ranging from
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`cardiovascular emergencies to unstable multi-system trauma, stroke, diabetic ketoacidosis and
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`shock, perforated viscus, and obstetrical emergencies.
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`16. At great risk to themselves and their families, Plaintiff Doctors treated COVID-19
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`patients when little was known about the disease. Their communities rely on Plaintiff Doctors.
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`17. At times, with limited pre-natal care, delivering mothers present, out of the blue, to
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`the Emergency Department, in labor, sometimes in breach presentation. Cases like these are
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`highly dangerous, anxiety producing and are categorically different from the daily work life most
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`people experience. The unpaid claims in this case fit within the broad spectrum of care that
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`Plaintiff Doctors must provide on a moment's notice.
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`18. No matter how busy the Emergency Department can be, there is a regular
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`professional workflow for all patients. Less emergent patients are registered by the Hospital,
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`triaged by a nurse, evaluated and then treated by Plaintiff Doctors. For more emergent patients
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`like those suffering from strokes, heart attacks and unstable trauma, those steps are typically
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`completed once the patient is stabilized.
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`19. When the patient registers, the patient's insurance card and related information are
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`entered into the Hospital's electronic medical record database known as "Epic."
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`20. At the other end of the process, following screening and treatment, Plaintiff Doctor
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`admits the patient to the Hospital, transfers the patient to another hospital, puts the patient in
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`emergency department observation status, or discharges the patient.
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`21.
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`Plaintiff Physicians do not ask their patients for assignments of benefits for their
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`Insurance Company health care policy.
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`22. Typically, ERISA plans are form documents that plan enrollees never read and never
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`even see (other than, potentially, a summary plan description).
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`23.
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`In the past, an out of network provider would obtain an assignment from the patient
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`and then seek compensation from the insurer based on the assignment. The provider would stand in
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`the shoes of the patient and make a claim for payment. Now, insurers use ERISA plan forms that
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`have anti-assignment provisions which make an assignment of benefits ineffective.
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`24. A healthcare provider does not have standing under ERISA's civil enforcement
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`provision; a patient does. Because anti-assignment provisions are now standard in ERISA plans, out-
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`of-network providers had no way to compel insurers to pay them under ERISA.
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`25. This changed when Connecticut passed the Surprise Billing Law because the statue
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`mandates that insurers must pay providers a specified amount, subject to certain requirements. With
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`respect to the Insurance Company, Plaintiff Doctors satisfied those requirements.
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`26. Under the statute, Plaintiff Doctors rendered "emergency services" to the patients at
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`issue. Each of the patients were protected by EMTALA and were provided an EMTALA medical
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`screening examination.
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`27.
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`Plaintiff Doctors' billing company, Gottlieb, LLC ("Gottlieb"), used and continues
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`to use the information contained in Epic to appropriately code the visit with one or more of the
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`CPT codes described above. The Surprise Billing Law provides that, for out of network insurers
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`like the Insurance Company, the insurer "shall reimburse" Plaintiff Doctors "the greatest of the
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`following amounts." (Emphasis added). See Conn. Gen. Stat. § 38a-477aa(b)(3)(A). Of the
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`"following amounts," the usual customary and reasonable rate, as set forth in FAIR Health's
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`"benchmarking database" "specified by the Insurance Commissioner" is always the "greatest" for
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`the few CPT codes billed by Plaintiff Doctors.
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`28. The purpose of the statute is to ensure that emergency physicians are paid for out of
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`network services at a specified rate and to protect patients from costs that exceed what they would
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`pay if the patient was treated at an in-network emergency department.
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`29.
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`The Surprise Billing Law provides that "[n]o health carrier shall impose, for
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`emergency services rendered to an insured by an out-of-network health care provider, a
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`coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the
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`coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such
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`emergency services were rendered by an in-network health care provider." See Conn. Gen. Stat. §
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`3 8a-477aa(b)(2).
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`30.
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`In other words, when a hypothetical patient receives treatment by an out of network
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`emergency department provider, and the in-network rate for this care is $200 and the FAIR Health
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`(UCR) rate is $250, and the patient has a $500 deductible, the patient would owe the emergency
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`physician $200 because of the patient's deductible. The out-of-network insurer would owe the
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`emergency physician $50 because the patient is only required to pay the amount s/he would have
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`paid had she gone to a hospital with in-network providers. The insurer owes the remaining $50.
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`The patient's responsibility is limited to the in-network rate. As a result, the patient would pay the
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`same amount regardless of whether the emergency department provider is in-network or out-of-
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`network with the insurer.
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`31. After the patients listed on Exhibit 12 were treated by Plaintiff Doctors, Gottlieb sent
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`bills to the Insurance Company. The bills complied with accepted practice in all respects and for
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`each of the patients at issue, Gottlieb submitted an appropriate electronic bill to the Insurance
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`Company.
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`32.
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`For each claim listed on Exhibit 1, emergency services were provided to Plaintiff
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`Doctor's patient who was also an Insurance Company subscriber. Because Plaintiff Doctors are out
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`of network with the Insurance Company, all emergency services described in the claims listed on
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`Exhibit 1 were performed by an "out-of-network health care provider."
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`33.
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`The Insurance Company accepted all the claims listed on Exhibit 1 as properly coded
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`emergency medicine claims. Generally, the Insurance Company applied the Surprise Billing Law
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`and used the amounts listed in the FAIR Health database for each applicable CPT code. Having
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`accepted and approved the services and the rate, it correctly listed the appliable amount as the
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`"allowable amount" on that portion of the patient's explanation of benefits ("EOB").
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`34. However, despite the clear language in the statute the Insurance Company failed to
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`pay the difference between the in-network rate and the FAIR Health database rate for each of the
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`claims listed on Exhibit 1. Instead, it shifted the cost over to patient and put it in the "You Pay"
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`column. The "You" in "You Pay" is the patient.
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`2 To comply with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and Connecticut's Rules
`of Court, a blank copy of the claims at issue without protected health information ("PHI") is attached hereto as Exhibit
`1. An unredacted copy will be provided to the Insurance Company's counsel. Plaintiffs counsel will file a motion
`that seeks the right to file Exhibit 1 under seal with the Court.
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`35. The Insurance Company acted and continues to act in bad faith. Upon information
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`and belief, it has sophisticated in house counsel and outside counsel. It is clearly aware of the
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`Surprise Billing Law and follows its requirements except for the portion which directs the Insurance
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`Company to pay emergency medicine providers the difference between the in-network rate and the
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`rate prescribed by the FAIR Health database.
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`36. On Plaintiff Doctor's behalf, Gottlieb appealed many of these EOBs, although there is
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`no such requirement as an out of network provider, but the Insurance Company either did not
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`respond or, after repeated requests for a response, simply denied the appeal. The appeals contained a
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`detailed summary of the Surprise Billing Law and linked the Insurance Company's obligation to pay
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`to specific language in the statute.
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`37.
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`In addition, surprise billing laws have been enacted in multiple states besides
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`Connecticut. In December 2020, a federal surprise billing law was enacted. In each case, one of the
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`purposes of these surprise billing laws was to protect patients from surprise bills, namely the amount
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`due above the in-network rate.
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`38. When the Insurance Company shifted its obligation to the patient, and in effect
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`directed Plaintiff Doctors to ask the patient for these monies, it not only violated the Surprise Billing
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`Law on its own behalf but was pressuring Plaintiff Doctors to violate the Connecticut Unfair Trade
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`Practices Act, Conn. Gen. Stat. § 42-110b et seq. ("CUTPA"). In doing so, the Insurance Company
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`violated CUTPA.
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`39.
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`Conn. Gen. Stat. Ann. § 20-7f(b) states that "[i]t shall be an unfair trade practice in
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`violation of chapter 735a for any health care provider to request payment from an enrollee, other than
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`a coinsurance, copayment, deductible or other out-of-pocket expense, for . . . (2) emergency services
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`covered under a health care plan and rendered by an out-of-network health care provider, or (3) a
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`surprise bill, as defined in section 38a-477aa."
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`40.
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`In other words, any follow up phone call with the patient to collect the unpaid
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`emergency department fees or sending a statement to the patient would potentially violate CUTPA.
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`The Insurance Company knowingly and illegally put Plaintiff Doctors in legal jeopardy.
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`41.
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`Upon information and belief, this conduct was particularly egregious as the Insurance
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`Company blocked Plaintiff Doctors from obtaining payment from the Insurance Company through
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`ERISA's civil enforcement provision by using ERISA plans with anti-assignment provisions.
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`42.
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`As a result of the forgoing, Plaintiff Doctors have not been paid the sums due
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`consistent with Exhibit 1 and they remain due and owing from the Insurance Company.
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`No Complete ERISA Preemption
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`43.
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`For each of the healthcare claims listed on Exhibit 1, the Insurance Company has
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`already determined the claims to be payable pursuant to the terms of the Members' respective health
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`plans and have actually processed the claims for a portion of the payment due from the Insurer and/or
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`patient. Thus, this action involves no dispute over whether the relevant claims are covered by the
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`Members' health benefits. Rather, this action solely involves a dispute over whether the Insurance
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`Company has paid the appropriate rates of reimbursement for the undisputedly covered claims. In
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`addition, there can be no dispute that the Surprise Billing Law regulates insurance and is therefore
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`not subject to complete or conflict preemption under ERISA's savings clause and that it provides a
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`legal duty, independent of ERISA, which obligates the Insurance Company to pay Plaintiff Doctors.
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`44.
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`All conditions precedent to the institution and maintenance of this action have been
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`performed, waived, or otherwise satisfied.
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`Count I. Violation of the Connecticut Unfair Trade Practices Act
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`CAUSES OF ACTION
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`1-44 Plaintiff Doctors re-allege and restate paragraphs 1-44 as if they were fully set forth
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`herein.
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`45.
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`The Insurance Company is and at all relevant times was engaged in the conduct of
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`"trade and commerce" within the meaning of Connecticut General Statutes § 42-110a et seq.
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`("CUTPA") and is and was subject to these statutory provisions.
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`46.
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`Plaintiff Doctors have treated the patients listed on Exhibit 1. The Insurance
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`Company's misconduct is ongoing and with each passing month, there are additional patients
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`beyond those listed on Exhibit 1. For each of these patients, the Insurance Company failed to pay
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`its portion of the amount due to Plaintiff Doctors under the Surprise Billing Law.
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`47.
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`This is a continuing pattern and practice. Upon information and belief, like most
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`large insurers, the Insurance Company uses computers to receive, analyze, process and pay
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`healthcare claims for payment by providers. When this set of payment rules, also called a "rate," is
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`implemented, the Insurance Company "loads" that "rate" into its computer systems so that claims
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`can be processed according to the "rate." This is why the Insurance Company's failure to pay the
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`amount specified by the Surprise Billing Law is, upon information and belief, uniform across
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`hospitals and different parts of the state.
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`48.
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`In other words, the Insurance Company's failure to comply with the Surprise
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`Billing Law, and its delegation of its obligation to pay any charges above the in-network rate, is a
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`general business practice. It has created a specific and ascertainable loss which is described in
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`detail on Exhibit 1 and in the cases subsequent to the last case date on Exhibit 1.
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`49. When it failed to comply with the Surprise Billing Law, as described above, the
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`Insurance Company violated, and continues to violate, CUTPA, by violating the Connecticut
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`Unfair Insurance Practices Act ("CUIPA"), specifically Conn. Gen. Stat. § 38a-816(6)(A), in
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`that the Insurance Company issued false EOBs to the patients listed on Exhibit 1 stating that the
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`patient, not the Insurance Company, was obligated to pay these amounts. The Insurance
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`Company made the same false statements to Plaintiff Doctors through their billing company.
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`As stated above, these false statements and misrepresentations also violated the spirit of Conn.
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`Gen. Stat. Ann. § 20-7f(b), as described above.
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`50.
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`The Insurance Company knew, or alternatively should have known, that the
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`content of the above false statements and misrepresentations were false and inconsistent with
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`Connecticut law.
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`51.
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`Plaintiff Doctors relied on the Insurance Company's oral representations that it
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`would comply with the Surprise Billing Law and they continue to suffer pecuniary harm and
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`ascertainable loss as a result including as set forth in detail in Exhibit 1.
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`52.
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`In addition, or in the alternative, the Insurance Company has violated, and continues
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`to violate, CUTPA, by violating CUIPA, specifically Conn. Gen. Stat. § 38a-816(6)(A), by issuing
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`false EOBs in which the Insurance Company systematically shifts its obligations to pay emergency
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`medicine claims covered by the Surprise Billing Law to its subscribers.
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`53.
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`The Insurance Company generally failed to respond to appeals which explained
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`why its actions were illegal under Connecticut law in violation of Conn. Gen. Stat. § 38a-
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`816(6)(B).
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`54.
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`The forgoing actions also violated Conn. Gen. Stat. § 38a-816(6)(C) in that the
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`Insurance Company failed to implement reasonable procedures and standards to address claims
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`made pursuant to the Surprise Billing Law. Not only did the Insurance Company violate CUIPA
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`when it failed to implement reasonable procedures and standards, but it violated Conn. Gen. Stat. §
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`38a-816(6)(D) when it refused to pay claims without conducting a reasonable review of the claims
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`and the statute. The Insurance Company simply refused to address or confront the plain language
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`of the statute setting forth its obligations or correspondence concerning the same issue.
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`55.
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`As stated above, the Insurance Company acted illegally in violation of Conn. Gen.
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`Stat. § 38a-816(6)(F) when it failed to settle or resolve the claims listed on Exhibit 1 despite the
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`fact that its legal obligations are clear under the Surprise Billing Law.
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`56.
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`The forgoing actions also violated Conn. Gen. Stat. § 38a-816(6)(G) in that Plaintiff
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`Doctors have been compelled to institute litigation to recover amounts due under an insurance
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`policy by offering substantially less than the amounts ultimately recoverable in actions, namely
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`this action, brought by Plaintiff Doctors.
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`57.
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`The Insurance Company failed to comply with Conn. Gen. Stat. § 38a-816(15) in
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`that it failed to timely pay claims described on Exhibit 1 and similar subsequent claims despite the
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`fact that Surprise Billing Law is clear.
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`58. With respect to claims filed in 2020, the Insurance Company failed to comply with
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`Conn. Gen. Stat. § 38a-816(23) in that it imposed a "coinsurance, copayment, deductible or other
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`out-of-pocket expense" beyond what is allowed by statute.
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`59.
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`The Insurance Company's conduct, as set forth above, constitutes an unfair
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`insurance practices in violation of CUIPA, and in turn constitutes a violation of CUTPA. These
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`practices are illegal and offend public policy. They are immoral, unethical, oppressive and/or cause
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`substantial injury to consumers.
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`60.
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`In addition, as alleged herein, the Insurance Company's actions violate CUTPA
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`independent of CUIPA because, among other reasons, the Insurance Company is violating multiple
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`Connecticut laws and is directing Plaintiff Doctors to violate Connecticut law by designating its
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`liability as the patient's (its subscriber's) liability and, in effect, directing Plaintiff Doctors to collect
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`these funds from patients, which is impermissible. As set forth herein, and including the forgoing,
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`the Insurance Company's conduct violates public policy.
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`61.
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`This is particularly true in this case as the Insurance Company is directly violating
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`several statutes as part of its attempt to force its subscribers to pay the Insurance Company's
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`obligations. Plaintiff Doctors are seeking damages, CUTPA damages and attorney's fees as a result
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`of the Insurance Company's bad acts.
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`62.
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`A copy of this Complaint has been/will be mailed to the Attorney General and the
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`Commissioner of Consumer Protection pursuant to Conn. Gen. Stat. § 42-110g(c).
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`Count II. Violation of the Connecticut Surprise Billing Law
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`1-61
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`Plaintiff Doctors re-allege and restate paragraphs 1-61 as if they were fully set forth
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`herein.
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`62. With respect to emergency medicine, the Surprise Billing Law was created to protect
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`patients from out of network charges when the patient receives emergency medicine services.
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`63.
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`In other words, when patients have an emergent medical condition, the patient drives
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`or is taken, in some cases by ambulance, to the closest hospital where s/he is treated by a trained
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`medical staff, like Plaintiff Doctors. The legislature mandated that insurers provide a certain level
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`of coverage in this situation so that the patient can focus on his or her emergent condition regardless
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`of whether the healthcare provider is in network with the patient's health insurer.
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`64.
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`At the same time, the legislature has elected to protect physicians and ensure that they
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`get paid by the patient's insurer at the rate set forth in the Surprise Billing Law. As discussed above,
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`the statute says that "the health carrier shall reimburse such health care provider the greatest of the
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`following amounts . . ."
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`65.
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`As also discussed above, the legislature also enacted Conn. Gen. Stat. Ann. § 20-
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`7f(b) which states that "[i]t shall be an unfair trade practice in violation of chapter 735a for any
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`health care provider to request payment from an enrollee, other than a coinsurance, copayment,
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`deductible or other out-of-pocket expense, for . . . (2) emergency services covered under a health care
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`plan and rendered by an out-of-network health care provider, or (3) a surprise bill, as defined in
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`section 38a-477aa."
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`66.
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`When an insurer fails to pay for a Surprise Bill, the legislature has made it a CUTPA
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`violation for an emergency medicine physician to seek payment from the patient in an amount that is
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`inconsistent with the Surprise Billing Law. See Conn. Gen. Stat. Ann. § 20-7f(b)(3).
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`67.
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`As discussed above, CUTPA prohibits businesses from engaging in unfair and
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`deceptive acts or practices. In addition to a private right of action for a violation of the Surprise
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`Billing Law, the Consumer Protection Commissioner can issue cease and desist orders, order
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`restitution in cases involving less than $10,000, enter into consent agreements, ask the attorney
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`general to seek injunctive relief, and accept voluntary statements of compliance. Courts may issue
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`restraining orders; award actual and punitive damages, costs, and reasonable attorney's fees; and
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`impose civil penalties of up to $5,000 for willful violations and up to $25,000 for a restraining
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`order violation.
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`68.
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`As also discussed above, because of anti-assignment provisions in ERISA plans, an
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`emergency physician has no way to recover the amounts provided under the Surprise Billing Law
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`except for a claim pursuant to the statute or CUTPA.
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`65.
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`The words "shall reimburse" in the Surprise Billing Law demonstrate that the
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`Surprise Billing Law was enacted, in part, for the benefit of emergency medicine physicians. The
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`language not only describes the amount insurers are supposed to pay but also commands them ("shall
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`reimburse") to pay it.
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`66.
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`The "shall reimburse" language demonstrates that the legislature implicitly intended
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`to create a private cause of action for emergency medicine physicians under the statute. For the
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`reasons described above, a private right of action is also consistent with the legislative scheme.
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`67.
`
`As discussed above, the Surprise Billing Law requires the Insurance Company to pay
`
`Plaintiff Doctors for the unpaid claims listed on Exhibit 1 and for claims subsequent to those listed
`
`on Exhibit 1. The Insurance Company failed to do so and illegally attempted to shift its obligations
`
`to its subscribers. Accordingly, Plaintiff Doctors are entitled to a judgment in the amount of the
`
`unpaid medical bills described, in part, on Exhibit 1.
`
`Count III. Declaratory Judgment
`
`1-67. Plaintiff Doctors re-allege and restate paragraphs 1-67 as if they were fully set forth
`
`herein.
`
`68.
`
`Plaintiff Doctors seek a judicial determination that under the Surprise Billing Law,
`
`the Insurance Company "shall reimburse" or pay Plaintiff Doctors for each patient, the greatest of
`
`the three rates listed in the Surprise Billing Law for the applicable CPT code(s) and shall not apply
`
`any co-insurance or deductible up to the amount of the in-network rate. The balance of the
`
`deductible, if any, cannot be applied. Difference Paid to provider
`
`69.
`
`There is an actual bona fide and substantial question in dispute and
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`substantial uncertainty of legal relations that requires resolution.
`
`70.
`
`There is no other forum of proceeding that can provide the Plaintiff Doctors with
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`timely redress.
`
`WHEREFORE, the Plaintiff claims:
`
`(1)
`
`Compensatory damages in the amount of the unpaid medical bills due Plaintiff
`
`under the Surprise Billing Law;
`
`(2)
`
`(3)
`
`(4)
`
`Statutory interest on the unpaid medical bills pursuant to CUIPA;
`
`Treble damages pursuant to CUTPA;
`
`Attorney's fees and costs pursuant to CUTPA;
`
`15
`
`

`

`(5)
`
`A declaratory judgment that under the Surprise Billing Law, the Insurance
`
`Company "shall reimburse" or pay Plaintiff Doctors for the greatest of the three rates listed in the
`
`Surprise Billing Law and shall not apply any co-insurance or deductible above the average in-
`
`network rate; and
`
`(6)
`
`Such other relief as this Court determines to be just and equitable.
`
`16
`
`

`

`THE PLAINTIFF,
`
`NORTHEAST EMERGENC; MEDICIN SPECIALISTS, LLC
`
`By: Simon I. Allentuch
`Simon I. Allentuch, Esq.
`90 Edgewood Way
`New Haven, CT 06515
`Telephone: 203.435.2467
`Facsimile: 860-906-4563
`Juris No. 416908
`sallentuch@nemsed.com
`
`Its Attorney
`
`17
`
`

`

`Case 3:21-cv-01172-VAB Documenti1-1 Filed 09/01/21 Page 19 of 20
`
`EXHIBIT 1
`
`EXHIBIT 1
`
`18
`
`

`

`RETURN DATE: August 112021
`
`X
`
`NORTHEAST EMERGENCY MEDICINE
`SPECIALISTS, LLC,
`
`Plaintiff,
`
`Vs.
`
`: SUPERIOR COURT
`: JUDICIAL DISTRICT OF NEW
`: NEW HAVEN
`
`: AT NEW HAVEN
`
`HARVARD PILGRIM HEALTH CARE OF
`CONNECTICUT, INC.,and HEALTH PLAN
`HOLDINGS, INC. n/k/a POINT32HEALTH, Inc., :
`
`Defendants.
`
`X
`
`STATEMENT OF AMOUNT IN DEMAND
`
`The amount of money damages claimed is greater than Fifteen Thousand Dollars
`
`($15,000.00), exclusive of interest and costs.
`
`NORTH AST EMERGENCY MEDICINE
`SPECI
`ISTS, LLC
`
`By:
`Simon I. Allentuch, Esq.
`90 Edgewood Way
`New Haven, CT 06515
`Telephone: 203.435.2467
`Facsimile: 860-906-4563
`Juris No. 416908
`sallentuch@nemsed.com
`Its Attorney
`
`19
`
`