Filing# 142521137 E-Filed 01/24/2022 02:26:17 PM
`
`IN THE CIRCUIT COURT OF THE 17TH
`JUDICIAL CIRCUIT IN AND FOR
`BROWARD COUNTY, FLORIDA
`
`CASE NO.:
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`DIVISION:
`
`VANGUARD PLASTIC SURGERY, PLLC d/b/a
`VANGUARD AESTHETIC AND PLASTIC
`SURGERY, a Florida limited liabilitycompany,
`
`Plaintiff.
`
`VS.
`
`FLORIDA DEPARTMENT OF MANAGEMENT
`SERVICES, DIVISION OF STATE GROUP
`INSURANCE, a governmental agency,
`
`Defendant.
`
`i
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`COMPLAINT AND DEMAND FOR JURY TRIAL
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`Plaintiff,Vanguard Plastic Surgery,PLLC d/b/a Vanguard Aesthetic & Plastic Surgery,a
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`Florida limited liabilitycompany ("Plaintiff'),sues Defendant, the Florida Department of
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`Management Service,Division of State Group Insurance ("DSGI"), and allegesas follows:
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`Nature ofAction
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`1.
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`This action concerns the unreasonably low rate at which Defendant reimbursed
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`Plaintiff for emergency medical services Plaintiff provided to a patient,J.L. ("Patient"),covered
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`under a group health insurance policyinsured and/or operatedby Defendant.
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`2.
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`Plaintiff provided medically necessary services to Patient consisting of an
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`emergency surgicalprocedurerelatingto a traumatic injuryto Patient's left forearm resultingfrom
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`a laceration with glassand associated pain,inabilityto extend the thumb, and loss of sensation.
`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`
`1
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`*** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 01/24/2022 02:26:16 PM.****
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`

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`The surgicalprocedure included reconstruction of numerous muscles of the forearm (including
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`brachioradialis,extensor pollicisbrevis, extensor pollicislongus,and abductor pollicislongus),
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`adjacenttissue transfer ofthe extensor retinaculum, repairoftwo branches ofthe radial nerve, Z-
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`plastyof skin, debridement of nonviable skin and subcutaneous tissue,and multipleother related
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`procedures.
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`3
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`Plaintiff performed the surgery on Patient with the understanding and expectation
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`that Defendant would reimburse Plaintiff for the services it providedto Patient at rates equalto the
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`fair market or reasonable value of Plaintiff's services. Plaintiff's understandingand expectationin
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`this regardwas based upon the requirementsof Florida law.
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`4.
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`Instead,Defendant wrongfully paid Plaintiff at rates below: (1) the usual and
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`customary providercharges for the services,in violation of Sections 627.662(15),627.64194, and
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`641.513, Florida Statutes,for claims subjectto those sections;and/or (2)the reasonable value of
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`the services in the marketplace requiredunder quantum meruit by the implied-in-factand/or
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`implied-in-law contract between the parties,for claims not subject to Sections 627.662(15),
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`627.64194, and 641.513.
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`5.
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`Plaintiffis obligatedby law to provide emergency services and care to Defendant's
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`members, and Defendant is obligatedby law to cover those services. Under the above-referenced
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`statutes, Florida law strikes a balance concerningemergency services and care providedby non-
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`partic*atingproviders like Plaintiff: Plaintiff must provide emergency services and care to all
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`individuals presentingwith an emergency medical condition,regardlessof insurance coverage;
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`and managed care organizations,like Defendant, must reimburse Plaintiff for providingthat care
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`to its members according to the dictates set forth by Section 641.513(5).
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`2
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`

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`6.
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`Section 641.513(5)imposes a requirementon certain managed care organizations
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`"to ensure that the non-participatingprovidersare adequatelypaid for a service they are required
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`by law to perform." Merkle v. Health Options,940 So. 2d 1190, 1196 (Fla.4th DCA 2006). Section
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`627.64194(4) incorporatesby reference the reimbursement requirements of Section 641.513(5)
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`and appliesthem to claims for both emergency and non-emergency services submitted by non-
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`participatinghospital-basedproviders to insurers operating preferredprovider networks or
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`organizations (commonly known as "PPO/POS"). Section 627.662(15) incorporates by
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`reference the requirementsof 627.64194 and appliesthem to group health insurance policies
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`like the one that provided coverage for the services at issue in this case.
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`7.
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`Florida has a strong publicpolicyof protectingboth patientswho receive medical
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`services in Florida and physicianswho providemedical services in Florida.
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`8
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`The foregoing statutes further Florida's public policy by protectingmembers of
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`insurers from being balance billed for services subjectto that statute, and by protectingnon-
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`partic*atingproviders who provide services subject to that statute from being unfairlyor
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`inadequatelycompensated for services they are legallyrequiredto perform.
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`9-
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`Defendant, as an insurer in the state of Florida,has a duty under Sections 627.662,
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`627.64194, and 641.513 to reimburse Plaintiff at rates that are, at a minimum, equivalentto the
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`"usual and customary provider charges for similar services in the community," which requires
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`payment atfair marketvalue. See Baker Cnty.Med. Servs. v. Aetna Health Mgmt., LLC, 31 So.3d
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`842,845-46 (Fla.1st DCA 2010).
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`10.
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`In this action,Plaintiff is seekingto have Defendant comply with its obligationto
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`pay Plaintiff at rates that represent the usual and customary providerchargesrequiredby Sections
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`627.662, 627.64194, and 641.513 and/or the reasonable value of Plaintiff's services in the
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`3
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`

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`marketplacerequiredunder quantum meruit based on the parties'implied-in-factand/or implied-
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`in-law contracts.
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`11.
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`For the claims at issue in this action,Plaintiffwas a non-participatingproviderwith
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`Defendant and, as a result,did not agree to accept discounted rates from Defendant for its services
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`and did not agree to be bound by Defendant's reimbursement policiesor rate schedules.
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`12.
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`Nevertheless, Defendant has not paid Plaintiff the fair market or reasonable value
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`of its services.
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`13.
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`The impact ofDefendant's underpayment on the claims at issue is considerable and
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`has left a balance due from Defendant exceeding the minimum jurisdictionallimits of this Court.
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`Parties
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`14.
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`Plaintiff is a Florida professionallimited liabilitycompany with its principalplace
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`of business located in Broward County, Florida.
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`15.
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`Defendant is a Florida state agency located in Leon County, Florida. Defendant is
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`a division within the Florida Department of Management Services. It was created pursuant to
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`Section 20.22(2)(h),Florida Statutes,as a governmental unit in the executive branch of the state
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`of Florida.
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`16.
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`Non-party Blue Cross and Blue Shield of Florida,Inc. ("BCBSF") is a Florida for-
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`profitcorporationwith its principaladdress located at 4800 Deerwood Campus Parkway,
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`Jacksonville,FL 32246. Defendant is a health insurer and/or health claims administrator actively
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`engaged in the transaction of health insurance servicingin the state of Florida and providing
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`managed healthcare products and administrative services throughout Florida, including in
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`Broward County, Florida.
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`4
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`

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`Jurisdiction and Venue
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`17.
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`The amount in controversy exceeds the sum of $30,000.00, exclusive of interest,
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`costs, and attorneys'fees.
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`18.
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`Jurisdiction is proper in the state of Florida pursuant to Section 48.193 because
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`Defendant is engaged in substantial and note isolated activitywithin the state of Florida, and
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`further because Defendant contracted to insured Patient,who was located within the state of
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`Florida at the time of contracting.
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`19.
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`Venue is proper in Broward County, Florida,pursuant to Section 47.011, Florida
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`Statutes,because the Plaintiff provided the medical services at issue to Patient in Broward County
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`and because the payments to Plaintiff for those services were due in Broward County, and
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`accordingly,Plaintiff's causes of action accrued in Broward County, Florida.
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`Facts
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`20.
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`Plaintiff,through its physicians,providesmedical services,includingemergency
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`services and care, reconstructive services,and other surgicalservices,to patientsin Broward
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`County, Florida,includingat Plantation General Hospital.
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`21.
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`22.
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`Plaintiff's physiciansare licensed medical doctors practicingin the state ofFlorida.
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`Plaintiff's physiciansare board-certified plasticsurgeons. They perform skin grafts,
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`flapprocedures,microsurgeries,and other surgicalservices that allow for complex repairofhuman
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`tissue after trauma, cancer, and congenitaldefects.
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`23.
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`Upon information and belief,Plaintiff's physicians,who are fellowshiptrained and
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`who specializein microsurgery,are the only plasticsurgeons at Plantation General Hospitalwith
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`those qualifications.
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`5
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`

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`24.
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`Both Florida and federal law obligate Plaintiff's physicians to examine any
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`individual presentingto the emergency departmentand to providetreatment to any individual with
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`an emergency medical condition,regardlessof the individual's insurance coverage or abilityto
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`pay. This legalobligationfurthers Florida's strong publicpolicyof protectingpatientswho need
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`medical services in Florida.
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`25.
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`Defendant providescoverage for healthcare services provided in the state of Florida
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`to members of its health insurance policies.
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`26.
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`In exchange for premiums, fees,and/or other forms of compensation, Defendant
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`agrees to provide reimbursement for healthcare services rendered to members of its health
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`insurance policies.
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`Patient's Health Insurance Policy
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`27.
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`At all material times,Patient was an insured member of the State Employee's PPO
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`Plan, a group health insurance policy insured by Defendant and administered by BCBSF, which
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`policyprovided coverage for services received by Patient and provided in the state of Florida (the
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`"Policy").
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`28.
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`Defendant delivered the Policy or issued the Policy for deliveryin the state of
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`Florida.
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`29.
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`The Policyis a group preferredproviderorganization("PPO") policyas defined in
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`and regulatedby Chapter 627, Florida Statutes.
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`Relevant Statutes
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`30.
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`Section 395.1041 requires hospitalsand other emergency medical services
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`providersto provide emergency services and care to patientsfor any emergency medical conditions
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`from which those patientsmay be sufferingas outlined in section 395.1041(3).
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`6
`
`

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`31.
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`Section 641.513, Florida Statutes,providesas follows:
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`Reimbursement for services pursuant to this section by a providerwho does not
`have a contract with the health maintenance organizationshall be the lesser of:
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`(a) The provider'scharges;
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`(b) The usual and customary provider charges for similar services in the
`community where the services were provided;or
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`(c) The chargemutually agreed to by the health maintenance organizationand the
`providerwithin 60 days of the submittal of the claim.
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`Such reimbursement shall be net of any applicablecopayment authorized pursuant
`to subsection (4).
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`32.
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`Florida courts have interpretedthe phrase "usual and customary providercharges
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`for similar services in the community where the services were provided"under Section 641.513(5)
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`to requirepayment of "fair market value" for the services rendered. Baker Cno'.Med. Servs. v.
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`Aetna Health Mgmt., LLC, 31 So. 3d 842, 845-46 (Fla.1st DCA 2010).
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`33.
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`Section 627.64194(4) incorporatesby reference the above dictates of section
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`641.513(5) concerning the reimbursement of non-participatingproviders with respect to
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`emergency and non-emergency services provided to patientscovered under a PPO policy as
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`outlined in sections 627.64194(2) and 627.64194(3).
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`34.
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`Section 627.662(15) incorporatesby reference the requirements of Section
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`627.64194 and appliesthem to group health insurance.
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`35.
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`Section 627.652(2)(c) provides that, for purposes of the statutory provisions
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`governing group health insurance policies,"insurer" includes any government unit providing a
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`plan of self-insurance.
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`7
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`

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`The Surgery
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`36.
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`On or around January 24, 2018, Patient presentedto Plantation General Hospital,
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`located in Plantation,Florida,with significantcomplicationsfrom a traumatic injuryto Patient's
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`left forearm resultingfrom a laceration with glass,includingincreasinglysevere pain,inabilityto
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`extend the thumb, and loss of sensation, which conditions manifested themselves by acute
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`symptoms of sufficient severitysuch that the absence of immediate medical attention could
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`reasonablyhave been expectedto result in serious jeopardyto Patient's health,serious impairment
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`to Patient's bodily functions,and/or serious dysfunctionof Patient's bodily organ(s)or part(s).
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`37.
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`On or about January 24, 2018, Plaintiff,through its physicians,provided medical
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`services to Patient at Plantation General Hospitalconsistingof a complex surgery that was
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`necessary to relieve or eliminate the medical conditions for which Patient initiallysought treatment
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`at Plantation General Hospital,which surgery included reconstruction ofnumerous muscles ofthe
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`forearm (includingbrachioradialis,extensor pollicisbrevis,extensor pollicislongus,and abductor
`
`pollicislongus),adjacenttissue transfer of the extensor retinaculum, repairoftwo branches of the
`
`radial nerve, Z-plastyof skin,debridement ofnonviable skin and subcutaneous tissue,and multiple
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`other related procedures(the"Surgery").
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`Defendant'sUnderpayment of the Claims
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`38.
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`Plaintiff submitted claims for reimbursement to BCBSF, acting on behalf of
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`Defendant as Defendant's claims administrator for the Policy,for the services Plaintiffprovidedto
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`Patient as part ofthe Surgery (collectively,the "Claims").
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`39.
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`Plaintiff's chargesfor services provided as part of the Surgery totaled $53,590.00,
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`as reflected on the Claims.
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`8
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`

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`40.
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`BCBSF, on behalf of Defendant, paid Plaintiff a total of $3,254.93 on the Claims,
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`which is a mere 6.1% of Plaintiff's chargesfor the services at issue and nowhere near the amount
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`Defendant is requiredto pay Plaintiffunder Florida law.
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`41.
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`BCBSF, on behalf of Defendant, issued the remittance notices of its foregoing
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`underpayments on the Claims to Plaintiff in Fort Lauderdale, Florida.
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`42.
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`Plaintiff did not and does not have applicableparticipationagreements with either
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`BCBSF or Defendant for purposes of Patient's Policy,and thus the Claims are considered non-
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`partic*atingor out-of-network claims.
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`43.
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`Plaintiff never agreedto accept discounted rates from Defendant or to be bound by
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`either Defendant's or BCBSF's reimbursement policiesor rate schedules with respect to the
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`Claims.
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`44.
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`Yet, the remittance notices BCBSF, on behalf of Defendant, sent to Plaintiff for the
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`services provided to Patient crypticallyincluded remarks such as, "This amount represents
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`BCBSFL'S maximum allowable payment," as well as, "Provider may balance bill unless F.S.
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`6927.64194 applies.
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`..
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`45.
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`Upon information and belief,BCBSF, on behalf of Defendant, has at all material
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`times approved Plaintiff's rendering of the medical services underlying the Claims to Patient,
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`includingby authorizingPatient's admission to Plantation General Hospitalon or about January
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`24,2018, for the treatment of Patient's medical conditions and by paying Plaintiff for the services
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`it rendered to Patient,albeit at inappropriatelylow rates.
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`46.
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`Defendant was and is aware that Plaintiffprovidedmedical services to Patient and
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`billed Defendant for the medical services Plaintiff's physicians provided to Patient with the
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`expectationand understandingthat its services had been approved by Defendant and that it would
`
`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`9
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`

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`be reimbursed by Defendant at rates reflecting:(a)the lesser of (i)Plaintiff's billed chargesor (ii)
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`the "usual and customary provider charges for similar services" (i.e.,fair market value),as
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`requiredby Section 641.513(5),for claims subjectto that section;and/or (b)the reasonable value
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`in the marketplace,or quantum meruit, of the medical services Plaintiff provided,for claims not
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`subjectto Section 641.513(5).
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`47.
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`Defendant, through BCBSF, in fact paid Plaintiff for the medical services Plaintiff
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`providedto Patient,albeit at rates in appropriatelybelow Plaintiff's billed charges,the fair market
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`value, and the usual and customary rates for Plaintiff's services in the marketplace.
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`48.
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`Further,the rates paid by Defendant are significantlyless than the rates requiredby
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`Florida law. For claims covered by Section 627.64194, Defendant has not paid Plaintiffthe lesser
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`of its billed charges or the fair market value of the services provided.For claims not covered by
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`that section,Defendant has not paid Plaintiff the reasonable value of the services in the
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`marketplace.
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`49.
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`The rates at which Defendant paid Plaintiff are less than the rates Plaintiff received
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`duringthe same time periodfrom other,similar insurers for similar services provided in the same
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`community.
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`50.
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`Defendant's refusal to pay Plaintiff the fair market value and/or the reasonable
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`value of the medical services Plaintiff providedto Patient has caused Plaintiff to suffer damages
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`in an amount equal to the difference between the amounts Defendant paid on the Claims and the
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`fair market value and reasonable value o f the services Plaintiff provided,plus Plaintiff's loss of
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`use of that money.
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`51.
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`The difference between the amounts Defendant paid and Plaintiff's billed charges
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`totals $50,335.07.
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`10
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`

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`52.
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`All necessary conditions precedent for Defendant to perform its obligations
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`pursuant to Section 627.64194, and/or the applicableimplied contracts between the parties
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`occurred or were performed, excused, and/or waived.
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`COUNTI
`Violation of Sections 627.662, 627.64194, and 641.513 - Emergency Services
`
`53.
`
`54.
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`Plaintiff re-allegesand incorporatesby reference paragraphs 1 through 52 above.
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`Sections 627.662(15),627.64194(4),and 641.513(5)impose a duty on Defendant,
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`as an insurer,to reimburse Plaintiff for the Claims accordingto the statutes' dictates.
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`55.
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`Plaintiff has a privateright of action to enforce the provisions of 641.513,
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`incorporatedby reference in 627.64194 and 627.662, againstDefendant.
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`56.
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`At all material times, Plaintiffwas a non-participatingemergency medical provider
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`that staffed the emergency department at Plantation General Hospital.
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`57.
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`The medical services Plaintiff provided to Patient as part of the Surgery were
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`emergency services and care as defined in section 641.47(8),Florida Statutes.
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`58.
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`Plaintiff submitted the Claims for the services it provided to Patient as part of the
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`Surgery,which Claims were subjectto Section 641.513(5), as incorporatedby reference in
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`627.64194 and 627.662.
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`59.
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`Plaintiff submitted the Claims to Defendant.
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`60.
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`Defendant, as the insurer of Patient's Policy,was responsiblefor payment of the
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`Claims.
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`61.
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`The Claims set forth Plaintiff's billed chargesfor the services itprovidedto Patient
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`as part of the Surgery.
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`62.
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`Defendant, through its claims administrator BCBSF, issued remittance notices to
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`Plaintiff for the Claims reflectingallowed amounts for the services significantlybelow the "usual
`
`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`11
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`

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`and customary providercharges for similar services in the community where the services were
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`provided" that Defendant was obligatedto pay Plaintiff pursuant to Sections 641.513(5),as
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`incorporatedby reference in 627.64194 and 627.662.
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`63.
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`Plaintiff and Defendant did not mutually agree on a specificchargefor any of the
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`Claims. Plaintiff did not agree to accept discounted rates from Defendant for the Claims, nor did
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`it agree to be bound by Defendant's reimbursement policiesor rate schedules with respect to the
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`Claims.
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`64.
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`Defendant violated Section 641.513(5),as incorporatedby reference in 627.64194
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`and 627.662, by failingto pay Plaintiff the "usual and customary provider charges for similar
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`services in the community where the services were provided"for the Claims.
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`65.
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`As a result ofDefendant's failure to fulfill its legalobligationsto reimburse Plaintiff
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`in accordance with Sections 627.662(15),627.64194(4),and 641.513(5),Plaintiff has suffered
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`injuryand is entitled to monetary damages from Defendant.
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`66.
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`Plaintiffseeks compensatory damages, as permittedby applicablelaw, in an amount
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`equalto the difference between the amounts Defendant paidto Plaintiff for the Claims and the fair
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`market value of the medical services underlyingthe Claims, plus interest.
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`WHEREFORE, Plaintiff prays that this Court enter a judgment againstDefendant and in
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`favor of Plaintiff in an amount representingthe difference between the amounts Defendant paidto
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`Plaintiff for the claims at issue and the fair market value of the medical services underlying those
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`claims,as determined by the finder of fact,togetherwith an award of prejudgment interest,costs,
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`and such other and further relief as the Court may deem justand proper.
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`COUNT II
`Violation of Sections 627.662, 627.64194, and 641.513 - Nonemergencv Services
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`67.
`
`Plaintiff re-allegesand incorporatesby reference paragraph 1 through 52 above.
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`12
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`

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`68.
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`Sections 627.662(15),627.64194(4),and 641.513(5)impose a duty on Defendant,
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`as an insurer,to reimburse Plaintiff for the Claims accordingto the statutes' dictates.
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`69.
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`Section 627.64194(3) provides that an insurer is solely liable for payment to a
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`nonpartic*atingproviderof covered nonemergency services provided to an insured where such
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`services are:
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`(a) Provided in a facilitythat has a contract for the nonemergency services with the
`insurer which the facilitywould be otherwise obligatedto provide under contract
`with the insurer;and
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`(b) Provided when the insured does not have the abilityand opportunityto choose a
`partic*atingprovider at the facilitywho is available to treat the insured.
`
`70.
`
`Plaintiff has a privateright of action to enforce the provisionsof 641.513,
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`incorporatedby reference in 627.64194 and 627.662, againstDefendant.
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`71.
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`At all material times, Plaintiff was a non-participatingmedical provider that
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`provided staffingat Plantation General Hospital.
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`72.
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`During the Surgery, Plaintiff provided covered medical services to Patient at
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`Plantation General Hospitalin accordance with the terms of the Policy.
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`73.
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`Upon information and belief,at all material times, Plantation General Hospitalhad
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`a contract with Defendant and/or BCBSF for the covered medical services Plaintiff provided to
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`Patient duringthe Surgery,which services Plantation General Hospitalwould otherwise have been
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`obligatedto provide to Patient under its contract with Defendant and/or BCBSF.
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`74.
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`Patient did not have the abilityor opportunityto choose a participatingproviderat
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`Plantation General Hospitalwho was available to treat Patient at the time Plaintiff providedthe
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`covered medical services to Patient as part of the Surgery because, upon information and belief,
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`Plaintiff's physicianswere the only reconstructive surgeons with privilegesat Plantation General
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`Hospitalat the time Patient underwent the Surgery.
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`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`13
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`

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`75.
`
`Plaintiff did not have the abilityor opportunityto choose a participatingprovider
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`at Plantation General Hospitalwho was available to treat Patient at the time Plaintiff provided the
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`covered medical services to Patient as part of the Surgery because Plaintiff's physicianswere the
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`on-call surgeons at Plantation General Hospitalwhen Patient was admitted and/or when Patient
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`underwent the Surgery.
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`76.
`
`Plaintiff submitted the Claims for the services it provided to Patient as part of the
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`Surgery,which Claims were subjectto Sections 627.662(15),627.64194(3),627.64194(4),and
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`641.513(5).
`
`77.
`
`Plaintiff submitted the Claims to BCBSF, as claims administrator and agent for
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`Defendant.
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`78.
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`The Claims set forth Plaintiff's billed charges for the services it provided to Patient
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`as part of the Surgery.
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`79.
`
`Defendant, as the insurer of Patient's Policy,was responsiblefor payment of the
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`Claims.
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`80.
`
`BCBSF, as claims administrator and agent for Defendant, issued payments to
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`Plaintiff for the Claims, but at a rate significantlybelow the "usual and customary providercharges
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`for similar services in the community where the services were provided" that Defendant was
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`obligatedto pay Plaintiff pursuant to Sections 627.662(15),627.64194(4),and 641.513(5).
`
`81.
`
`Plaintiff and Defendant did not mutually agree on a specificcharge for any of the
`
`Claims. Plaintiff did not agree to accept discounted rates from Defendant for the Claims, nor did
`
`it agree to be bound by Defendant's reimbursement policiesor rate schedules with respect to the
`
`Claims.
`
`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`14
`
`

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`82.
`
`Defendant violated Section 641.513(5),as incorporatedby reference in 627.64194
`
`and 627.662, by failingto pay Plaintiff the "usual and customary provider charges for similar
`
`services in the community where the services were provided" for the Claims.
`
`83.
`
`As a result ofDefendant's failure to fulfillits legalobligationsto reimburse Plaintiff
`
`in accordance with Sections 627.662(15),627.64194(4),and 641.513(5),Plaintiff has suffered
`
`injuryand is entitled to monetary damages from Defendant.
`
`84.
`
`Plaintiffseeks compensatory damages, as permittedby applicablelaw, in an amount
`
`equalto the difference between the fair market value ofthe medical services underlyingthe Claims,
`
`plus interest.
`
`WHEREFORE, Plaintiff prays that this Court enter a judgment againstDefendant and in
`
`favor of Plaintiff in an amount representingthe difference between the amounts Defendant paid to
`
`Plaintiff for the claims at issue and the fair market value of the medical services underlyingthose
`
`claims, as determined by the finder of fact,togetherwith an award of prejudgment interest,costs,
`
`and such other and further relief as the Court may deem justand proper.
`
`COUNT III
`Uniust Enrichment/Breach of Implied-in-Law Contract
`
`85.
`
`86.
`
`Plaintiff re-allegesand incorporatesby reference paragraphs 1 through 52 above.
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`Plaintiff conferred a direct benefit on Defendant by providingvaluable medical
`
`services to Patient as part ofthe Surgery,with the knowledge and/or approval of Defendant.
`
`87.
`
`Defendant collects premiums, fees,and/or other forms of compensation from its
`
`insureds in return for agreeingto properlyreimburse providers,like Plaintiff,that render medical
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`services to insureds,like Patient.
`
`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`15
`
`

`

`88.
`
`In exchange for these premiums, fees, and/or other forms of compensation,
`
`Defendant owes its insureds, includingPatient, an obligationto pay for the covered medical
`
`services the insureds receive.
`
`89.
`
`Under Florida law, Defendant is obligatedto provide coverage for emergency and
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`non-emergency services provided by out-of-network providerslike Plaintiff.
`
`90.
`
`Defendant derives a direct benefit from Plaintiff's provisionofmedical services to
`
`its insureds because it is through Plaintiff's provisionof those services that Defendant fulfills its
`
`legalobligationsto its insureds.
`
`91.
`
`The medical services Plaintiff provided to Patient as part of the Surgery were
`
`undisputedlycovered because Defendant adjudicatedand paid for those services,albeit at an
`
`amount less than the reasonable value of the services in the marketplace.
`
`92.
`
`When Plaintiff provided covered medical services to Patient,Defendant received
`
`the benefit of having its legalobligationsto Patient discharged.Plaintiff's provisionof covered
`
`medical services to Patient further benefitted Defendant because it offered a more permanent
`
`solution to the medical conditions for which Patient initiallypresented to Plantation General
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`Hospital in or around January 24, 2018, potentiallynegating Patient's need to seek additional
`
`medical treatment in the future for which Defendant would be financiallyliable.
`
`93.
`
`Defendant was aware of and implicitlyapproved Plaintiff's provisionof covered
`
`medical services to Patient because Defendant paid Plaintiff for those services, albeit at
`
`inappropriatelylow rates, and because,upon information and belief,Defendant and/or Defendant's
`
`claims administrator and agent, BCBSF, authorized and/or paid for Patient's admission to
`
`Plantation General Hospitalin or around January 24,2018 and services relatingto that admission.
`
`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`16
`
`

`

`94.
`
`Defendant's liabilityas the party responsiblefor payment to Plaintiff for the
`
`services it provided to Patient as part of the Surgery is established by Defendant's determination
`
`that the services were covered and its payment for the services,albeit in an amount far below that
`
`to which Plaintiff is entitled.
`
`95.
`
`Defendant voluntarilyaccepted,retained,and enjoyed, and continues to accept,
`
`retain,and enjoy,the benefits conferred upon it by Plaintiff,knowing that Plaintiff expected to be
`
`paidthe reasonable value of its services in the marketplace.
`
`96.
`
`Defendant has failed to pay the reasonable value ofthe benefit conferred upon it by
`
`Plaintiff,in this case, the reasonable value ofthe services providedto Patient as part ofthe Surgery.
`
`As a result,Defendant has withheld for itself monies that should have been paid to Plaintiff for
`
`Plaintiff's services and has received an unjustifiedwindfall.
`
`97.
`
`By refusingto pay Plaintiff appropriately,Defendant has been unjustlyenriched.
`
`Under the circumstances set forth above, it is unjustand inequitablefor Defendant to retain the
`
`benefit it received without paying the value of that benefit,i.e.,by paying Plaintiffthe reasonable
`
`value in the marketplaceof the medical services Plaintiffprovidedto Patient.
`
`98.
`
`Plaintiffseeks compensatory damages, as permittedby applicablelaw, in an amount
`
`equal to the difference between the amounts Defendant paid to Plaintiff for the Claims and the
`
`reasonable value of the medical services underlyingthe Claims, plusinterest.
`
`WHEREFORE, Plaintiff prays that this Court enter a judgment againstDefendant and in
`
`favor of Plaintiff in an amount representingthe difference between the amounts Defendant paid to
`
`Plaintiff for the claims at issue and the reasonable value in the marketplaceofthe medical services
`
`underlyingthose claims, as determined by the finder of fact,togetherwith an award ofprejudgment
`
`interest,costs, and such other and further relief as the Court may deem justand proper.
`
`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`17
`
`

`

`COUNT IV
`Breach of Implied-in-Fact Contract
`
`99.
`
`Plaintiff re-allegesand incorporatesby reference paragraphs 1 through 52 above.
`
`100.
`
`At all material times, Patient was an insured under the Policy,which was issued
`
`and insured by Defendant, and which provided coverage for medical services provided to Patient.
`
`101.
`
`At all material times, Defendant was obligated to cover and pay for medical
`
`services Patient received at Plantation General Hospital.
`
`102.
`
`Defendant, individuallyand/or through its agent BCBSF, knew or should have
`
`known that Plaintiff was a non-participatingmedical providerthat provided staffingat Plantation
`
`General Hospital.
`
`103.
`
`Defendant knew or should have known that Plaintiffis obligatedby law to provide
`
`emergency services and care to Defendant's insureds,includingPatient,and that Defendant is
`
`obligatedby law to cover those services.
`
`104.
`
`Defendant derives a direct benefit from Plaintiff's provisionofmedical services to
`
`its insureds because it is through Plaintiff's provisionof those services that Defendant fulfills its
`
`legalobligationsto its insureds.
`
`105.
`
`Defendant was aware of its obligationsto non-contracted providers like Plaintiff
`
`and was or should have been aware that Plaintiff providedmedical services to Patient in Florida
`
`with the reasonable expectation and understanding that Plaintiff would be reimbursed by
`
`Defendant at rates, under quantum meruit, reflectingthe reasonable value of its services in the
`
`marketplace.
`
`106.
`
`Defendant knew that Plaintiff did not agree to accept discounted rates from
`
`Defendant for the Claims and did not agree to be bound by Defendant's reimbursement policiesor
`
`rate schedules.
`
`Shapiro, Blasi, Wasserman & Hermann, P.A.
`Attorneys for Plaintiff
`18
`
`

`

`107.
`
`The parties'reciprocallegalobligations,described in detail above, created an
`
`implied-in-factcontract pursuant to which Defendant impliedly agreed to pay Plaintiff the
`
`reasonable valu