`Case 1:22-cv-02407 Document1-1 Filed 04/26/22 Page 1 of 11 PagelD: 8
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`EXHIBIT A
`EXHIBIT A
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`Lawall & Mitchell, LLC
`Dara J. Lawall, Esquire (I.D. #028332008)
`55 Madison Avenue
`Morristown, New Jersey 07960
`Attorneys for Plaintiff
`973-285-3280
`--------------------------------------------------------- X
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`PREMIER ORTHOPAEDIC ASSOCIATES
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`SUPERIOR COURT OF NEW JERSEY
`OF SOUTHERN NJ, LLC,
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`LAW DIVISION: CUMBERLAND COUNTY
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` Plaintiff,
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`DOCKET NO.:
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`CIVIL ACTION
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`COMPLAINT, JURY DEMAND AND
`ANTHEM BLUE CROSS BLUE SHIELD,
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`DESIGNATION OF TRIAL COUNSEL
`JOHN DOES 1-10, JANE DOES 1-10, AND
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`ABC CORPORATIONS 1-10,
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` Defendants.
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`--------------------------------------------------------- X
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`vs.
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`Plaintiff Premier Orthopaedic Associates of Southern NJ, LLC, by and through its
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`attorneys, Lawall and Mitchell, LLC and as and for its Complaint against Defendants Anthem Blue
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`Cross Blue Shield, John Does 1-10, Jane Does 1-10, and ABC Corporations 1-10, says:
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`THE PARTIES
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`1.
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`Plaintiff Premier Orthopaedic Associates of Southern NJ, LLC (hereinafter referred
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`to as "Premier Orthopaedic "and "Plaintiff") with a business address of 352 South Delsea Drive,
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`City of Vineland, County of Cumberland, and State of New Jersey, is now and was at all times
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`relevant to this action, a company organized and operating under the Law of the State of New
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`Jersey, providing healthcare services.
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`2.
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`Upon information and belief, at all relevant times, Defendant Anthem Blue Cross
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`Blue Shield (hereinafter referred to as "BCBS") was a corporation whose headquarters are located
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`at 200 Virginia Avenue, Indianapolis, Indiana, which conducted and continues to conduct
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`significant business in the State of New Jersey.
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`CUM-L-000109-22 02/28/2022 12:41:08 PM Pg 1 of 7 Trans ID: LCV2022816568
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`3.
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`At all times relevant, upon information and belief, fictitious Defendants John Does
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`1-10, Jane Does 1-10 and ABC Corporations 1 through 10, are yet to be identified entities who
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`directly and proximately caused damages to Plaintiff.
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`JURISDICTION AND VENUE
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`4.
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`Plaintiff's office is located in Cumberland County, New Jersey, and all medical
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`services which are the subject matter of this action were rendered in Cumberland County, New
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`Jersey.
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`5.
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`Patient, "MV" herein
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`identified only by BCBS Identification Number
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`TQSAN6271121 (hereinafter referred to as the "Patient") received medical benefits through
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`defendant BCBS.
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`6.
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`7.
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`At all relevant times, the Patient lived in Salem County, New Jersey.
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`Plaintiff is proceeding on its own individual claims concerning medical services
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`provided to the Patient.
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`8.
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`This matter is properly venued in State Court. None of Plaintiff’s claims, as detailed
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`infra, are governed by federal law, including the Employee Retirement Income Security Act
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`(“ERISA”). See, Pascack Valley Hosp. v. Local 464A UFCW Welfare Reimbursement Plan, 388
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`F. 3d 393, 403-4 (3d Cir. 2004). (medical provider’s claims not preempted by ERISA where (1)
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`the medical provider’s claims arose from a contract independent of the ERISA plan; (2) the patients
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`were not parties to the contract between the provider and insurer; and (3) the dispute was limited
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`to the amount of the payment, not the right to be paid.)
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`9.
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`10.
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`The amount in controversy is at least $301,344.00.
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`For all the reasons stated above, this Court has jurisdiction over this matter and,
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`further, it is the proper venue for this matter to be heard.
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`2
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`FACTUAL BACKGROUND
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`11.
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`This dispute arises out of the Defendants’ refusal to pay Plaintiff the money to
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`which Plaintiff is entitled for providing necessary medical services to the Patient.
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`12.
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`At all relevant times, Plaintiff was a non-participating or out-of-network provider
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`that rendered medically necessary services to the Patient.
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`13.
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`On July 11, 2016, the Patient presented to Inspira Medical Center (hereinafter
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`referred to as "IMC"), where Dr. Rahul Shah (hereinafter “Dr. Shah”) performed medically
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`necessary services, including: aborted cervical decompression and fusion, c5-c6, c6-c7, partial
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`corpectomy c5-c6, c6-c7; SSEP, EMG intraoperative fluoroscopy; application of local bone,
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`aborted; application of instrumentation 3 levels, aborted; and partial corpectomy c5, c6, and c7
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`aborted.
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`14.
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`Dr. Shah is a Board-Certified orthopaedic surgeon who is employed and/or
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`contracted by the Plaintiff.
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`15.
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`Plaintiff, as part of its normal business practice, obtained authorization for the
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`medically necessary treatment of the Patient. This authorization is also applicable to all
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`physicians, including Dr. Shah, who is employed and/or contracted by the Plaintiff.
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`16.
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`Specifically, a representative of Defendant approved (pre-certification number
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`0243250657) the services to be performed by Plaintiff.
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`Primary surgery, on July 11, 2016 was performed by Dr. Shah.
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`Dr. Shah was assisted by Cristian Brenner, PA, who is employed and/or contracted
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`17.
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`18.
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`by Plaintiff.
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`19.
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`Plaintiff billed Defendant BCBS for the primary surgeon charges a total of
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`$150,672.00
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`3
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`20.
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`21.
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`Plaintiff billed Defendant BCBS for the assistant charges a total of $150,672.00.
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`The total billed charges of $301,344.00 for this medically necessary treatment
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`represents normal and reasonable charges for the complex procedures performed by a Board-
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`Certified Orthopaedic Surgeon, practicing in New Jersey, with an assistant.
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`22.
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`Defendants paid nothing towards these reasonable charges, leaving a balance due
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`on this bill of approximately $301,344.00.
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`23. While Defendants were aware that Plaintiff was an out-of-network provider,
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`Defendants never disclosed that it did not intend to pay the fair and reasonable value for said
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`services. To the contrary, by issuing an authorization number for the services, Defendants
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`accepted and approved the medically necessary services provided by Plaintiff, with the explicit
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`knowledge that Defendants never intended to pay the amounts they were obligated to pay.
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`FIRST COUNT
`(Breach of Contract)
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`24.
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`Plaintiff repeats, reiterates and re-alleges each and every allegation set forth in
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`paragraphs "1" through "23" of this Complaint with the same force and effect as if fully set forth
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`herein at length.
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`25.
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`Plaintiff hereby alleges that an implied in-fact contract has been created through
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`Defendants’ course of conduct and interaction with Plaintiff (hereinafter, the "Contract").
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`26.
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`By authorizing the surgery, Defendants agreed to pay the fair and reasonable rates
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`for the medical services provided by Plaintiff and Plaintiff performed said services based upon
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`those terms.
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`27.
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`This implied Contract indicated that Plaintiff would be paid by Defendants a fair
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`and reasonable amount for the highly-skilled services provided by the Plaintiff.
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`4
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`28.
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`However, Plaintiff was paid nothing --$0-- of the fair and reasonable amount of
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`$301,344.00 for the highly-skilled services provided to the Patient.
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`29.
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`Plaintiff has suffered significant damages as a result of Defendants’ failure to pay
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`the fair and reasonable value for the services.
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`30.
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`As a direct result of Defendants’ breach of the Contract, Plaintiff has been damaged
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`in an amount to be determined at trial, but not less than $301,344.00, plus interest, costs, and
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`attorneys' fees.
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`SECOND COUNT
`(Promissory Estoppel)
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`Plaintiff repeats, reiterates and re-alleges each and every allegation set forth in
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`31.
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`paragraphs "1" through "30" of this Complaint with the same force and effect as if fully set forth
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`herein at length.
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`32.
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`By providing a pre-surgery authorization to Plaintiff, Defendants promised that
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`Plaintiff would be paid for its services at a fair and reasonable rate.
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`33.
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`Plaintiff relied upon this promise to its detriment by spending valuable time,
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`resources, and energy in providing medical services to the Patient.
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`34.
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`As a direct result of Defendants’ refusal to pay Plaintiff the fair and reasonable
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`value for the services Plaintiff provided at the behest of Defendant, Plaintiff has been damaged in
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`an amount to be determined at trial, but not less than $301,344.00, plus interest, costs, and
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`attorneys' fees.
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`5
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`CUM-L-000109-22 02/28/2022 12:41:08 PM Pg 5 of 7 Trans ID: LCV2022816568
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`THIRD COUNT
`(Account Stated)
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`35.
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`Plaintiff repeats, reiterates and re-alleges each and every allegation set forth in
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`paragraphs “1” through “34” of this Complaint with the same force and effect as if fully set forth
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`herein at length.
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`36.
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`After providing the medical services, which were authorized by Defendants,
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`Plaintiff submitted bills and requests for payment to Defendants in the sum total of $301,344.00.
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`37.
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`To date, Defendants, having acknowledged receipt of the bills, have paid $0 of the
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`invoices, but have not objected in any manner to the billed amounts, including, inter alia, the
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`amount billed or to the services provided.
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`38.
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`39.
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`Plaintiff has suffered significant damages as a result of Defendants’ actions.
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`As a direct result of Defendants’ refusal to pay Plaintiff for the medical services
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`provided and billed to Defendants, who acknowledged receipt without objection, Plaintiff has been
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`damaged in an amount to be determined at trial, but not less than $301,344.00, plus interest, costs,
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`and attorneys’ fees.
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`WHEREFORE, Plaintiff respectfully demands judgment against Defendants:
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`1. As and for its First cause of action, for breach of an implied contract in an amount to
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`be determined at trial, but not less than $301,344.00, along with its reasonable attorneys' fees,
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`interest, costs and expenses; and
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`2. As and for its Second cause of action under the theory of promissory estoppel in an
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`amount to be determined at trial, but not less than $301,344.00, along with its reasonable
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`attorneys' fees, interest, costs and expenses; and
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`6
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`CUM-L-000109-22 02/28/2022 12:41:08 PM Pg 6 of 7 Trans ID: LCV2022816568
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`3. As and for its Third cause of action for an account stated in an amount to be determined
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`at trial, but not less than $301,344.00, along with its reasonable attorneys’ fees, interest, costs
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`and expenses; and
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`4. Along with such other and further relief to plaintiff as this Court deems just, fair, and
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`proper.
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`JURY DEMAND
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`Pursuant to R. 4:35-1, plaintiff hereby demands a trial by jury as to all counts.
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`DESIGNATION OF TRIAL COUNSEL
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`Pursuant to R. 4:25-4, Dara J. Lawall, Esquire is hereby designated as trial counsel.
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`CERTIFICATION
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`I hereby certify that pursuant to R. 4:5-1 that the matter in controversy is not the subject of
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`any other action pending in any Court or of a pending arbitration proceeding related to claims
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`arising from medical services provided from Plaintiff to the Patient. No such action or arbitration
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`proceeding is contemplated by plaintiff at this time.
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`LAWALL & MITCHELL, LLC
`Attorneys for Plaintiff
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`BY: /s/ Dara J. Lawall
` Dara J. Lawall, Esquire
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`Dated: February 25, 2022
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`7
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`CUM-L-000109-22 02/28/2022 12:41:08 PM Pg 7 of 7 Trans ID: LCV2022816568
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`Civil Case Information Statement
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`Case Details: CUMBERLAND | Civil Part Docket# L-000109-22
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`Case Caption: PREMIER ORTHOPAEDIC ASSOCIATE
`VS ANTHEM BLUE CR
`Case Initiation Date: 02/28/2022
`Attorney Name: DARA J LAWALL
`Firm Name: LAWALL & MITCHELL
`Address: 55 MADISON AVE STE 400
`MORRISTOWN NJ 07960
`Phone: 9732853280
`Name of Party: PLAINTIFF : Premier Orthopaedic
`Associates
`Name of Defendant’s Primary Insurance Company
`(if known): None
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`Case Type: CONTRACT/COMMERCIAL TRANSACTION
`Document Type: Complaint with Jury Demand
`Jury Demand: YES - 12 JURORS
`Is this a professional malpractice case? NO
`Related cases pending: NO
`If yes, list docket numbers:
`Do you anticipate adding any parties (arising out of same
`transaction or occurrence)? NO
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`Are sexual abuse claims alleged by: Premier Orthopaedic
`Associates? NO
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`THE INFORMATION PROVIDED ON THIS FORM CANNOT BE INTRODUCED INTO EVIDENCE
`CASE CHARACTERISTICS FOR PURPOSES OF DETERMINING IF CASE IS APPROPRIATE FOR MEDIATION
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`Do parties have a current, past, or recurrent relationship? NO
`If yes, is that relationship:
`Does the statute governing this case provide for payment of fees by the losing party? NO
`Use this space to alert the court to any special case characteristics that may warrant individual
`management or accelerated disposition:
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`Do you or your client need any disability accommodations? NO
`If yes, please identify the requested accommodation:
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`Will an interpreter be needed? NO
`If yes, for what language:
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`Please check off each applicable category: Putative Class Action? NO Title 59? NO Consumer Fraud? NO
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`I certify that confidential personal identifiers have been redacted from documents now submitted to the
`court, and will be redacted from all documents submitted in the future in accordance with Rule 1:38-7(b)
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`02/28/2022
`Dated
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`/s/ DARA J LAWALL
`Signed
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`CUM-L-000109-22 02/28/2022 12:41:08 PM Pg 1 of 2 Trans ID: LCV2022816568
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`CUM-L-000109-22 02/28/2022 12:41:08 PM Pg 2 of 2 Trans ID: LCV2022816568
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`CUM L 000109-22 03/01/2022 4:33:54 AM Pg 1 of 1 Trans ID: LCV2022851932
`Case 1:22-cv-02407 Document 1-1 Filed 04/26/22 Page 11 of 11 PageID: 18
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`CUMBERLAND COUNTY SUPERIOR COURT
`CIVIL CASE MANAGEMENT
`60 W BROAD ST
`BRIDGETON
`
`NJ 08302
`
`COURT TELEPHONE NO. (856) 878-5050
`COURT HOURS 8:30 AM - 4:30 PM
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`TRACK ASSIGNMENT NOTICE
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`DATE: FEBRUARY 28, 2022
`RE:
`PREMIER ORTHOPAEDIC ASSOCIATE VS ANTHEM BLUE CR
`DOCKET: CUM L -000109 22
`
`THE ABOVE CASE HAS BEEN ASSIGNED TO: TRACK 2.
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`DISCOVERY IS 300 DAYS AND RUNS FROM THE FIRST ANSWER OR 90 DAYS
`FROM SERVICE ON THE FIRST DEFENDANT, WHICHEVER COMES FIRST.
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`THE PRETRIAL JUDGE ASSIGNED IS: HON JAMES R. SWIFT
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`IF YOU HAVE ANY QUESTIONS, CONTACT TEAM
`AT: (856) 878-5050.
`
`101
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`IF YOU BELIEVE THAT THE TRACK IS INAPPROPRIATE YOU MUST FILE A
`CERTIFICATION OF GOOD CAUSE WITHIN 30 DAYS OF THE FILING OF YOUR PLEADING.
`PLAINTIFF MUST SERVE COPIES OF THIS FORM ON ALL OTHER PARTIES IN ACCORDANCE
`WITH R.4:5A-2.
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`ATTENTION:
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`ATT: DARA J. LAWALL
`LAWALL & MITCHELL
`55 MADISON AVE
`STE 400
`MORRISTOWN
`
`NJ 07960
`
`ECOURTS
`
`