Case 2:21-cv-11453-ES-MAH Document 1-3 Filed 05/19/21 Page 1 of 38 PageID: 8
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`EXHIBIT 1
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`# 2141447 v. 1
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`Case 2:21-cv-11453-ES-MAH Document 1-3 Filed 05/19/21 Page 2 of 38 PageID: 9
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`BRACH EICHLER L.L.C.
`Keith J. Roberts, Esq. (043681993)
`Shannon Carroll, Esq. (025922008)
`101 Eisenhower Parkway
`Roseland, New Jersey 07068-1067
`(973) 228-5700
`Attorneys for Plaintiff Gotham City Orthopedics, LLC
`
`GOTHAM CITY ORTHOPEDICS,
`LLC,
`
`Plaintiff,
`
`SUPERIOR COURT OF NEW JERSEY
`LAW DIVISION: PASSAIC COUNTY
`DOCKET NO.: PAS-L-001296-21
`
`V.
`
`OXFORD, OXFORD HEALTH
`PLANS, INC., OXFORD HEALTH
`PLANS, LLC, OXFORD HEALTH
`PLANS (NJ), INC., OXFORD
`HEALTH INSURANCE, NON-NEW
`JERSEY OXFORD PLANS 1-10 and
`JOHN DOES 1-10,
`
`Civil Action
`
`SUMMONS
`
`The State of New Jersey, to the Above Named Defendant:
`
`OXFORD HEALTH PLANS INC. C-10 c-T c°70nroan
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`The plaintiff, named above, has filed a lawsuit against you in the Superior Court of New
`Jersey. The complaint attached to this summons states the basis for this lawsuit. If you dispute this
`complaint, you or your attorney must file a written answer or motion and proof of service with the
`deputy clerk of the Superior Court in the county listed above within 35 days from the date you
`received this summons, not counting the date you received it. (A directory of the addresses of each
`deputy clerk of the Superior Court is available in the Civil Division Management Office in the
`above
`and
`online
`at
`county
`listed
`http://www.iudiciarv.state.ni.us/pro se/10153 deputyclerklawrelpdf) If the complaint is one in
`foreclosure, then you must file your written answer or motion and proof of service with the Clerk
`of the Superior Court, Hughes Justice Complex, P.O. Box 971, Trenton, NJ 08625-0971. A filing
`fee payable to the Treasurer, State of New Jersey and a completed Case Information Statement
`(available from the deputy clerk of the Superior Court) must accompany your answer or motion
`when it is filed. You must also send a copy of your answer or motion to plaintiffs attorney whose
`name and address appear above, or to plaintiff, if no attorney is named above. A telephone call
`will not protect your rights; you must file and serve a written answer or motion (with fee of $175
`and completed Case Information Statement) if you want the court to hear your defense.
`
`If you do not file and serve a written answer or motion within 35 days, the court may enter
`a judgment against you for the relief plaintiff demands, plus interest and costs of suit. If judgment
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`BE:11735195.1/G0T052-279811
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`

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`is entered against you, the Sheriff may seize your money, wages or property to pay all or part of
`the judgment.
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`If you cannot afford an attorney, you may call the Legal Services office in the county where
`you live or the Legal Services of New Jersey Statewide Hotline at 1-888-LSNJ-LAW (1-888-576-
`5529). If you do not have an attorney and are not eligible for free legal assistance, you may obtain
`a referral to an attorney by calling one of the Lawyer Referral Services. A directory with contact
`information for local Legal Services Offices and Lawyer Referral Services is available in the Civil
`at
`above and online
`in
`the county listed
`Division Management Office
`http://www.judiciarv.state.ni.us/pro se/10153 deputyc I erklawref. pdf.
`
`DATED: April 15, 2021
`
`/s/ Michelle M Smith
`Michelle M. Smith
`
`Name of Defendant to be served:
`
`Address for Service:
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`OXFORD HEALTH PLANS INC.
`
`do CT Corporation System
`820 Bear Tavern Road
`West Trenton, NJ 08628
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`BE:11735195.1/GOT052-279811
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`- 2 -
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`PAS-L-001296-21 04/15/2021 4:11:56 PM Pg 1 of 25 Trans ID: LCV2021980166
`
`BRACH EICHLER L.L.C.
`Keith J. Roberts, Esq. (043681993)
`Shannon Carroll, Esq. (025922008)
`101 Eisenhower Parkway
`Roseland, New Jersey 07068-1067
`(973) 228-5700
`Attorneys for Plaintiff Gotham City Orthopedics, LLC
`
`GOTHAM CITY ORTHOPEDICS, LLC,
`
`Plaintiff,
`
`V.
`
`OXFORD, OXFORD HEALTH PLANS, INC.,
`OXFORD HEALTH PLANS, LLC, OXFORD
`HEALTH PLANS (NJ), INC., OXFORD
`HEALTH INSURANCE, NON-NEW JERSEY
`OXFORD PLANS 1-10 and JOHN DOES 1-10,
`
`Defendants.
`
`SUPERIOR COURT OF NEW JERSEY
`CIVIL DIVISION: PASSAIC COUNTY
`
`DOCKET NO.:
`
`Civil Action
`
`COMPLAINT AND JURY DEMAND
`
`Plaintiff, Gotham City Orthopedics ("Plaintiff"), by way of this Complaint against
`
`Defendants, Oxford, Oxford Health Plans, Inc., Oxford Health Plans, LLC, Oxford Health Plans
`
`(NJ), Inc., Oxford Health Insurance, Non-New Jersey Oxford Plans 1-10 (collectively "Oxford"
`
`or the "Oxford Defendants"), and John Does 1-10, alleges as follows:
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`PRELIMINARY STATEMENT
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`1.
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`Plaintiff brings this action to redress Oxford's repeated failure to process and make
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`payment upon legitimate and proper claims for emergency medical services rendered to
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`participants in health plans insured and/or administered by Oxford.
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`2.
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`As a matter of law, Oxford's members and beneficiaries are entitled to be covered
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`for out-of-network emergency care at any hospital emergency room with their only responsibility
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`being to pay the plan's copayments, coinsurance and deductibles at an in-network level when
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`emergency services are rendered.
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`3.
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`Plaintiff is required by law to treat Oxford's insureds for out-of-network emergency
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`BE:! 1667573.!100T052-279811
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`PAS-L-001296-21 04/15/2021 4:11:56 PM Pg 2 of 25 Trans ID: LCV2021980166
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`health coverage. In each case described further below, Plaintiff rendered emergent, medically
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`necessary surgical and medical services to the Oxford's insureds which are indisputably covered
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`under Oxford's healthcare plan. In doing so, Plaintiff reasonably expected Oxford to properly
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`compensate Plaintiff.
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`4.
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`Oxford, however, has repeatedly underpaid Plaintiff for these emergency medical
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`services provided to Oxford Insureds. For the patients listed below, Plaintiff has incurred
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`$476,525.31 in charges for which Oxford has only paid $45,613.08—a payment rate of less than
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`10% for services that are to be paid at 100% as a matter of law. Accordingly, Plaintiff has
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`incurred no less than $430,912.23 in unpaid services because of Oxford's baseless refusal to pay
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`for the necessary, emergency surgical and medical services Plaintiff rendered to Oxford's insureds.
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`5.
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`Detailed information is not set forth herein solely to protect the identity and
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`Protected Health Information of the patients. Plaintiff will provide a list of Claims with complete
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`identifying information, including patient names and Oxford identification numbers to the Oxford
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`Defendants' counsel. In addition, Plaintiff has provided the Claims detail at issue, redacted for
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`Personal Health Information, attached as "Exhibit A."
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`6.
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`In short, Plaintiff seeks a judgment in its favor for the relief requested below.
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`PARTIES
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`7.
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`Plaintiff is a medical practice located at 50 Mount Prospect Avenue, Suite 104,
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`Clifton, New Jersey 07013.
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`8.
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`Defendant Oxford is, upon information and belief, a Connecticut Corporation or
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`Corporations, with a headquarters at 48 Monroe Turnpike, Trumbull, Connecticut, and various
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`offices in New Jersey Founded in 1984, Oxford offers health plans to employer and individuals
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`in New Jersey, New York and Connecticut. Oxford was acquired by United Healthcare in July
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`PAS-L-001296-21 04/15/2021 4:11:56 PM Pg 3 of 25 Trans ID: LCV2021980166
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`2004, and currently operates as a fully-owned subsidiary under its own name
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`9.
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`"Oxford" is a brand name used for products and services provided by one or more
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`of the Oxford group of subsidiaries or affiliates that offer, underwrite, or administer benefits.
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`When used in this Complaint, "Oxford" includes all Oxford subsidiaries or affiliates owned and
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`controlled by any of the named Defendants.
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`10.
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`Defendants, Non-New Jersey Oxford Plans 1-10, as yet unidentified, are health
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`insurers or similar entities, and are fictitious defendants to be identified in the course of litigation.
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`Upon information and belief, Oxford provided administrative services for the Oxford Plans 1-10.
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`1 1.
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`The individual insureds are employees or covered relatives of employees covered
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`under their employers' health insurance plan and entitled to health benefits under plans, which are
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`sponsored, funded and administered by Oxford. At all relevant times, Defendants provided
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`healthcare coverage to and/or administrative services for the health insurance plans of the
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`individual insureds. Defendants' health insurance plan provided health, medical and hospital
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`coverage, including emergency room coverage, expressly and/or by operation of law.
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`12.
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`Defendants John Does 1-10, yet unidentified, are individuals and/or corporations
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`who, upon information and belief, committed, participated in, solicited others to engage in, and/or
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`knowingly assisted, conspired with or urged others to commit the wrongful acts set forth herein.
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`John Does 1-10 are fictitious defendants to be identified in the course of litigation.
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`THE FACTS
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`13.
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`Plaintiff is a group of orthopedic surgeons that have visiting rights at various New
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`Jersey hospitals.
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`14.
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`Plaintiff provided emergent, medically necessary surgical and medical services to
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`the following patients, which are services indisputably covered under Oxford's health care plans,
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`and Plaintiff reasonably expected Oxford to properly compensate Plaintiff for these services,
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`which they have failed to do.
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`Oxford Insured #1: .IL. Date of Service: 5/17/14
`
`15. On May 17, 2014, J.L. was admitted to the Beth Israel Medical Center emergency
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`room after she injured her arm.
`
`16.
`
`J.L. was insured through her Oxford Plan provided by her employer.
`
`17.
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`Upon being admitted to the emergency room, x-rays and examination revealed that
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`J.L. had suffered a right distal radius fracture.
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`18.
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`Due to the severity of J.L.'s injuries, the emergency room physician referred J.L.
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`to Plaintiff to take over her care.
`
`19.
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`Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`20. On May 17, 2014, Plaintiff performed medically necessary surgery. Plaintiff
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`performed a closed reduction and splinting of the right distal radius fracture.
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`21.
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`The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as J.L. had no choice in selecting the medical
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`provider.
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`22.
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`Oxford provided J.L. with coverage for emergency medical care, either expressly
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`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to J.L.
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`23.
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`Plaintiff submitted a claim to Oxford for the surgical services provided to J.L. in
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`the amount of $24,000.00.
`
`24.
`
`Oxford drastically underpaid the claim for surgical services, allowing
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`reimbursement in the amount of $0.00.
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`PAS-L-001296-21 04/15/2021 4:11:56 PM Pg 5 of 25 Trans ID: LCV2021980166
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`25.
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`After Plaintiffs claims for services provided to J.L. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #2: S.G., Date of Service: 10/11/14
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`26. On October 11, 2014, S.G. was admitted to the Emergency Medical Care
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`emergency room after she fell down stairs.
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`27.
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`S.G. was insured through her Oxford Freedom Plan.
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`28.
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`Upon being admitted to the emergency room, x-rays and examination revealed that
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`S.G. had suffered a severely displaced left 3`d and 4'h toe proximal phalanges.
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`29.
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`Due to the severity of S.G.'s injuries, the emergency room physician referred S.G.
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`to Plaintiff to take over her care.
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`30.
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`Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`31.
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`On October 11, 2014, Plaintiff performed medically necessary surgery. Plaintiff
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`performed a closed reduction close reduction of the injury..
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`32.
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`The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as S.G. had no choice in selecting the medical
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`provider.
`
`33.
`
`Oxford provided S.G. with coverage for emergency medical care, either expressly
`
`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to S.G.
`
`34.
`
`Plaintiff submitted a claim to Oxford for the surgical services provided to S.G. in
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`the amount of $14,300.00.
`
`35.
`
`Oxford drastically underpaid the claim for surgical services, allowing
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`PAS-L-001296-21 04/15/2021 4:11:56 PM Pg 6 of 25 Trans ID: LCV2021980166
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`reimbursement in the amount of $435.51.
`
`36.
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`After Plaintiffs claims for services provided to S.G. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #3: MW. Date of Service: 1/7/15
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`37.
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`On January 7, 2015, M.W. was admitted to the Emergency Medical Care
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`emergency room after he injured his left elbow from a fall.
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`38. M.W. was insured through his Oxford Plan provided by his employer.
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`39.
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`Upon being admitted to the emergency room, x-rays and examination revealed that
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`M.W. had suffered fracture of the upper end of the forearm and head of the radius.
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`40.
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`Due to the severity of M.W.'s injuries, the emergency room physician referred
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`M.W. to Plaintiff to take over his care.
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`41.
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`Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`42. On January 7, 2015, Plaintiff performed medically necessary surgery. Plaintiff
`
`performed a closed reduction of the fraCture and application of a splint.
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`43.
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`The treatment rendered was emergent and continuous medical care arising out of
`
`an emergency admission at an in-network facility as M.W. had no choice in selecting the medical
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`provider.
`
`44.
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`Oxford provided M.W. with coverage for emergency medical care, either expressly
`
`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to M.W.
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`45.
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`Plaintiff submitted a claim to Oxford for the surgical services provided to M.W. in
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`the amount of $29,000.00.
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`46.
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`Oxford drastically underpaid the claim for surgical services, allowing
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`reimbursement in the amount of $899.00.
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`47.
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`After Plaintiff's claims for services provided to M.W. were underpaid, Plaintiff
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`filed unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #4: N.K., Date of Service: 4/25/15
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`48.
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`On September 25, 2015, N.K. was admitted to the Emergency Medical Care
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`emergency room after she kicked a stair and injured her foot.
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`49.
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`N.K. was insured through her Oxford Freedom Plan.
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`50.
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`Upon being admitted to the emergency room, x-rays and examination revealed that
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`N.K. had a closed fracture of her toe.
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`51.
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`Due to the severity of N.K.'s injuries, the emergency room physician referred N.K.
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`to Plaintiff to take over her care.
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`52.
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`Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`53. On April 25, 2015, Plaintiff performed medically necessary surgery. Plaintiff
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`performed a closed reduction and taping of the injury.
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`54.
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`The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as N.K. had no choice in selecting the medical
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`provider.
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`55.
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`Oxford provided N.K. with coverage for emergency medical care, either expressly
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`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to N.K.
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`56.
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`Plaintiff submitted a claim to Oxford for the surgical services provided to N.K. in
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`the amount of $7,500.00.
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`57.
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`Oxford drastically underpaid the claim for surgical services, allowing
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`reimbursement in the amount of $1,275.00.
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`58.
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`After Plaintiff's claims for services provided to N.K. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #5: KB., Date of Service: 5/11/15
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`59. On May 11, 2015, K.B. was admitted to the Hoboken University Medical Center
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`emergency room with his right knee in an extraordinary amount of pain and difficulty bending his
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`knee.
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`60.
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`K.B. was insured through his Oxford Plan provided by his school, Stevens Institute
`
`of Technology.
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`61.
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`Upon being admitted to the emergency room, x-rays and examination revealed that
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`K.B. had suffered a bucket-handle type tear of the right lateral meniscus.
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`62. Due to the severity of K.B.'s injuries, the emergency room physician referred K.B.
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`to Plaintiff to take over his care..
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`63.
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`Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`64. On May 11, 2015, Plaintiff performed medically necessary surgery. Plaintiff
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`performed an arthroscopic lateral meniscus repair, debridement of the medial plica band and
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`debridement of the synovium in the notch and lateral compartment.
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`65.
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`The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as K.B. had no choice in selecting the medical
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`provider.
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`66.
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`Oxford provided K.B. with coverage for emergency medical care, either expressly
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`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to K.B.
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`67.
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`Plaintiff submitted a claim to Oxford for the surgical services provided to K.B. in
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`.the amount of $42,500.00.
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`68.
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`Oxford drastically underpaid the claim for surgical services, allowing
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`reimbursement in the amount of $9,567.22.
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`69.
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`After Plaintiff's claims for services provided to K.B. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #6: A.D., Date of Service: 7/27/15
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`70. On July 27, 2015, A.D. was admitted to the Bayonne Medical Center emergency
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`room after he injured his right leg kicking a door.
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`71.
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`A.D. was insured through his Oxford Freedom Plan.
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`72.
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`Upon being admitted to the emergency room, x-rays and examination revealed that
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`A.D. had suffered a right spiral, nondisplaced fracture of the tibia.
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`73.
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`Due to the severity of A.D.'s injuries, the emergency room physician referred A.D.
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`to Plaintiff to take over his care.
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`74.
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`Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`75. On July 27, 2015, Plaintiff performed medically necessary surgery. Plaintiff
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`performed a closed treatment and splint of the tibia fracture.
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`76.
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`The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as A.D. had no choice in selecting the medical
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`provider.
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`77.
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`Oxford provided A.D. with coverage for emergency medical care, either expressly
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`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to A.D.
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`78.
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`Plaintiff submitted a claim to Oxford for the surgical services provided to A.D. in
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`the amount of $11,500.00.
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`79.
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`Oxford drastically underpaid the claim for. surgical services, allowing
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`reimbursement in the amount of $0.00.
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`80.
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`After Plaintiff's claims for services provided to A.D. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #7: 0.M, Date of Service: 6/6/15
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`81.
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`On June 6, 2015, O.M. was admitted to the Hackensack University Medical Center
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`emergency room after he fell off his skateboard.
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`82.
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`O.M. was insured through his Oxford Freedom Plan provided by his mother's
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`employer.
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`83.
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`Upon being admitted to the emergency room, x-rays and examination revealed that
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`O.M. had suffered a left radius ulnar shaft fractures, type 2 open fractures.
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`84. Due to the severity of 0.M.'s injuries, the emergency room physician referred O.M.
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`to Plaintiff to take over his care.
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`85.
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`Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`86. On June 6, 2015, Plaintiff performed medically necessary surgery. Plaintiff
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`performed an open reduction and internal fixation of the radius and ulnar shaft.
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`87.
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`The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as O.M. had no choice in selecting the medical
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`provider.
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`88.
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`Oxford provided O.M. with coverage for emergency medical care, either expressly
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`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to O.M.
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`89.
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`Plaintiff submitted a claim to Oxford for the surgical services provided to O.M. in
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`the amount of $99,514.81.
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`90.
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`Oxford drastically underpaid the claim for surgical services, allowing
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`reimbursement in the amount of $11,599.50.
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`91.
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`After Plaintiffs claims for services provided to O.M. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #8: R.R., Date of Service: 9/11/16
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`92. On September 11, 2016, R.R. was admitted to the Clara Maas Medical Center
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`emergency room after he fell while rollerblading.
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`93.
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`R.R. was insured through his Oxford Plan provided by his employer, Philipe's
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`Precision.
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`94.
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`Upon being admitted to the emergency room, x-rays and examination revealed that
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`R.R. had suffered a grade 2 open tibia fracture in his right leg.
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`95.
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`Due to the severity of R.R.'s injuries, the emergency room physician referred R.R.
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`to Plaintiff to take over his care.
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`96.
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`Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`97. On September 11,2016, Plaintiff performed medically necessary surgery. Plaintiff
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`performed an open reduction of the fracture and applied and external fixator.
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`98.
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`The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as R.R. had no choice in selecting the medical
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`provider.
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`99.
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`Oxford provided R.R. with coverage for emergency medical care, either expressly
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`in the plan, or as required by operation of law, thus permitting Plaintiffto render treatment to R.R.
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`100. Plaintiff submitted. a claim to Oxford for the surgical services provided to R.R. in
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`the amount of $112,500.00.
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`101. Oxford drastically underpaid the claim for surgical services, allowing
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`reimbursement in the amount of $7,377.50.
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`102. After Plaintiff's claims for services provided to R.R. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #9: ER., Date of Service: 1/16/17
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`103. On January 16, 2017, E.R. was admitted to the Hackensack University Medical
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`Center emergency room complaining of pain and swelling in his right hand.
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`104. E.R. was insured through his Oxford Plan provided by his employer, Kriegman and
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`Smith.
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`105. Upon being admitted to the emergency room, x-rays and examination revealed that
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`E.R. was suffering from right hand cellulitis on the dorsal aspect of the hand.
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`106. Due to the severity of E.R.'s injuries, the emergency room physician referred E.R.
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`to Plaintiff to take over his care.
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`107. Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`108. On January 16, 2017, Plaintiff performed medically necessary surgery. Plaintiff
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`provided and orthopedic consult, splinting of the injury and follow-up in-patients consults.
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`109. The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as E.R. had no choice in selecting the medical
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`provider.
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`1 10. Oxford provided ER. with coverage for emergency medical care, either expressly
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`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to E.R.
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`I ll. Plaintiff submitted a claim to Oxford for the surgical services provided to E.R. in
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`the amount of $11,700.00.
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`1 12. Oxford drastically underpaid the claim for surgical services, allowing
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`reimbursement in the amount of $931.20.
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`1 13. After Plaintiff's claims for services provided to E.R. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #10: R.M. Date of Service: 2/13/17
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`1 14. On February 13, 2017, R.M. was admitted to the Clara Maas Medical Center
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`emergency room after he slipped on ice.
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`1 15. R.M. was insured through his Oxford Freedom Plan provided by his employer,
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`Bloomfield College.
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`1 16. Upon being admitted to the emergency room, x-rays and examination revealed that
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`R.M. had suffered right quadriceps tendon rupture.
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`1 17. Due to the severity of R.M.'s injuries, the emergency room physician referred R.M.
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`to Plaintiff to take over his care.
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`1 18. Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`1 19. On February 13, 2017, Plaintiff performed medically necessary surgery. Plaintiff
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`performed a right quadriceps tendon repair.
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`120. The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as R.M. had no choice in selecting the medical
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`provider.
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`1 21. Oxford provided R.M. with coverage for emergency medical care, either expressly
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`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to R.M.
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`1 22. Plaintiff submitted a claim to Oxford for the surgical services provided to R.M. in
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`the amount of $53,000.00.
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`123. Oxford drastically underpaid the claim for surgical • services, allowing
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`reimbursement in the amount of $1,941.80.
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`124. After Plaintiff's claims for services provided to R.M. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #11: P.B., Date of Service: 2/20/17
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`125. On February 20, 2017, P.B. was admitted to the Hackensack University Medical
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`Center emergency room after he injured his husband hitting a punching bag.
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`126. P.B. was insured through his Oxford Freedom Plan provided by his employer,
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`Hudson County Community College.
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`1 27. Upon being admitted to the emergency room, x-rays and examination revealed that
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`P.B. had a fifth metacarpal base fracture with possible ligamentous disruption.
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`128. Due to the severity of P.B.'s injuries, the emergency room physician referred P.B.
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`to Plaintiff to take over his care.
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`129. Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`130. On September 25, 2015, Plaintiff performed medically necessary surgery. Plaintiff
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`performed a splinting of the metacarpal fracture.
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`1 31. The treatment rendered was emergent and continuous medical care arising out of
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`an emergency admission at an in-network facility as P.B. had no choice in selecting the medical
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`provider.
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`1 32. Oxford provided P.B. with coverage for emergency medical care, either expressly
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`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to P.B.
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`133. Plaintiff submitted a claim to Oxford for the surgical services provided to P.B. in
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`the amount of $25,625.00.
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`1 34. Oxford drastically underpaid the claim for surgical services, allowing
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`reimbursement in the amount of $1,255.15.
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`135. After Plaintiffs claims for services provided to P.B. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford Insured #12: A. C.. Date of Service: 5/14/17
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`136. On May 14, 2017, A.C. was admitted to the Clara Maas Medical Center emergency
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`room suffering from post-surgical knee pain.
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`137. A.C. was insured under the Oxford Plan through his employer, AC Energy Brokers.
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`1 38. Upon being admitted to the emergency room, x-rays and examination revealed that
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`A.C. was suffering from a partial anterior cruciate ligament tear with bucket handle tear of the
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`medial meniscus of the right knee, and Plaintiff performed a right knee arthroscopy, complete
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`medial meniscectomy, partial lateral meniscectomy, partial synovectomy and extensive
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`debridement of the medial compartment plica formation.
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`1 39. Due to the severity of A.C.'s injuries, the emergency room physician referred A.C.
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`to Plaintiff to take over his care.
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`140. Plaintiff provided continuous, emergent medically necessary care and a
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`determination was made to proceed with surgery.
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`141. On September 25, 2015, Plaintiff performed medically necessary surgery. Plaintiff
`
`performed a splinting of the metacarpal fracture.
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`142. The treatment rendered was emergent and continuous medical care arising out of
`
`an emergency admission at an in-network facility as A.C. had no choice in selecting the medical
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`provider.
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`143. Oxford provided A.C. with coverage for emergency medical care, either expressly
`
`in the plan, or as required by operation of law, thus permitting Plaintiff to render treatment to A.C.
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`144. Plaintiff submitted a claim to Oxford for the surgical services provided to A.C. in
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`the amount of $45,385.50.
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`145. Oxford drastically underpaid the claim for surgical services, allowing
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`reimbursement in the amount of $10,331.61.
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`146. After Plaintiffs claims for services provided to A.C. were underpaid, Plaintiff filed
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`unsuccessful appeals of Oxford's gross underpayment, which appeals were rejected and the
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`improper underpayment was upheld.
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`Oxford's Improper Under Payments
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`147. At all relevant times, Oxford provided the patients noted above with coverage for
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`emergency medical care, either expressly in the plan or as required by operation of law, thus
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`permitting Plaintiff to render emergency treatment to these patients.
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`148. Oxford knew or should have known, that pursuant to New Jersey and federal law,
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`statutes and regulations, Plaintiff was and is required to provide emergent care to all patients,
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`regardless of their ability to pay, or the source of payment. N.J.S.A. 26:2H-18.64.
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`149. As Oxford knows, the law requires Oxford to hold its insured harmless and pay
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`Plaintiff 100% of Plaintiff's billed usual, customary and reasonable ("UCR") charges, less the
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`patient's copay, coinsurance or deductible, if any for emergency services.
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`150. This is true under New Jersey law (N.J.A.C. 11:22-5.8, 11:24-5.3, 11:24-5.1 and
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`1 1:24-9.1(d)) and federal law pursuant to the Affordable Care Act (Public Health Service Act, §
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`2719A (setting minimum reimbursement amounts for out-of-network emergency care).
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`151. The UCR fee is defined as, or is reasonably interpreted to mean, the amount that
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`out-of-network providers, like Plaintiff, normally charge to patients in the free market, i.e.,
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`Without an agreement with an insurance company or other payor to reduce such a charge in
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`exchange for obtaining access to Oxford's members and