`JOHN D. LIPANI, M.D., as an assignee,
`authorized representative, and attorney-in-fact
`of his patient S.L.,
`
`
`Plaintiff,
`
`
`CIGNA HEALTH AND LIFE INSURANCE
`COMPANY,
`
`
`- v. -
`
`Defendant.
`
`
`
`
`
`
`
`
`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 1 of 16 PageID: 1
`
`John W. Leardi
`Nicole P. Allocca
`BUTTACI LEARDI & WERNER LLC
`212 Carnegie Center Suite 202
`Princeton, New Jersey 08540
`609.799.5150
`Attorneys for Plaintiff
`
`
`IN THE UNITED STATES DISTRICT COURT
`DISTRICT OF NEW JERSEY
`
`
`
`
`Civil Action No.: 3:21-cv-16851
`
`
`
`
`COMPLAINT
`
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`Plaintiff JOHN D. LIPANI, M.D. as an assignee, duly-appointed authorized representative,
`
`and attorney-in-fact of his patient S.L., by way of this Complaint against CIGNA HEALTH AND
`
`LIFE INSURANCE COMPANY, hereby alleges upon personal knowledge as to himself and his
`
`own acts, and upon information and belief as to all other matters, based upon, inter alia, the
`
`investigation made by and through his attorneys, as follows:
`
`PARTIES
`
`1.
`
`Dr. John D. Lipani, MD, PhD, FAANS, FACS, is a board certified, fellowship-
`
`trained neurosurgery specialist in brain surgery and spine surgery. Dr. Lipani’s neurosurgery
`
`specialties include complex and minimally invasive spine surgery and non-invasive brain and
`
`spine radiosurgery. Dr. Lipani also specializes in revision spinal surgery including correction of
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 2 of 16 PageID: 2
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`cervical and lumbar fusion and cervical disc replacement surgery. He is the sole owner and
`
`operator of Princeton Neurological Surgery, P.C. (“PNS”).
`
`2.
`
`PNS is a New Jersey professional corporation with a principal place of business
`
`located at 3836 Quakerbridge Road Suite 203 Hamilton, New Jersey 08619, which owns and
`
`operates a neurological surgery practice that specializes in brain tumor treatment, treatment of
`
`intracranial conditions, complex brain surgery, brain tumor surgery, complex spine surgery, and
`
`minimally invasive surgery.
`
`3.
`
`Upon information and belief, Cigna Health and Life Insurance Company (“Cigna”)
`
`is an operating subsidiary of Cigna Corporation with a principal place of business of Two Chestnut
`
`Place, 1601 Chestnut Street, Philadelphia, PA 19192.
`
`4.
`
`Upon information and belief Cigna underwrites and/or administers certain
`
`commercial health plans (“Plan” or “Plans”), through which healthcare expenses incurred by Plan
`
`insureds (“Insureds”) for services and/or products covered by the Plans (“Covered Services”) are
`
`reimbursed by and/or through Cigna, subject to each Plan’s terms.
`
`5.
`
`At all times relevant hereto, S.L. was a “beneficiary,” as defined by 29 U.S.C. §
`
`1002(8), in an “Employee Health Benefit Plan,” as defined by 29 U.S.C. § 1002(1) administered
`
`by Cigna, through her Employer Prudential Insurance Company of America. S.L. received health
`
`benefits through the Prudential Insurance Company of America Medical Plan (the “Plan”).
`
`6.
`
`Dr. Lipani is authorized pursuant to an assignment to bring this claim on his own
`
`behalf, or alternatively on behalf of S.L. as her authorized representative and attorney-in-fact to
`
`the extent her Plan contains an “anti-assignment clause.”
`
`
`
`JURISDICTION AND VENUE
`
`7.
`
`Cigna’s actions in administrating the Plans are governed by the Employee
`
`2
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 3 of 16 PageID: 3
`
`Retirement Income Security Act of 1974, 29 U.S.C. § § 1001 to 1461 (“ERISA”). This Court,
`
`therefore, has subject matter jurisdiction over the claim for benefits brought under 29 U.S.C. §
`
`1132(a)(1)(B) herein pursuant to 29 U.S.C. § 1132(e).
`
`8.
`
`Venue in this District is appropriate pursuant to 28 U.S.C. § 1391, as the District of
`
`New Jersey is the District where a substantial amount of the activities forming the basis of the
`
`Complaint occurred.
`
`9.
`
`This Court has personal jurisdiction over Cigna because Cigna has substantial
`
`contacts with, and regularly conducts business in, New Jersey.
`
`STANDING
`
`10.
`
`As a beneficiary of the Plan as that term is defined in 29 U.S.C. § 1002(8), S.L., has
`
`standing to bring this action under 29 U.S.C. § 1132(a)(1)(B).
`
`11.
`
`By and through an assignment of benefits, S.L, has assigned her right to bring this
`
`action to Dr. Lipani, who therefore has standing to bring this action under 29 U.S.C. §
`
`1132(a)(1)(b). The instrument S.L. executed in favor of Dr. Lipani incorporates, inter alia, the
`
`below language:
`
`I hereby assign all applicable health insurance benefits to which I and/or my
`dependents are entitled to [PNS] and/or [Dr. Lipani] . . . I hereby authorize the
`[PNS] and/or [Dr. Lipani] to submit claims, on my and/or my dependent’s behalf,
`to the benefit plan.
`
`12.
`
`The assignment of benefits and claims also states, in relevant part:
`
`
`
`I hereby designate, authorize, and convey to [PNS] and/or [Dr. Lipani] to the full
`extent permissible under law and under any applicable insurance policy and/or
`employee health care benefit plan. . . the right and ability to act as my Authorized
`Representative in connection with any claim, right or cause in action said that I may
`have under such insurance policy insurance policy and/or benefit plan.
`
`13.
`
`S.L. has also designated Dr. Lipani as her “authorized representative,” as defined
`
`in 29 C.F.R. § 2560.503-1, and Dr. Lipani may, therefore, bring this action on behalf of S.L. under
`
`3
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 4 of 16 PageID: 4
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`29 U.S.C. § 1132(a)(1)(B). The instrument S.L. executed in favor of Dr. Lipani incorporates, inter
`
`alia, the below language:
`
`I hereby designate, authorize, and convey to [PNS] and/or [Dr. Lipani] to the full
`extent permissible under law and under any applicable insurance policy and/or
`employee health care benefit plan: (1) the right and ability to act as my Authorized
`Representative in connection with any claim, right, or cause in action that I may
`have under such insurance policy and/or benefit plan; and (2) the right and ability
`to act as my Authorized Representative to pursue such claim, right, or cause of
`action in connection with said insurance policy and/or benefit plan (including but
`not limited to, the right and ability to act as my Authorized Representative with
`respect to a benefit plan governed by the provisions of ERISA as provided in 29
`C.F.R. §2560.5031(b)(4) with respect to any healthcare expense incurred as a result
`of the services I received from Provider and, to the extent permissible under the
`law, to claim on my behalf, such benefits, claims, or reimbursement, and any other
`applicable remedy, including fines.
`S.L. also designated Dr. Lipani as her “attorney-in-fact” for purposes of pursuing
`14.
`
`this claim. The instrument S.L. executed in favor of PNS incorporates, inter alia, the below
`
`language:
`
`I hereby designate, authorize, and convey to Provider to conduct insurance
`transactions and to demand, sue for, collect, recover and receive all goods, claims,
`debts, monies, and demands whatsoever now or shall hereafter become due, owning
`or belonging to me (including the right to institute any action, suit or legal
`proceedings, for the recovery of any claims or any part, or parts, thereof, to the
`possession whereof I may be entitled), to have and take all means for the recovery
`thereof, by action at law, suits in equity, or otherwise, and to compromise and agree
`for the same, and to make, execute and deliver receipts, releases, acquittances or
`other sufficient discharges therefore, and to sue and to settle suits of any kind in my
`name or on my behalf. This Power of Attorney extends to the power to conduct
`litigation and other legal proceedings, including the acceptance of service of
`process on my behalf, related to any insurance transactions.
`This Power of Attorney includes the power to conduct health care billing,
`recordkeeping and payment, which authorizes the Provider to act as my
`representative pursuant to the Health Insurance Portability and Accountability Act
`of 1996 (“HIPAA”), sections 1171 through 1179 of the Social Security Act, 42
`U.S.C. Section 1320d, and applicable regulations, in order to take action including
`but not limited to obtaining access to my health care information.
`
`4
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 5 of 16 PageID: 5
`
`Provider shall follow my instructions as set forth in this Assignment of Benefits.
`The Provider shall not be authorized to make any health care decisions on my
`behalf. Furthermore, I do not authorize the Provider to: (a) make gifts or gratuitous
`transfers, including but not limited to gifts or gratuitous transfers of my property to
`the Provider; or (b) designate, change or revoke the beneficiary designations in any
`life insurance, annuity, or similar contract, employee benefit or plan or retirement
`benefit or plan, payable on death or transfer on death account, or any other account
`or benefit; or (c) make, amend, alter, revoke or terminate any inter vivos trust,
`registration of my securities in beneficiary form, or any provisions for nonprobate
`transfer at death or to open, modify or terminate a transfer on death account; or (d)
`make transfers of property, money or other assets to any trust; or (e) disclaim
`property or disclaim a power of appointment or discretion held by me as executor
`or trustee or in a similar fiduciary capacity; or (f) open or close any account of mine
`including an account naming the Provider and I as joint owners unless the change
`in account status is solely ministerial in nature; or (g) create or change rights of
`survivorship; or (h) renounce my designation as fiduciary for another person; or (i)
`reject, renounce, disclaim, release, or consent to a reduction in or modification of a
`share in or payment from an estate, trust or other beneficial interest; or (j) delegate
`to others any one, more or all of the powers that have been conferred on the
`Provider.
`
`15.
`
`The Power of Attorney is duly witnessed and notarized, and therefore comports
`
`with the New Jersey Revised Durable Power of Attorney Act, N.J.S.A. 46:2B-8.1 to -17
`
`(“RDPAA”). It is attached hereto as Exhibit A.
`
`S.L.’S CLAIM FOR BENEFITS
`
`16.
`
`S.L. presented to Dr. Lipani with a long-standing history of low back pain and prior
`
`lumbar decompression and fusions. She was complaining of unremitting mechanical low back
`
`pain, in addition to neurogenic claudication.
`
`17.
`
`After an extensive review of the patient’s history, medical records and imaging
`
`studies, Dr. Lipani identified adjacent level disease at L3-4 where there was a 6 mm degree of
`
`spondylolisthesis and severe central canal stenosis as a consequence of bilateral hypertrophied
`
`facet joints. Additionally, S.L. suffered from severe sclerotic degenerative disease at L1-2, where
`
`there was bone-on-bone and moderate central canal stenosis. Lastly, a CT scan of the lumbar spine
`
`5
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 6 of 16 PageID: 6
`
`revealed incomplete fusion at L4-5 and L5-S1.
`
`18.
`
`As such, Dr. Lipani diagnosed L1-2 degenerative disc disease, endplate sclerosis,
`
`stenosis with L3-4 spondylolisthesis, bilateral facet hypertrophy, stenosis, L4-5, L5-S1
`
`pseudoarthrosis with mechanical low back pain and neurogenic claudication.
`
`19.
`
`Because of this diagnosis, Cigna approved a lumbar spine fusion, which includes
`
`arthrodesis, poster segmental instrumentation, insertion of interbody biomechanical device,
`
`morselized allograft, autograft and laminectomy, facetectomy and foraminotomy of a single
`
`vertebral segment. The pre-authorization confirmation number for this procedure was B5729HK1.
`
`20.
`
`Based upon this diagnosis, Dr. Lipani attempted to perform an invasive surgical
`
`procedure on S.L. on December 27, 2019, to alleviate severe back pain.
`
`21.
`
`Specifically, S.L. was placed under general anesthesia. However, prior to
`
`positioning the patient prone on the table, it was noted that the patient exhibited significant
`
`hypotension and the anesthesiologist was having difficulty maintaining her blood pressure.
`
`22.
`
`Consequently, there was a grave concern that proceeding with a long and involved
`
`spinal surgery in the prone position would be extremely dangerous and life threatening to S.L.
`
`23.
`
`As such, Dr. Lipani and the anesthesia physicians decided to abort the surgery to
`
`void unnecessary injury to the patient.
`
`24.
`
`Pursuant to the aforementioned assignment, PNS timely submitted bills directly to
`
`Cigna for the services rendered to S.L. on December 31, 2021, totaling $515,162.00.
`
`25.
`
`Importantly, the Health Insurance Claim Form (“HICF”) submitted to Cigna
`
`appended the “53 Modifier” to each and every CPT code billed.
`
`26.
`
`According to Cigna’s Modifier Reference Guide, which is incorporated by
`
`reference into Cigna’s Plans, including S.L.’s Plan, the 53 Modifier is used to describe
`
`6
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 7 of 16 PageID: 7
`
`discontinued procedures. Specifically, “it should be reported when a procedure is terminated by
`
`the physician or other qualified health care personnel.”
`
`27.
`
`Cigna describes this policy’s effect on reimbursement as “Cigna provides
`
`reimbursement for the billed procedure at 50% of the fee schedule or other allowed amount when
`
`modifier 53 is appended correctly.”
`
`28.
`
`On February 26, 2020, Cigna denied payment to PNS for S.L.’s services in full,
`
`stating, “operative report does not support procedures performed as billed. Documentation clearly
`
`states surgery was aborted prior to skin incision being made.”
`
`29.
`
`On March 5, 2020, a corrected HCFA was issued for the services rendered to S.L.
`
`This totaled $317,872.00. Again, the “53 Modifier” was appended to each CPT code.
`
`30.
`
`S.L.’s operative report, which was submitted with PNS’s corrected claim form for
`
`S.L.’s services, states that S.L.’s operation was discontinued after anesthesia was administered
`
`because the patient “exhibited significant hypotension” and “the anesthesiologist was having
`
`difficulty maintaining her blood pressure with Neo-Synephrine.” It further stated, “consequently,
`
`there was a grave concern that proceeding with a long and involved spinal surgery in the prone
`
`position would be extremely dangerous and life threatening for the patient. After some [discussion]
`
`myself and the anesthesia physicians, we decided to abort the surgery in an [effort] to avoid
`
`unnecessary injury to the patient.”
`
`31.
`
`On March 27, 2020, Cigna issued a claim review decision that stated each and every
`
`CPT code was denied because “operative report does not support procedures performed as billed.
`
`Documentation clearly states surgery was aborted prior to skin incision being made.”
`
`32.
`
`On April 21, 2020, PNS submitted a Request for Healthcare Professional Payment
`
`Review for the S.L.’s services. This appeal challenged Cigna’s denial of the CPT codes with the
`
`7
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 8 of 16 PageID: 8
`
`53 Modifier as well as Cigna’s denial of CPT 63047 as incidental to another service.
`
`33.
`
`On May 20, 2020, Cigna responded to PNS’s appeal. Cigna upheld the original
`
`determination and found that the claim was processed correctly. Again, Cigna’s reason for the full
`
`denial was “operative report does not support procedures performed as billed. Documentation
`
`clearly states surgery was aborted prior to skin incision being made.”
`
`34.
`
`On June 29, 2020, Cigna acknowledged PNS’s request for an external review using
`
`an independent review organization.
`
`35.
`
`Any administrative remedies that may be required to be pursued under ERISA have,
`
`therefore, been exhausted, should be deemed exhausted under applicable regulations, or would be
`
`futile under the circumstances, and are therefore excused.
`
`36.
`
`Cigna’s denial of benefits was contrary to the terms and conditions of S.L.’s Plan,
`
`including but not limited to, the Modifier Reference Guide referenced herein.
`
`37.
`
`Specifically, Cigna’s determination that Modifier 53 can only be appended to a
`
`claim after a skin incison has been made is incorrect, and not supported by either its own modifier
`
`policy or the AAPC guidelines.
`
`38.
`
`According to the AAPC, the “Discontinued Procedure” Modifier 53 can be
`
`appended to a diagnostic or surgical procedure “when the physician begins a procedure and then
`
`decides to terminate it, since continuing the procedure will threaten the patient’s health.”
`
`39.
`
`The “modifier explanation” goes on to list an example of reasons why a physician
`
`might discontinue a procedure, which includes “severe hypertension or hypotension.” It then
`
`states, “the provider’s documentation should explain why he discontinued the procedure. Submit
`
`the documentation with the insurance claim to justify using modifier 53.”
`
`40.
`
`Neither the AAPC guidelines nor Cigna’s own Modifier Reference Guide, make
`
`8
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 9 of 16 PageID: 9
`
`any reference to the necessity of a skin incision prior to aborting the surgery.
`
`41.
`
`Because Cigna failed to pay the claims here in issue within the time frames set forth
`
`in 29 C.F.R. § 2560.503-1, PNS and Dr. Lipani are permitted to immediately pursue remedies
`
`available under 29 U.S.C. § 1132 on behalf of S.L.
`
`FIRST COUNT
`(Claim for Plan Benefits Under 29 U.S.C. § 1132(a)(1)(B))
`
`36.
`
`PNS and Dr. Lipani repeat and re-allege each and every allegation contained in
`
`Paragraphs 1 to 35 of the Complaint as if set forth at length herein.
`
`37.
`
`By failing to pay benefits to PNS for services provided to S.L., Cigna violated
`
`obligations set forth in its Plan, and such denials were arbitrary, capricious, and manifestly
`
`mistaken.
`
`38.
`
`Because S.L. was a beneficiary of her respective Plan, and because Dr. Lipani is
`
`S.L.’s assignee, authorized representative, and/or attorney-in-fact with respect to the benefit claims
`
`here in issue, Dr. Lipani has standing to bring this cause of action under 29 U.S.C. § 1132(a)(1)(B)
`
`to enforce rights created by the Plan and to seek benefits relating to services provided by Dr. Lipani
`
`to S.L.
`
`WHEREFORE, Plaintiff, Dr. Lipani, as the assignee, authorized representative, and/or
`
`the attorney-in-fact of S.L., demands judgment against Defendant Cigna, as follows: (a) declaring
`
`that Defendant Cigna violated its duties and obligations under the Plan by failing to pay benefits
`
`relating to the services provided by Dr. Lipani to S.L.; (b) directing Defendant Cigna to pay
`
`benefits to Dr. Lipani relating to the services provided to S.L.; (c) prejudgment interest; (d)
`
`attorney’s fees pursuant to 29 U.S.C. § 1132(g)(1); (e) costs pursuant to 29 U.S.C. § 1132(g)(1);
`
`and (f) such other and further relief as the Court may deem equitable and just.
`
`
`
`9
`
`

`

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`
`
`
`
`10
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 11 of 16 PageID: 11
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`CERTIFICATION PURSUANT TO LOCAL CIVIL RULES 11.2 AND 40.1
`
`I hereby certify that, to the best of my knowledge, the matter in controversy is not the
`
`subject of any other pending or anticipated litigation in any court or arbitration proceeding, nor are
`
`there any non-parties known to Plaintiff that should be joined to this action. In addition, I recognize
`
`a continuing obligation during this litigation to file and to serve on all other parties and with the
`
`Court an amended certification if there is a change in the facts stated in this original certification.
`
`CERTIFICATION PURSUANT TO LOCAL CIVIL RULE 201.1
`
`I hereby certify that the above-captioned matter is not subject to compulsory arbitration in
`
`that the Plaintiff seeks declaratory relief and benefits under the Plan exceeding $150,000.00,
`
`exclusive of interest and costs.
`
`
`
`DATED: September 13, 2021
`
`
`
`
`
`
`
`Respectfully submitted,
`
` /s/ Nicole P. Allocca
`Nicole P. Allocca
`BUTTACI LEARDI & WERNER LLC
`212 Carnegie Center, Suite 202
`Princeton, New Jersey 08540
`609-799-5150
`Attorneys for Plaintiff
`
`
`11
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 12 of 16 PageID: 12
`
`
`
`Exhibit A
`
`
`
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 13 of 16 PageID: 13
`Case 3:21-cv-16851 Document1 Filed 09/13/21 Page 13 of 16 PagelD: 13
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`ASSIGNMENT OF BENEFITS /ERISA AUTHORIZED REPRESENTATIVE
`LIMITED POWER OF ATTORNEYTS
`
`FINANCIAL
`
`RESPONSIBILITY
`
`I have requested professional services from Princeton Neurological Surgery, P.C. (“Practice”)
`on behalf of myself and/or my dependents, and understand
`and/or Dr. John Lipani(“Provider”)
`1 am
`that by making this request,
`responsible for all charges incurred during said services.
`I
`understandthatall fees for said services are due and payable
`on the date services are rendered and
`agree to pay all such charges incurred in full immediately upon presentation
`ofthe appropriate
`statementunless other arrangements have been made in advance.
`
`ASSIGNMENT OF INSURANCE BENEFITS
`I hereby assign all applicable health insurance benefits to which | and/or my dependents
`are
`entitled to Practice and/or Provider. I certify that the health insurance information that I provided
`to Practice and/or Provideris accurate as of the date set forth below and that I am
`responsible for
`it updated.
`keeping
`I hereby authorize Practice and/or Provider to submit claims, on my and/or my dependent’s behalf,
`to the benefit plan(orits administrator) listed on the current insurance card I provided
`to Practice
`and/or Provider, in good faith. | also hereby instruct my benefit plan (or its administrator) to pay
`Practice and/or Provider directly for services rendered to me or my dependents. To the extentthat
`my current
`policy prohibits direct payment to Practice and/or Provider, I hereby instruct anddirect
`my benefit plan (or its administrator) to
`to
`provide documentation stating such non-assignment
`I instruct
`myself and Practice and/or Provider upon request. Upon proofof such
`non-assignment,
`to make out the check to me and mail it directly
`my benefit plan (or its
`to Practice
`administrator)
`and/or Provider.
`
`1 am
`aware that having health insurance does not absolve me ofmyresponsibility to ensure
`fully
`that my bills for professional services from Practice and/or Provider are
`paid in full.
`1 also
`understand that I am
`responsible for all amounts not covered by my health insurance,
`including
`co-payments, co-insurance, and deductibles.
`
`AUTHORIZATION TO RELEASE INFORMATION
`
`I hereby authorize Practice and/or Providerto: (1) release any information necessary to my
`health
`my
`benefit plan (orits administrator) regarding
`illness and treatments; (2) process insurance claims
`generated during examinationor treatment; and (3) allow a
`to be used
`photocopy of my signature
`to process insurance claims. This orderwill remain in effect until revoked by
`mein
`writing.
`
`ERISA AUTHORIZATION
`
`I hereby designate, authorize, and convey to Practice and/or Providerto the full extent
`permissible
`under law and underany
`applicable insurance policy and/or employee health care benefit plan: (1)
`to act as my Authorized Representative in connection with any claim,right,
`the right and
`ability
`
`Page lof4
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 14 of 16 PageID: 14
`14
`14 of 16 PagelD:
`Case 3:21-cv-16851 Document1 Filed 09/13/21 Page
`
`or cause in action that may have undersuch insurance policy and/or benefit plan; and (2) theright
`to act as
`or cause ofaction
`and
`to pursue such claim, right,
`my Authorized
`ability
`Representative
`in connection with said insurance policy and/or benefit plan (including but notlimited to, the right
`to act as my Authorized Representative with respect to a benefit plan governed by the
`and ability
`provisions of ERISA as
`provided in 29 C.F.R. §2560.5031(b)(4) with respect to any healthcare
`expense incurred asa result of the services | received from Providerand, to the extent permissible
`under the law, to claim on my behalf, such benefits, claims, or
`reimbursement, and any other
`applicable remedy,includingfines.
`
`POWEROF ATTORNEY
`
`I hereby designate, authorize, and convey to Provider to conduct insurance transactions and to
`demand, sue for, collect, recover and receive all goods, claims, debts, monies, and demands
`whatsoever now orshall hereafter become due, owning
`or
`belonging to me
`to
`(includingtheright
`institute any action, suit or
`or
`legal proceedings, for the recovery of
`any claims or any part,
`parts,
`thereof, to the possession whereofI may be entitled), to have and take all means for the recovery
`thereof, by action at law,suits in equity,
`or otherwise, and to
`compromise and agree for the same,
`and to make, execute and deliver receipts, releases, acquittances
`or other sufficient discharges
`therefore, and to sue andto settle suits of any kind in my name or on my behalf. This Powerof
`Attomey extends to the power to conductlitigation and other legal proceedings, including the
`ofservice of process on my behalf, related to any insurance transactions.
`acceptance
`This Power of Attomey includes the power to conduct health care
`billing, recordkeeping and
`payment, which authorizes the Provider to act as my representative pursuant to the Health
`Insurance Portability and
`Accountability Act of 1996 (“HIPAA”), sections 1171 through 1179 of
`the Social Security Act, 42 U.S.C. Section 1320d, and applicable regulations,
`in order to take
`including but not
`access to my health care information and to
`limited to
`action
`obtaining
`communicate with my health care
`provider.
`Provider shall follow my
`instructions as set forth in this Assignment of Benefits. The Provider
`shall not be authorized to make any health care decisions on my behalf. Furthermore, I do not
`or
`authorize the Providerto: (a) makegifts
`gratuitoustransfers, including but notlimited to
`gifts
`or
`or
`gratuitous transfers of my property to the Provider;
`or revoke the
`(b) designate, change
`beneficiary designationsin any
`or similar contract, employee benefit or
`life insurance, annuity,
`or retirement benefit or
`on death or transfer on death account, or any other
`plan
`plan, payable
`account or
`or
`(c) make, amend, alter, revoke or terminate any inter vivos trust, registration
`benefit;
`of my
`securities in beneficiary form, or any provisions for nonprobatetransfer at death or to open,
`or terminate a transfer on death account; or
`(d) maketransfers of property, moneyor other
`modify
`assets to any
`or
`or disclaim a
`or discretion held
`(e) disclaim property
`powerof appointment
`trust;
`meas executorortrustee or in a similar fiduciary capacity;
`(f) open or close any account of
`or
`by
`an account
`owners unless the changein account
`mine including
`naming the Provider and I as
`joint
`statusis solely ministerial in nature; or
`(g) create or
`of
`or(h) renounce
`changerights
`survivorship;
`as
`or consent
`fiduciary for another person;or(i) reject, renounce, d isclaim, release,
`my designation
`to a reduction in or modification of a share in or paymentfrom anestate, trust or other beneficial
`or
`(j) delegate to others any one, more orall of the powers that have been conferred on
`interest;
`the Provider.
`
`Page 2 of 4
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 15 of 16 PageID: 15
`Case 3:21-cv-16851 Document1 Filed 09/13/21 Page 15 of 16 PagelD: 15
`
`or...
`will continue to be effective if 1 become disabled, incapacitated,
`-This Power of Attomey
`or
`or die. This Power of Attorney is not affected by lapse
`of time. A
`photocopy
`incompetent;
`shall be as effective and valid as
`electronically transmitted copy of this
`Assignment/Authorization
`the original.
`
`
`
`
`
`WITNESSES
`
`f-22 ->/
`
`Date
`
`-
`
`LOW
`
`XS- AUG
`Date
`
`G-28-Z0Z/
`Date
`
`IN WITNESS WHEREOF, I have hereunto set my hand andsealthe
`Signed, sealed, and delivered in the presenceof:
`
`day of, 20
`
`
`
`
` “Print 1 Witness Name
`
`Witness 2
`
`Signature
`
`:
`
`oy
`
`Lut’
`
`x
`Date
`
`*
` Print 2 Witness Name
`
`:
`
`Page 3 of 4
`
`

`

`Case 3:21-cv-16851 Document 1 Filed 09/13/21 Page 16 of 16 PageID: 16
`Case 3:21-cv-16851 Document1 Filed 09/13/21 Page 16 of 16 PagelD: 16
`
`Notary!
`
`State ofNew
`
`Jersey
`
`\,dicllenex
`
`_,
`
`County of
`On
`
`}
`
`before me,
`_,202\
`©/23
`
`county,
`appeared
`
`satisfactorily identifi
`er/themselvés]
`Assignment/A uthorization.
`
`vie |G ___, Notary Public in and forsaid
`,
`[signer/witness(es)] who
`[has/have]
`as the [signer/witness(es)] to the above referenced
`
`oe
`
`sa
`
`> ae,
`a
`FH
`pang A
`SS
`Lf LGA
`
`3
`
`~
`(Affix Notary Stamp Here)
`
`Notary Public Signature
`
`My Commission Expires:_/ |
`
`Meranns Nicoles
`NOTARY PUBLIC
`State of New
`1D @ 50131681
`My Commission Expires 7/16/2025
`
`IS [Zuzz
`
`
`‘Pursuant to New Jersey Assembly Bill 3903, a New Jersey notary public, or an officer authorized in New Jersey to take oaths and
`acknowledgments—including but not limited to a New Jersey licensed attorney—may notarize this Power of Attomey so
`as
`long
`(a) New Jersey Executive Order 103 remains in effect for the duration of the COVID-19 public health emergency; (b) the notary
`or officer is able to communicate with the individual electronically in real time with sight and sound capabilities, including but not
`limited to
`or
`app-based such as Zoom, WebEx, or Facetime; (c) the notary or officer records
`videoconferencing web applications
`the signing and maintains this recording for a
`often (10) years; (d) the notary or officer has either personal knowledge of
`period
`or
`satisfactory evidence ofthe individual's identity from a verifiable source, such as a driver's license,
`the individual's identity
`passport, governmentissued identification, or other form ofidentification issued by
`a verifiable third party; (¢) the notary or officer
`can
`reasonably confirm that the document before the notary or officer is the same document the signee signed; and (f) the notary
`orofficer includes a
`special annotation that the document was signed using “communication technology.”
`
`4 of 4
`
`Page
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`