`
`/ NJ ID 030112003
`Afiyfa H. Ellington, Esq.
`Abira Medical Laboratories, LLC d/b/a
`Genesis Diagnostics
`| #322
`957 Route 33 | Suite 12
`Hamilton Square | New Jersey | 08690
`Tel:
`(212)220-1616 | Fax:
`(609) 798-0327
`aellington@genesisdx.com
`Counsel for Abira Medical Laboratories, LLC d/b/a Genesis
`Diagnostics
`
`UNITED STATES DISTRICT COURT
`FOR THE
`
`DISTRICT OF NEW JERSEY
`
`ABIRA MEDICAL LABORATORIES,
`LLC d/b/a GENESIS DIAGNOSTICS,
`
`|
`!
`|
`
`CASE NO.
`
`VERIFIED COMPLAINT
`
`Plaintiff
`
`VS.
`
`COMMUNITY HEALTH ALLIANCE, ABC
`COMPANTES 1-100, AND JOHN DOES
`1-100
`
`Defendants
`
`I. INTRODUCTION
`
`1.
`
`This is an action seeking to collect,
`
`inter alia,
`
`for
`
`medical laboratory services rendered in the amount of, or in excess
`
`of $467,157.00, exclusive of interest and costs. The Plaintif?f,
`
`Abira Medical Laboratories,
`
`LLC
`
`d/b/a Genesis Diagnostics
`
`(hereafter,
`
`“GENESIS” or “Plaintiff”), performed laboratory test
`
`services,
`
`including but not
`
`limited to COVID-19 tests,
`
`for
`
`the
`
`Defendants,
`
`its agents, servants, employees,
`
`insureds, or others
`
`through whom it acted, or others on whose behalf it acted. GENESIS
`
`Page 1 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 2 of 22 PagelD: 2
`
`performed medical
`
`laboratory testing for
`
`tests
`
`ordered by
`
`physician members of insurance companies, ordered by a non-member
`
`physician, or an insured/patient member of an insurance company.
`
`2.
`
`The Defendant, Community Health Alliance
`
`(hereafter,
`
`“CHA” or “Defendants”), its agents, servants, employees,
`
`insureds,
`
`or others with or through whom it acted, or others on whose behalf
`
`it acted,
`
`including but net
`
`limited to its affiliates,
`
`the ABC
`
`companies
`
`1-100,
`
`and John Does
`
`1-100
`
`(collectively with CHA
`
`referred to as “Defendants”), ordered and/or authorized laboratory
`
`services
`
`including but not
`
`limited to COVID-19
`
`tests
`
`to be
`
`performed by GENESIS.
`
`3.
`
`Plaintiff,
`
`an
`
`authorized
`
`representative
`
`of
`
`the
`
`insured/claimants pursuant
`
`to 29 C.F.R.
`
`§ 2650.503-1(b) (4), has
`
`the right
`
`to file appeals and take any necessary legal action to
`
`secure for the claimants the benefits already paid for under their
`
`insurance contract.
`
`4.
`
`There is iittle dispute that services were rendered.
`
`There is a dispute by Defendants as to whether a few of the tests
`
`
`
`were already paid for,
`
`and the amount of
`
`the remaining balance.
`
`There is a dispute wherein Defendants sought additional records,
`
`which were
`
`supplied,
`
`but which did not
`
`result
`
`in payment.
`
`Effectively, this was an appeal process culminating in the improper
`
`
`
`denial of payment for laboratory services rendered, and exhausting
`
`the available administrative remedy.
`
`Page 2 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 3 of 22 PagelD: 3
`
`5.
`
`A December 22, 2022 demand letter to CHA from attorney
`
`David Ghisalbert, Esq,
`
`(see copy attached hereto as “EXHIBIT A”)
`
`clearly made demand for all unpaid claims. CHA has refused to make
`
`payment for services rendered.
`
`II.
`
`PARTIES
`
`6.
`
`Abira Medical
`
`Laboratories,
`
`LLC
`
`d/b/a
`
`Genesis
`
`Diagnostics
`
`is a domestic limited liability company organized
`
`under
`
`the laws of
`
`the State of New Jersey. Several of GENESIS’
`
`administrators and decision-makers live in New Jersey, work in New
`
`Jersey, and run GENESIS’ affairs from New Jersey.
`7.
`defendant, Community Health Alliance, provides health
`
`insurance services throughout
`
`the United States,
`
`including the
`
`State of Nevada, and has its principal place of business located
`
`at
`
`680 S. Rock Blvd, Reno, NV,
`
`89502, attn.: Casey Gillham,
`
`registered agent.
`
`8.
`
`CENESTS is unaware of the true names and capacities of
`
`Defendants
`
`named
`
`herein
`
`as
`
`ABC
`
`Companies
`
`1
`
`through
`
`100
`
`and JOHN DOFS 1
`
`through 100,
`
`inclusive,
`
`and therefore asserts
`
`
`claims against these Defendants by such fictitious names.
`
`9,
`
`GENESIS will amend this Complaint to show the true names
`
`and capacities of such ABC Companies and JOHN DOES when the same
`
`have been ascertained.
`
`10. GENESIS, on information and belief, alleges that each of
`
`the
`
`fictitious
`
`named Defendants,
`
`jointly and
`
`severally,
`
`are
`
`Page 3 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 4 of 22 PagelD: 4
`
`responsible in some manner for the actions and occurrences herein
`
`alleged,
`
`and that GENESIS’ damages were approximately caused by
`
`their acts.
`
`11.
`
`On further information and belief, GENESIS alleges that
`
`at
`
`all
`
`times
`
`herein
`
`mentioned,
`
`the
`
`ABC
`
`Companies
`
`and JOHN DOR Defendants
`
`acted in
`
`concert with,
`
`through,
`
`and
`
`were/was -the
`
`agent,
`
`employee,
`
`contractor,
`
`partner,
`
`servant,
`
`employee and/or representative, with the permission and consent of
`
`the other Defendants.
`
`III.
`
`JURISDICTION AND VENUE
`
`12.
`
`Jurisdiction is proper
`
`in this court pursuant
`
`to 28
`
`U.S.C. § 1332, due to the complete diversity of the parties,
`
`the
`
`existence of
`
`a
`
`justiciable dispute between the parties,
`
`the
`
`issue(s)
`
`involving federal statutes,
`
`a dollar amount in excess of
`
`that
`
`required for
`
`federal
`
`jurisdiction,
`
`and the fact
`
`that
`
`the
`
`
`services at issue were rendered within the State of New Jersey.
`
`13.
`
`There were continuing and substantial contacts with the
`
`medical
`
`laboratory testing operations
`
`in New Jersey,
`
`between
`
`GENESIS and Defendants.
`
`14. Defendants processed and paid several claims that were
`
`submitted by GENESIS, which taken with the other
`
`factors
`
`is
`
`sufficient to establish sufficient continuing and minimum contacts
`
`in the State of New Jersey, for jurisdictional purposes.
`
`Page 4 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 5 of 22 PagelD: 5
`
`15. Moreover,
`
`the Employee Retirement Income Security Act of
`
`1974
`
`(*ERISA”)
`
`is
`
`unique
`
`in
`
`having
`
`relaxed jurisdictional
`
`requirements,
`
`as
`
`it was designed to remove
`
`jurisdictional
`
`and
`
`procedural obstacles that would hinder effective enforcement
`
`1;
`
`this is reflected directly in the code:
`
`- “Where an action under
`29 U.S.C. § 1132(e) (2)
`this subchapter is brought in a district court of
`the United States,
`it may be brought
`in the
`district where the pian is administered, where
`the breach took place..”,
`
`and
`
`
`§ 1132(f£) “the district courts of the
`i. 29 U.S.C.
`United States shall have jurisdiction, without
`respect
`to the amount
`in controversy or
`the
`citizenship of the parties,
`to grant
`the relief
`provided for in subsection (a) of this section in
`any action.”
`
`femphasis supplied)
`
`16.
`
`Pursuant
`
`to 29 U.S.C. § 1132(e), State courts
`
`have
`
`concurrent jurisdiction over this action.
`
`Iv.
`
`FACTS
`
`GENESIS Operated A Medical Testing Laboratory And Rendered
`[A]
`Services to the Defendants’
`Insurance Companies’
`Insureds/Claimants
`
`17.
`
`GENESIS operated a licensed medical
`
`testing laboratory
`
`business, which provided services nationwide, with approximately
`
`150 limited=toemployees, including but not necessarily
`
`
`
`
`
`
`
`
`
`
`
`
`
`1 Senate Report No. 127,
`Cong.
`& Ad. News 4871.
`
`93*¢ Congress,
`
`15* Session (1973),
`
`in 1974 U.S. Code
`
`Page 5 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 6 of 22 PagelD: 6
`
`physicians,
`
`scientists,
`
`technicians,
`
`administrative personnel,
`
`and sales representatives.
`
`18.
`
`As part
`
`of
`
`its business model,
`
`GENESIS
`
`performed
`
`clinical laboratory,
`
`toxicology, pharmacy, genetics, and addiction
`
`rehabilitation testing services on
`
`specimens
`
`submitted
`
`for
`
`numerous
`
`insureds/claimants located throughout
`
`the United States
`
`(the “Laboratory Testing Services”).
`
`19.
`
`The insurance contracts between the insurance companies
`
`and the insureds/claimants include Benefits clauses or provisions,
`
`which require the Defendants to pay for laboratory testing of the
`
`insureds’ /claimants’ specimen.
`
`20.
`
`As
`
`the Defendants
`
`are
`
`required under
`
`the Benefits
`
`clauses
`
`in the insurance contracts
`
`to pay for
`
`the laboratory
`
`testing
`
`of
`
`the
`
`insureds’ /claimants’
`
`specimen,
`
`the
`
`insureds/claimants designated GENESIS
`
`as
`
`an
`
`assignee
`
`of
`
`the
`
`insurance contracts, as evidenced by providing their authorization
`
`and/or insurance information to GENESIS, specifically for GENESIS
`
`to claim payments from the Defendants for the lab tests.
`
`
`
`21.
`
`Tn addition to being an authorized representative of the
`
`claimants pursuant
`
`to 29 C.F.R.
`
`§ 2560.503-1{b) (4}, when
`
`the
`
`insureds/claimants designated GENESIS
`
`as
`
`an assignee
`
`of
`
`the
`
`insurance contracts,
`
`this did in fact put. GENFSIS in privity of
`
`contract with the Defendants to be paid for the lab tests.
`
`
`Page 6 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 7 of 22 PagelD: 7
`
`92,
`
`CHA regularly refused to pay and/or underpaid claims
`
`instances failed to
`and in some
`properly submitted by GENESIS,
`respond in any way to claims properly submitted by GENESIS, all in
`
`violation of applicable state and federal law.
`
`23.
`
`The Defendants were supposed to pay the claims, pursuant
`
`to the GENESIS fee schedule or
`
`the insurer’s fee schedule,
`
`ofr
`
`typically, negotiate a reasonable fee.
`
`24.
`
`The dates of service for
`
`the claims underlying this
`
`action are from on or about February 2016 to December 2016, with
`
`communication between the parties occurring the latest in 2019.
`
`25, Defendants, however, processed and paid one claim and
`
`communicated concerning hundreds of claims,
`
`so that:
`
`i. by processing/payment
`
`and the communication involved
`
`with
`
`GENESIS’
`
`claim submission,
`
`plus Defendants’
`
`advising from time-to-time that claims submitted were
`
`“processed and paid,” defendants impressed upon GENESIS
`
`that they would continue to honor the claims;
`
`ii. whereas Defendants representatives knew that they merely
`
`induced GENESIS to continue to provide specimen testing
`
`to their insureds/ciaimants,
`
`from whom they collected
`
`premium payments
`
`for
`
`the
`
`insurance
`
`contracts,
`
`but
`
`Defendants intended to watch GENESIS’ claims increase,
`
`knowing that they would later refuse to pay GENESIS for
`
`a substantial amount of outstanding claims;
`
`Page 7 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 8 of 22 PagelD: 8
`
`iii. the Defendants
`
`engaged in the processing/payment of
`
`GENESIS’
`
`claim and
`
`the
`
`intermittent
`
`communication
`
`representing to GENESIS that they would continue to pay
`subsequent claims, with the intention that GENESIS would
`
`rely on such,
`
`to continue providing testing services to
`
`Defendants’
`
`insureds/claimants,
`
`the
`as
`iv. Even
`processing/payment,
`
`prior
`to
`due
`grew,
`claims
`and communication from Defendants’
`
`representatives,
`
`GENESIS reasonably
`
`relied
`
`on
`
`the
`
`Defendants to pay subsequent claims;
`
`grow
`to
`claims
`allowed GENESIS’
`then
`v. Defendants
`substantially and caused financial damage to GENESIS, by
`refusing to pay GENESIS for the substantial outstanding
`
`claims.
`
`GENESIS Is An Authorized Representative of the
`[B]
`Insureds/Claimants
`
`26. Defendants, being health insurance companies,
`
`third-
`
`party administrators, health and welfare funds,
`
`or
`
`even
`
`self-
`
`insured employers, providing health insurance services to their
`
`members,
`intentionally and unlawfully denied benefits to their
`insureds/claimants
`(and their assignees),
`by
`failing to pay
`GENESIS,
`for
`laboratory testing of
`specimen,
`including but not
`limited to COVID-193
`tests, which GENESIS performed for
`the
`
`insureds/claimants.
`
`Page § of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 9 of 22 PagelD: 9
`
`27, Defendants have contractual obligations to the natural
`
`person insureds/claimants.
`
`28.
`
`To
`
`the
`
`extent
`
`that
`
`the contracts
`
`relevant
`
`to the
`
`underlying claims are governed by ERISA,
`
`this action is brought
`
`to:
`
`(1)
`
`recover benefits pursuant
`
`to 29 U.S.C,
`
`§ 1132 (a) {1) (B),
`
`and (2)
`
`for equitable relief, pursuant to 29 U.S.C.
`
`§ 1132 (a) (3).
`
`29,
`
`Pursuant to 29 C.F.R. § 2560.503-1(b) (4), GENESIS is an
`
`“authorized
`
`representative”
`
`acting
`
`on
`
`behalf
`
`
`of
`
`the
`
`insureds/claimants for any necessary legal action,
`
`to secure for
`
`the insureds/claimants,
`
`the benefits that
`
`they already paid for
`
`under the contracts with the Defendants.
`
`30.
`
`For the purpose of their claims,
`
`the insureds/claimants
`
`designated GENESIS
`
`as
`
`their
`
`assignee,
`
`as
`
`evidenced by
`
`the
`
`insureds/claimants
`
`providing
`
`their
`
`insurance
`
`information
`
`to
`
`GENESIS,
`
`for
`
`the purpose of GENESIS
`
`filing claims with the
`
`Defendants for payment of lab tests, which the insurance contracts
`
`require Defendants to cover.
`
`31. As anyone who has had a medical laboratory test performed
`
`knows, or should know,
`
`it is the usual and customary business
`
`practice of medical
`
`testing laboratories to obtain an insured’s
`
`signature (a)
`
`to authorize the laboratory test
`
`to be performed
`
`(i.e. blood draw, etc.), and (b)
`
`to authorize the medical testing
`
`laboratory to charge the insured’s insurance company and collect
`
` from the insured’s insurance company for the laboratory test
`
`(or
`
`Page 9 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 10 of 22 PagelD: 10
`
`other service) performed; assigning the right of collection to the
`
`laboratory. This was the usual business practice of GENESIS.
`
`32.
`
`GENESIS
`
`exhausted the
`
`administrative
`
`remedies
`
`over
`
`nonpayment of these claims, by filing appeals when the claims were
`
`denied,
`
`thus preserving this action with regard to over two hundred
`
`claims underlying this action,
`
`and any applicable statute of
`
`limitations.
`
`GENESIS seeks benefits under 29 U.S.C. § 1132 (a) (1) (B),
`33.
`and equitable relief 29 U.S.c,
`§ 1132(a) (3),
`in the amount or in
`
`excess of $467,157.00, exclusive of costs and interest.
`
`34.
`
`GENESIS is also entitled to attorney fees and costs of
`
`suit pursuant
`
`to 29 U.S.c.
`
`§ L132(g) (1),
`
`and other Legal
`
`equitable relief as
`
`this court deems appropriate, pursuant
`
`or
`
`to
`
`29 U.S.C. § 1132 (q) (2) (&).
`
`35. Where Defendants are an insurer, it failed to pay GENESIS
`directly for claims GENESIS submitted for its services rendered by
`laboratory testing of the insureds’ /claimants’ specimens.
`
`36. Where Defendants are a
`
`third-party administrator,
`
`it
`
`acted as an agent of the insurer,
`
`furnished by the insurer with
`
`
`the necessary funds
`
`to perform the administrative service of
`
`processing and paying claims on the insurer’s behalf, but
`
`for
`
`avarice,
`
`the third-party administrator failed to process and pay
`
`said claims.
`
`Page 10 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 11 of 22 PagelD: 11
`
`37. Defendants were supposed to verify and honor the claims
`
`submitted by the laboratory, but instead,
`
`they:
`
`i.
`
`entered
`
`inte
`
`insurance
`
`contracts with
`
`the
`
`insureds/ciaimants, by which they communicated to
`
`the insureds/claimants,
`
`that pursuant
`
`to Benefits
`
`Clauses
`
`or
`
`provisions
`
`of
`
`contract,
`
`if
`
`the
`
`insureds/claimants got
`
`tested and gave
`
`the lab
`
`their insurance information,
`
`the insurer would pay
`
`the lab when it submits its claims to the insurer
`
`for laboratory testing it performed;
`
`ii. Defendants
`
`knew that
`
`the
`
`representations
`
`and
`
`promises made
`
`to the insureds/claimants via the
`
`insurance contracts were misrepresentations
`
`and
`
`false promises, with regard to paying for
`
`their
`
`laboratory testing, and knew that such would not be
`
`honored;
`
`1ii. Defendants intended for the insureds/claimants to
`
`rely
`
`on
`
`the
`
`promises
`
`and
`
`representations
`
`communicated to the
`
`insureds/claimants via the
`
`insurance contracts,
`
`that the insurer would ray the
`
`lab when it submits its invoice or claims to the
`
`insurer for laboratory testing it performed;
`
`iv.
`
`The
`
`insureds’ /claimants’
`
`reliance
`
`on
`
`the
`
`Defendants' promises were reasonable, because they
`
`Page 11 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 12 of 22 PagelD: 12
`
`made
`
`the
`
`premium payments
`
`to
`
`the Defendants,
`
`submitted their specimen to GENESIS for testing,
`
`and
`
`designated
`
`GENESIS
`
`assignee/authorized representative
`
`as
`
`of
`
`an
`
`the
`
`insurance contracts
`
`pursuant
`
`to
`
`29 C.FLR. §
`
`2960.503-1(b) (4),
`
`to process payment
`
`for
`
`the lab
`
`testing, as evidenced by providing their insurance
`
`information to GENESIS;
`
`v. Ultimately,
`
`the
`
`Defendants
`
`damaged
`
`the
`
`insureds/claimants by refusing to pay GENESIS,
`
`for
`
`the
`
`laboratory
`
`testing
`
`performed
`
`for
`
`the
`
`insureds/claimants, and also damaged GENESIS, who
`
`came into privity of contract with the Defendants
`
`as an assignee of the insured.
`
`v.
`
`LEGAL CLAIMS
`
`COUNT ONE
`BREACH OF CONTRACT
`
`38.
`
`GENESIS realleges and incorporates herein by reference,
`
`each of the foregoing allegations, paragraphs 1
`
`through 38, as if
`
`expressly rewritten herein.
`
`Page 12 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 13 of 22 PagelD: 13
`
`39,
`
`The Benefits clause in the valid and binding insurance
`
`contracts and insurance plans which the insureds/claimants paid
`
`for,
`
`require the Defendants to pay for the laboratory testing of
`
`the insureds’ /claimants’ specimen.
`
`40.
`
`The insureds/claimants assigned to GENESIS,
`
`the right to
`
`collect from the insurance company, file insurance claims for the
`
`lab testing, as evidenced by insureds/claimants providing GENESIS
`
`the necessary insurance information for GENESIS to file the claims
`
`and collect the payments on behalf of the insureds.
`
`41,
`
`GENESIS is in privity with Defendants,
`
`so that GENESIS
`
`is entitled to prompt processing and payment of
`
`the claims for
`
`lab testing services rendered to Defendants'
`
`insureds/claimants.
`
`42. Defendants, however,
`
`repeatedly breached the insurance
`
`contracts by either failing to respond at all to properly submitted
`
`claims or,
`
`for
`
`those claims
`
`in which Defendants did choose to
`
`respond, xegularly refusing to pay claims submitted by GENESIS,
`
`for intentional dilatory reasons that were
`
`(and remain) entirely
`
`groundless.
`
`43.
`
`Due
`
`te Defendants’ acts and/or omissions,
`
`including
`
`their multiple
`
`breaches
`
`of
`
`the
`
`insurance
`
`contracts
`
`and/or
`
`statutory requirements,
`
`the insureds/claimants have been deprived
`
`of
`
`payments
`
`for
`
`lab
`
`testing
`
`GENESIS
`
`provided
`
`to
`
`the
`
`insureds/claimants.
`
`Page 13 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 14 of 22 PagelD: 14
`
`44.
`
`Due
`
`to Defendants’ multiple breaches of
`
`the insurance
`
`contracts, GENESIS has been deprived of payment for the insurance
`
`claims, which the insureds/claimants assigned GENESIS to collect
`
`on their behalf.
`
`45. Defendants made no payments on the balance due and owing,
`
`which is in the amount or
`
`in excess of $467,157.00,
`
`for services
`
`rendered by GENESIS to Defendants'
`
`insureds/claimants, exclusive
`
`of interest and costs.
`
`46. Defendants’ failure to pay GENESIS as required under the
`insurance
`contracts
`(and applicable law)
`caused
`the
`
`insured/claimants and GENESIS to suffer damages,
`
`in the amount of
`
`Or in excess of $467,157.00, exclusive of costs and interest.
`
`COUNT TWO
`BREACH OF IMPLIED COVENANT OF GOOD FAITH AND FAIR DEALINGeeeNSBRDEALLNG
`
`47.
`
`GENESIS realleges and incorporates herein by reference,
`
`each of the foregoing allegations, paragraphs 1
`
`through 47, as if
`
`expressly rewritten herein.
`
`48.
`
`Implied in all contracts is the covenant of good faith
`
`and fair dealing.
`
`49. Defendants’ acts and/or omissions,
`
`including but not
`
`limited to, failure and/or refusal
`
`to respond at all to properly
`
`submitted claims, or
`
`for
`
`those claims
`
`in which Defendants did
`
`choose to respond,
`
`regularly refusing to pay claims submitted by
`
`GENESIS for intentional dilatory reasons that were
`
`{and remain)
`
`entirely groundless, breached the implied covenants.
`
`Page 14 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 15 of 22 PagelD: 15
`
`50. Consequently, Defendants caused the insured/claimants
`
`and GENESIS to suffer damages, for which Defendants are liable,
`
`in
`
`the amount of or in excess of $467,157.00, exclusive of costs and
`
`interest.
`
`COUNT THREE
`FRAUDULENT MISREPRESENTATION
`
`51.
`
`GENESIS realleges and incorporates herein by reference,
`
`each of the foregoing allegations, paragraphs 1
`
`through 51, as if
`
`expressly rewritten herein.
`
`52, Defendants
`
`promised
`
`the
`
`insureds/claimants
`
`in
`
`the
`
`Benefits clause of the insurance contracts,
`
`that they would cover
`
`for the insureds/claimants,
`
`the cost of lab tests for specimen.
`
`53, Defendants knew, by their acts and/or omissions,
`
`that
`
`they merely intended for the insureds/claimants to rely on their
`
`representations in the insurance contracts, and subsequently for
`
`GENESIS,
`
`to rely on their representations, knowing that Defendants
`
`
`would later refuse to pay a substantial amount of claims that would
`
`grow over time.
`
`54.
`
`The insureds/claimants, and subsequently GENESIS, relied
`
`on Defendants’
`
`representations,
`
`in good faith, and such reliance
`
`was reasonable and justified.
`
`55. Defendants
`
`have
`
`therefore
`
`fraudulently induced
`
`the
`
`insureds/claimants to pay insurance premiums, and induced GENESIS
`
`to continue to perform laboratory testing services for Defendants'
`
`Page 15 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 16 of 22 PagelD: 16
`
`insureds/claimants, for which Defendants had no intention to Pay,
`
`and for which Defendants,
`
`in fact, did not pay GENESIS.
`
`56. Consequently, Defendants caused the insured/claimants
`
`and GENESIS to suffer damages, for which Defendants are liable,
`
`in
`
`the amount of or in excess of $467,157.00, exclusive of costs and
`
`interest.
`
`COUNT FOUR
`NEGLIGENT MISREPRESENTATION
`
`S?.
`
`GENESIS realleges and incorporates herein by reference,
`
`each of the foregoing allegations, paragraphs 1
`
`through 57, as if
`
`expressly rewritten herein.
`
`58. Defendants
`
`promised
`
`the
`
`insureds/claimants
`
`in
`
`the
`
`Benefits clause of the insurance contracts,
`
`that they would cover
`
`for the insureds/claimants,
`
`the cost of lab tests for specimen.
`
`
`59. Defendants
`
`knew that
`
`they merely intended for
`
`the
`
`insureds/claimants
`
`to rely on their
`
`representations
`
`in the
`
`insurance contracts, and subsequently for GENESIS,
`
`to rely on their
`
`representations, knowing that Defendants would later refuse to pay
`
`
`a substantial amount of claims that would grow over time.
`
`60.
`
`The insureds/claimants, and subsequently GENESIS, relied
`
`on Defendants’ representations and/or promises,
`
`in good faith, and
`
`such reliance was reasonable and justified.
`
`61. Defendants' negligent misrepresentations
`
`fraudulently
`
`induced the insureds/claimants
`
`to pay insurance premiums,
`
`and
`
`Defendants'
`
`induced
`
`GENESIS
`
`to
`
`continue
`
`Lo
`
`perform
`
`Page 16 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 17 of 22 PagelD: 17
`
`insureds/claimants,
`for Defendants'
`laboratory testing services
`intention to pay,
`and for which
`for which Defendants had no
`Defendants,
`in fact, did not pay GENESIS,
`
`62, Consequently, Defendants caused the insured/claimants
`and GENESIS to suffer damages, for which Defendants are liable,
`in
`the amount of or in excess of $467,157.00, exclusive of costs and
`interest.
`
`COUNT FIVE
`PROMISSORY ESTOPPEL——eeere
`
`GENESIS realleges and incorporates herein by reference,
`63.
`each of the foregoing allegations, Paragraphs 1
`through 63, as if
`expressly rewritten herein.
`
`the
`in
`insureds/claimants
`the
`promised
`64, Defendants
`Benefits clause of the insurance contracts,
`that they would cover
`for the insureds/claimants,
`the cost of lab tests for specimen,
`65. Defendants
`knew that by their acts and/or omissions,
`their payments and communication,
`they merely intended for
`the
`insureds/claimants,
`and for GENESIS to rely on their promises,
`knowing that they would later refuse to pay a substantial amount
`of claims that would grow over time.
`
`The insureds/claimants and GENESIS relied on Defendants,
`66.
`especially because Defendants actually sprinkled payments
`to
`GENESIS, and Defendants’ representatives communicated with GENESIS
`in good faith,
`and such reliance was
`reasonable and justified,
`with regard to ongoing and outstanding claims,
`
`Page 17 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 18 of 22 PagelD: 18
`
`67. Defendants,
`
`in fact,
`
`did not pay GENESIS
`
`for
`
`the
`
`continued testing,
`
`and the substantial amount of claims GENESIS
`
`later submitted to them.
`
`68. Defendants
`
`are
`
`or
`
`should be
`
`estopped
`
`from acting
`
`contrary to their representations and statutory obligations.
`
`69. Consequently, Defendants caused the insured/claimants
`
`and GENESIS to suffer damages, for which Defendants are liable,
`
`in
`
`the amount of or in excess of $467,157.00, exclusive of costs and
`
`interest.
`
`COUNT SIX
`
`EQUITABLE ESTOPPEL
`
`70.
`
`GENESIS realleges and incorporates herein by reference,
`
`each of the foregoing allegations, paragraphs 1
`
`through 70, as if
`
`expressly rewritten herein.
`
`71. Defendants
`
`promised
`
`the
`
`insureds/claimants
`
`in
`
`the
`
`Benefits clause of the insurance contracts,
`
`that they would cover
`
`for the insureds/claimants,
`
`the cost of lab tests for specimen.
`
`7z. Defendants
`
`knew,
`
`by their acts and/or omissions,
`
`by
`
`their payments and communication,
`
`they merely intended for
`
`the
`
`insureds/claimants,
`
`and for GENESIS to rely on their promises,
`
`knowing that they would later refuse to pay a substantial amount
`
`of claims that would grow over time.
`
`73.
`
`The
`
`insureds/claimants did not
`
`know that Defendants
`
`intended only for them to believe Defendants would pay for the
`
`Page 18 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 19 of 22 PagelD: 19
`
`laboratory testing, without actually intending to pay for the lab
`
`tests.
`
`74,
`
`GENESIS did not know that Defendants intended only for
`
`it to believe they would pay for the laboratory testing, without
`
`actually intending to pay GENESIS
`
`for
`
`subsequent
`
`lab tests,
`
`especially because Defendants paid GENESIS at one point.
`
`75.
`
`The insureds/claimants and GENESIS relied on Defendants,
`
`especially because Defendants actually sprinkled payments
`
`to
`
`GENESIS, and Defendants' representatives communicated with GENESIS
`
`in good faith,
`
`and such reliance was
`
`reasonable and justified,
`
`with regard to ongoing and outstanding claims.
`
`76. Defendants are or
`
`should be equitably estopped from
`
`acting
`
`contrary
`
`to
`
`their
`
`representations
`
`and
`
`statutory
`
`obligations.
`
`77. Defendants did not pay for the continued testing,
`
`and
`
`the substantial amount of claims GENESTS later submitted to them.
`
`78. Consequently, Defendants caused the insureds/claimants
`
`and GENESIS to suffer damages, for which Defendants are liable,
`
`in
`
`the amount of or in excess of $467,157.00, exclusive of costs and
`
`interest.
`
`COUNT SEVEN
`QUANTUM MERUIT / UNJUST ENRICHMENT
`
`79,
`
`GENESIS realleges and incorporates herein by reference,
`
`each of the foregoing allegations, paragraphs 1
`
`through 79, as if
`
`expressly rewritten herein.
`
`Page 193 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 20 of 22 PagelD: 20
`
`80.
`
`In accordance with the insurance contracts between the
`
`Defendants
`
`and -the
`
`insureds/claimants, Defendants
`
`collected
`
`insurance premium payments,
`
`in exchange
`
`for which they were
`
`Supposed to use a portion of the premium payments they pooled to
`
`pay
`
`for
`
`the
`
`laboratory testing services promised under
`
`the
`
`contracts.
`
`is against equity and good conscience to permit
`It
`Sl.
`Defendants to retain the money it intentionally and wrongfully
`failed to pay for lab tests, on behalf of the insureds/claimants.
`
`82. Defendants have been unjustly enriched in the amount of
`
`not less than $467,157.00, plus interest, which pursuant to which
`
`pursuant
`
`to 29 C.F.R.
`
`§ 2560,.503-1(b) (4),
`
`the insureds/claimants
`
`authorized GENESIS to collect on their behalf.
`
`VI. RELIEF SOUGHT
`
`WHEREFORE, Plaintiff, Abira Laboratories, LLC d/b/a Genesis
`
`judgment against Defendants, Community
`for
`Diagnostics prays
`Health Alliance, as follows:
`
`i. Damages in the amount of or in excess of $467,157.00 for
`
`(a) benefits due to the insureds/claimants, cumulatively,
`
`pursuant to 29 U.S.C, § 1132(a) (1) (B) and/or (b) equitable
`
`relief
`
`due
`
`to
`
`the
`
`insureds/claimants,
`
`cumulatively,
`
`pursuant
`
`to 29 U.S.C. § 1132 (a} (3);
`
`ii. Compensatory damages, contractual damages, consequential
`
`damages and punitive damages;
`
`Page 20 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 21 of 22 PagelD: 21
`
`iii. Award of pre-judgment and post-judgment interest;
`
`iv. Attorney’s fees and costs of suit; and
`
`v. For such other relief deemed just and equitable.
`
`JURY DEMAND
`
`Pursuant
`
`to Federal Rule of Civil Procedure 38, Plaintiff
`
`hereby demands
`
`trial by jury of all applicable issues in this
`
`action.
`
`Respectfully submitted,
`
`Dated: March 29, 2024
`
`s/
`
`Afiyfa H. Ellington, Esq.
`Afiyfa H. Ellington, Esq.
`
`Abira Medical Laboratories, LLC d/b/a
`Genesis Diagnostics
`957 Route 33 | Suite 12 | #322
`Hamilton Square | New Jersey | 08690
`Tel: (212)220-1616 |Fax:
`(609) 798-0327
`aellington@genesisdx.com
`
`
`
`VERIFICATION
`
`I, Alan Miller, being of full age and duly sworn according
`
`to law upon my oath, depose and say:
`
`1.
`
`I am the Chairman of the Board of Directors of
`
`Abira Medical Laboratories, LLC d/b/a Genesis Diagnostics,
`
`a limited liability company of the State of New Jersey.
`
`Page 21 of 22
`
`
`
`Case 3:24-cv-04524-GC-JBD Document1 Filed 04/04/24 Page 22 of 22 PagelD: 22
`
`Zs
`
`IT have read the foregoing Verified Complaint, and
`
`the information contained therein is true and accurate
`
`based upon my personal knowledge and information.
`
`I certify that the foregoing statements made by me are
`
`true.
`
`I am aware that if any of the foregoing statements made by
`
`me are willfully false,
`
`I am subject to punishment.
`
`Dated: March 29, 2024
`
`ABRIA MEDICAL LABORATORIES, LLC
`D/B/A GENESIS DIAGNOSTICS
`
`
`ad
`
`eats gg,
`Alan Miller
`
`Chairman of the Board of
`
`Directors
`
`Page 22 of 22
`
`