Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 1 of 18 PageID #: 9
`Case 1:21-cv-06290 Document1-1 Filed 11/11/21 Page 1 of 18 PagelD #: 9
`
`EXHIBIT A
`EXHIBIT A
`
`
`
`
`
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 2 of 18 PageID #: 10
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF QUEENS
`NORMAN MAURICE ROWE, M.D., M.H.A.,L.L.C. &
`EAST COAST PLASTIC SURGERY, PC
`
`
`
`
`
`
`Plaintiffs,
`
`
` - Against -
`
`
`OXFORD HEALTH INSURANCE, INC.; OXFORD
`HEALTH PLANS (NJ), INC.; OXFORD HEALTH
`PLANS (NY), INC., and OXFORD HEALTH PLANS
`LLC,
`
`
`
`
`
`
`
`
`
`
`
`
` Defendants.
`
`
`
`
`
`
`
`
`
`
`
`Index No.
`
`SUMMONS
`
`Plaintiff’s Residence:
`NORMAN MAURICE ROWE, M.D.,
`M.H.A.,L.L.C. & EAST COAST
`PLASTIC SURGERY, PC
`
`Plaintiff designates QUEENS as
`the place of trial. The basis of this
`designation is: Defendant transacts
`business in QUEENS
`
`Breach of Contract
`
`To the above named defendant:
`
`September 13, 2021
`
`YOU ARE HEREBY SUMMONED to answer the complaint in this action and to serve a
`copy of your answer, or, if the complaint is not served with this summons, to serve a
`notice of appearance, on the Plaintiff's attorney within 20 days after the service of
`this summons, exclusive of the day of service (or within 30 days after the service is
`complete if this summons is not personally delivered to you within the State of New
`York); and in case of your failure to appear or answer, judgment will be taken
`against you in the amount of $293,126.15
`
`Dated:
`
`Defendant’s Address:
`OXFORD HEALTH INSURANCE, INC.
`One Penn Plaza, Floor 8
`New York, NY 10119
`OXFORD HEALTH PLANS (NJ), INC.
`c/o CT CORPORATION SYSTEM
`28 Liberty Street
`New York, NY 10005
`OXFORD HEALTH PLANS (NY), INC.
`c/o CT CORPORATION SYSTEM
`28 Liberty Street
`New York, NY 10005
`OXFORD HEALTH PLANS LLC
`c/o CT CORPORATION SYSTEM
`28 Liberty Street
`New York, NY 10005
`
`
`
`LEWIN & BAGLIO, LLP
`By: Michael Baglio, Esq.
`Attorneys for the Plaintiff
`1100 Shames Drive
`Suite 100
`Westbury, New York 11590
`Tel: (516) 307- 1777
`Fax: (516) 307- 1770
`L&B File No.: 2125.COM.55
`
`L&B File No.: 2125.COM.55
`
`1 of 17
`
`
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 3 of 18 PageID #: 11
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF QUEENS
`NORMAN MAURICE ROWE, M.D., M.H.A.,L.L.C. &
`EAST COAST PLASTIC SURGERY, PC
`
`
`
`
`
`Plaintiffs,
`
`
` - Against -
`
`
`OXFORD HEALTH INSURANCE, INC.; OXFORD
`HEALTH PLANS (NJ), INC.; OXFORD HEALTH
`PLANS (NY), INC., and OXFORD HEALTH PLANS
`LLC,
`
`
`
`
`Plaintiff, NORMAN MAURICE ROWE, M.D., M.H.A.,L.L.C. & EAST COAST
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Index No.
`
`COMPLAINT
`
`
`
`
`
`
`
`
`
`
`
`Defendants.
`
`PLASTIC SURGERY, PC, alleges:
`
`JURISDICTION AND VENUE
`
`1) This Court has personal jurisdiction over the parties because Defendant,
`
`OXFORD HEALTH INSURANCE, INC. is an insurance company licensed and
`
`authorized to do business in the State of New York; OXFORD HEALTH
`
`INSURANCE, INC. violated New York Law while doing business in New York
`
`State.
`
`2) OXFORD HEALTH INSURANCE, INC. transacts business in QUEENS
`
`County.
`
`L&B File No.: 2125.COM.55
`
`2 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 4 of 18 PageID #: 12
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`PARTIES
`
`3) Defendant, OXFORD HEALTH INSURANCE, INC.(hereinafter “OXFORD”
`
`or “the Insurer”) is an insurance company licensed and authorized to do business in
`
`the State of New York.
`
`4) NORMAN MAURICE ROWE, M.D., M.H.A.,L.L.C. & EAST COAST
`
`PLASTIC SURGERY, PC (“ROWE” or “the Provider”) is a Professional Services
`
`Company that provides health services in the State of New York.
`
`FACTUAL ALLEGATIONS
`
`5) Dr. Norman Rowe and Dr. Charles Pierce are affiliated with ROWE;
`
`OXFORD considers Dr. Norman Rowe and Dr. Charles Pierce to be out-of-network
`
`providers. That means Dr. Charles Pierce and OXFORD did not pre-negotiate
`
`charges for services billed to OXFORD.
`
`6) OXFORD offered to pay for medical services rendered to a person with
`
`initials “M.F.” (herein after “M.F.”).
`
`7) By letter dated October 5, 2020, OXFORD offered to pay for medical services
`
`provided by ROWE to M.F. at amount equal to the “in-network” benefit level.
`
`8) Based on information and belief, the source being a networking agreement
`
`that OXFORD participated in on October 5, 2020, the “in-network” benefit level is
`
`equal to 80% of the amount billed by the provider.
`
`9) ROWE accepted OXFORD’s offer by doing what it was required to do when it
`
`provided M.F. with medical services on November 18, 2020.
`
`L&B File No.: 2125.COM.55
`
`3 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 5 of 18 PageID #: 13
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`10) ROWE billed OXFORD for the services rendered to M.F.
`
`11) OXFORD did not do what it was required to do.
`
`12) OXFORD did not reject ROWE’s performance within 45 days.
`
`13) OXFORD never provided ROWE with any notice of any good faith dispute
`
`regarding the following: eligibility of M.F. for payment by OXFORD, the liability of
`
`another insurer or corporation or organization for all or part of the bill, the amount
`
`of the bill, or the manner in which the services were accessed or provided within 45
`
`days.
`
`14) OXFORD ultimately, issued payment that was late and unreasonable for the
`
`services ROWE provided.
`
`15) OXFORD knew that its actions would increase M.F.‘s liability to ROWE in an
`
`amount equal to the billed amount, $300,000.00 less OXFORD’s late and
`
`unreasonable payment of $6,873.85.
`
`16) OXFORD knows or should know that its payment, $6,873.85, is less than
`
`what it offered to pay ROWE for providing Reduction Mammaplasty to M.F.
`
`17) OXFORD offered to pay 80% of the amount billed by ROWE for Reduction
`
`Mammaplasty rendered by Dr. Norman Rowe and Dr. Charles Pierce to M.F.
`
`EXPLANATION OF BILLING
`
`18) ROWE billed OXFORD $300,000.00 for the services Norman Rowe provided
`
`to M.F. on November 18, 2020.
`
`L&B File No.: 2125.COM.55
`
`4 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 6 of 18 PageID #: 14
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`19) ROWE indicated Dr. Norman Rowe and Dr. Charles Pierce performed
`
`Reduction Mammaplasty with the following billing code: 19318 - Reduction
`
`Mammaplasty. ROWE annexed modifiers '50' and '80' to billing code 19318.
`
`Healthcare providers use modifiers to indicate a modifying condition. The purpose
`
`of the modifiers used here is to indicate: '50' indicates a procedure that was
`
`performed bi-laterally, '80' indicates assistant surgeon.
`
`20) ROWE billed $150,000.00 for the services Dr. Norman Rowe performed. 80%
`
`of the billed amount is equal to $120,00.00. OXFORD paid $5,924.36.
`
`21) ROWE billed $150,000.00 for the services Dr. Charles Pierce performed. 80%
`
`of the billed amount is equal to $120,000.00. OXFORD paid $949.49.
`
`EXPLANATION OF MONIES OWED
`
`22) Based upon information and belief after reading a network agreement that
`
`Oxford participated in at the time the services were rendered, the in-network
`
`reimbursement rate was equal to 80 percent of the billed amount.
`
`23) OXFORD purported to explain its payment with a form (EOR).
`
`24) The EOR that OXFORD provided to ROWE stated: “This provider or health
`
`care provider is a non-participating (out-of-network) provider. As a result, the claim
`
`has been processed using a percentage of the Medicare rate for the services
`
`provided.”
`
`25) The EOR does not reference the October 5, 2020 letter to ROWE promising to
`
`cover the aforementioned services at the “in-network” rate.
`
`L&B File No.: 2125.COM.55
`
`5 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 7 of 18 PageID #: 15
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`26) There is nothing on the EOR that provides any understanding or justification
`
`for how OXFORD calculated $6,873.85.
`
`27) OXFORD issued a payment of $6,873.85 (“Prior Payment”).
`
` OXFORD’S PAYMENT IS NOT A REASONABLE AMOUNT
`
`28) OXFORD’s payment of $$6,873.85 is not a reasonable amount.
`
`29) In the medical and insurance industry, a reasonable amount is also referred
`
`to as “Reasonable and Customary,” "Usual and Customary," "Usual, Customary,
`
`and Reasonable," or "UCR" (collectively “UCR”).
`
`30) In the medical and insurance industry, the usual and customary
`
`reimbursement is defined as the provider’s actual charge, or the provider’s usual
`
`charge for the same or similar services, or the usual charge of other providers for
`
`the same or similar services in the same geographic region (“GEOZIP”).
`
`31) When calculating UCR insurers typically rely on rate schedules assembled
`
`from a survey of average treatment charges in a given GEOZIP.
`
`32) There are several resources insurance companies frequently use to determine
`
`UCR for a given procedure in a GOEZIP. Examples of frequently used sources that
`
`are widely available and recognized as being reliable are FAIR Health and Centers
`
`for Medicare and Medicaid (“CMS”).
`
`33) New York State Department of Financial services recognizes the 80th
`
`percentile of the FAIR Health rate as UCR.
`
`L&B File No.: 2125.COM.55
`
`6 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 8 of 18 PageID #: 16
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`34) The amount OXFORD paid was not the billed amount, was not a reasonable
`
`amount for the services rendered because it is not comparative to payments for
`
`similarly situated surgeons performing the same services.
`
`35) $6,873.85 is not consistent with any percentile of the FAIR Health rate, is not
`
`consistent with any multiple of the CMS rate, and is not equal to the 80th
`
`percentile of the FAIR Health.
`
`36) OXFORD is intentionally withholding the difference between what it paid
`
`and what it was required to pay because it incorrectly paid ROWE “out-of-network”
`
`benefits, when OXFORD previously and expressly promised to pay “in-network”
`
`benefits.
`
`
`
`
`
`FIRST CAUSE OF ACTION—BREACH OF EXPRESS
`AGREEMENT
`
`37) Plaintiff repeats and re-alleges the allegations of all previous paragraphs as
`
`if fully set forth herein.
`
`38) ROWE and OXFORD had an agreement.
`
`39) ROWE did what it was required to do under the agreement by rendering
`
`services to M.F. and then billing OXFORD.
`
`40) OXFORD did not do what it was required to do under the agreement because
`
`it did not pay ROWE the billed amount, a reasonable amount, or 80% of the billed
`
`amount.
`
`L&B File No.: 2125.COM.55
`
`7 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 9 of 18 PageID #: 17
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`41) As a result of the foregoing, ROWE has been damaged in the amount of
`
`$233,126.15.
`
`SECOND CAUSE OF ACTION—UNJUST ENRICHMENT
`
`42) Plaintiff repeats and re-alleges the allegations of all previous paragraphs as
`
`if fully set forth herein.
`
`43) In good faith and with the expectation of compensation from OXFORD,
`
`ROWE rendered medical treatment to M.F. on November 18, 2020.
`
`44) ROWE expected payment from OXFORD because OXFORD had paid ROWE
`
`for the same or similar services under the same or similar circumstances in the
`
`past.
`
`45) M.F.’s perception, valid or otherwise, that OXFORD facilitated M.F.
`
`receiving services from the medical provider of their own choosing has a value to
`
`OXFORD; OXFORD’s opportunity to showcase its product to ROWE, a medical
`
`provider with which OXFORD had no contractual relationship, also has value to
`
`OXFORD. OXFORD, therefore, directly benefited by ROWE providing medical
`
`services to M.F. based on OXFORD’s promise of payment in the form of goodwill,
`
`the value attributed by OXFORD to the expectancy of M.F.’s continued customer
`
`patronage.
`
`46) OXFORD profited by not paying ROWE in an amount equal to the difference
`
`between what it actually paid ROWE and the full amount it was otherwise legally
`
`obligated to pay ROWE.
`
`L&B File No.: 2125.COM.55
`
`8 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 10 of 18 PageID #: 18
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`47) As a result of the foregoing ROWE was damaged in an amount equal to
`
`$233,126.15.
`
`THIRD CAUSE OF ACTION—QUANTUM MERUIT
`
`48) Plaintiff repeats and re-alleges the allegations of all previous paragraphs as
`
`if fully set forth herein.
`
`49) OXFORD clearly and unambiguously promised ROWE that if ROWE
`
`rendered medical treatment to M.F., OXFORD would pay out-of-network benefits
`
`for the services ROWE provided.
`
`50) ROWE relied on OXFORD’s promise that its payment would equal 80% of the
`
`billed amount because OXFORD is in the business of paying medical providers like
`
`ROWE for the same or similar services, and ROWE has received payment from
`
`OXFORD for the same or similar services in the past.
`
`51) ROWE provided medical treatments, at little or no cost to M.F., in reliance on
`
`OXFORD's promises of payment.
`
`52) But for OXFORD’s promises of payment ROWE would not have provided the
`
`services to M.F. or would have collected a greater payment from M.F. prior to
`
`rendering any service.
`
`53) OXFORD has benefitted at ROWE’s expense by not having to pay a medical
`
`benefit that it was otherwise obligated to pay and keeping difference between the
`
`two as profit.
`
`L&B File No.: 2125.COM.55
`
`9 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 11 of 18 PageID #: 19
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`54) As a result of the foregoing ROWE was damaged in an amount equal to the
`
`80th percentile of the FAIR Health rate for the services rendered, a reasonable
`
`value for the services rendered, less any partial payment.
`
`FOURTH CAUSE OF ACTION—AIDING AND ABETTING A
`BREACH OF FIDUCIARY DUTY
`
`55) Plaintiff repeats and re-alleges the allegations of all previous paragraphs as
`
`if fully set forth herein.
`
`56) On or about November 18, 2020, OXFORD knew that it owed M.F. a fiduciary
`
`duty. OXFORD was obligated to act in the best interest of M.F., rather than in
`
`OXFORD’s self-interest, as it regards reimbursement for medical services received
`
`by M.F.
`
`57) OXFORD knowingly acted in its own self-interest and not M.F.’s best interest
`
`by not paying 80% of the billed amount, the amount it was legally obligated to pay
`
`for the medical services M.F. received from ROWE.
`
`58) OXFORD knew that its actions would increase M.F.‘s liability to ROWE in an
`
`amount equal to $300,000.00 less $6,873.85.
`
`59) As a direct result of OXFORD’s knowing breach of its fiduciary duty, ROWE
`
`was injured in an amount equal to $233,126.15.
`
`FIFTH CAUSE OF ACTION—VIOLATION OF NEW YORK’S
`PROMPT PAY LAW
`
`60) Plaintiff repeats and re-alleges the allegations all previous paragraphs as if
`
`fully set forth herein.
`
`L&B File No.: 2125.COM.55
`
`10 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 12 of 18 PageID #: 20
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`61) ROWE submitted its claim to OXFORD.
`
`62) OXFORD did not issue payment, object to payment, or request further
`
`information from ROWE regarding the claim within 45 days of receipt of the claim.
`
`63) ROWE is entitled to payment of $300,000.00, the billed amount, less
`
`$6,873.85 OXFORD‘s late and partial payment, PLUS interest at the rate of ONE-
`
`PERCENT (1%) per month computed from THIRTY (30) days after the date the
`
`claim was submitted to the OXFORD until the amount due is paid in full, pursuant
`
`to Insurance Law § 3224-a.
`
`WHEREFORE, NORMAN MAURICE ROWE, M.D., M.H.A.,L.L.C. & EAST COAST
`
`PLASTIC SURGERY, PC demands judgment in the amount of $293,126.15 together
`
`with interest and costs; or in the alternative judgment in the amount of $233,126.15
`
`and granting such other and further relief as the Court may deem just and proper.
`
`
`
`
`
`LEWIN & BAGLIO, LLP
`Attorneys for the Plaintiff
`1100 Shames Drive
`Suite 100
`Westbury, New York 11590
`Tel: (516) 307- 1777
`Fax: (516) 307- 1770
`L&B File No.: 2125.COM.55
`
`L&B File No.: 2125.COM.55
`
`11 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 13 of 18 PageID #: 21
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`DocuSlgn Envelope ID: 1978ASC34E!6-4002-BF69-ED844DB27318
`
`,
`
`COURT OF THE STATE
`SUPREME
`OFRUEENS
`COUNTY
`MAURICE
`NORMAN
`EAST
`COAST
`PLASTIC
`
`OF NEW YORK
`
`ROWE,
`M.D.,
`SURGERY,
`Plaintiffs,
`
`M.H.A.,L.L.C.
`PC
`
`&
`
`Index
`
`No.
`
`VERIFICATION
`
`- Against
`
`-
`
`HEALTH
`PLANS
`
`(NY),
`
`INC.,
`
`OXFORD
`INCJ
`INSURANCE,
`HEALTH
`OXFORD
`INCJ
`(NJ),
`and OXFORD
`HEALTH
`PLANS
`
`OXFORD
`HEALTH
`PLANS
`
`LLC,
`
`. ..
`
`.
`
`Defendants.
`
`I
`
`//f
`
`being
`
`duly
`
`sworn,
`
`deposes
`
`and
`
`says:
`
`I am an
`
`cher
`
`of NORMAN MAURICE
`
`ROWE,
`
`M.D.,
`
`M.H.A.,L.L.C.
`
`& EAST
`
`COAST
`
`PLASTIC
`
`SURGERY,
`
`PC,
`
`the
`
`plaintiff
`
`in
`
`the
`
`above
`
`êñtitled
`
`action.
`
`I have
`
`read
`
`the
`
`foregoing
`
`complaint
`
`and
`
`know
`
`the
`
`contents
`
`thereof.
`
`The
`
`same
`
`are
`
`true
`
`to
`
`my knowledge,
`
`except
`
`as to matters
`
`therein
`
`stated
`
`to be alleged
`
`on information
`
`and
`
`belief
`
`and
`
`as to those
`
`matters
`
`I believe
`
`them
`
`to be true.
`
`Dated:8eptember
`
`13,
`
`2021
`
`Sworn
`
`to before
`
`me this
`
`day
`
`o
`
`0
`
`NOT Ry p
`AGURyou
`CotnadeshnC OF NSW JERegy
`My
`S/fM02
`ac
`
`Notary
`
`L&B File No.: 2126.COM.55
`
`12 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 14 of 18 PageID #: 22
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`Docu8ign Envelope ID: 1B78ABC3-428646CBBF69-ED8440027318
`
`OF NEW YORK
`
`&
`
`Index
`
`No.
`
`VERIFICATION
`
`OF THE STATE
`COURT
`SUPREME
`OF QUEENS
`COUNTY
`MAURICE
`NORMAN
`EAST COAST
`PLASTIC
`
`ROWE,
`M.D.,
`SURGERY,
`Plaintiffs,
`
`M.H.A.,L.L.C.
`PC
`
`- Against
`
`-
`
`HEALTH
`PLANS
`(NY),
`INC.,
`
`OXFORD
`INC.;
`INSURANCE,
`HEALTH
`OXFORD
`(NJ),.INC.:
`HEALTH
`and OXFORD
`PLANS
`
`OXFORD
`HEALTH
`PLANS
`
`LLC,
`
`Defendants.
`
`I.
`
`AÝ ..
`
`being
`
`duly
`
`sworn,
`
`deposes
`
`and
`
`says:
`
`I am an
`
`offleer
`
`of NORMAN
`
`MAURICE
`
`ROWE,
`
`M.D.,
`
`M.H.A.,L.L.C.
`
`& EAST
`
`COAST
`
`PLASTIC
`
`BURGERY,
`
`PC,
`
`the
`
`plaintiff
`
`in the
`
`above
`
`entitled
`
`action.
`
`I have
`
`read
`
`the
`
`foregoing
`
`complaint
`
`and
`
`know
`
`the
`
`contents
`
`thereof.
`
`The
`
`same
`
`are
`
`true
`
`to
`
`my
`
`knowledge,
`
`except
`
`as to mattere
`
`therein
`
`stated
`
`to
`
`be alleged
`
`on information
`
`and
`
`belief
`
`and
`
`as
`
`to
`
`those
`
`matters
`
`I believe
`
`them
`
`to be tru
`
`Dated:September
`
`18,
`
`2021
`
`Sworn
`
`to before
`
`me this
`
`day
`
`o
`
`20
`
`MICHGLE
`
`,tga
`
`Notary
`
`Publie
`
`L&B File No.: 2125.COM.55
`
`13 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 15 of 18 PageID #: 23
`c
`O
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`.
`
`O
`FORM
`INSURANCE
`HEALTH
`CLAIM
`APPROVGDBYNATIONALUN1FORMCLAIMCOMMITTEE(NUCCJ02/12
`ET PICA
`1. MEDICARE
`(MetHaare/)
`·
`u. a
`
`MEDICAID
`TRICARE
`(Medicald4)
`(DNDoDD
`. :- m - a a u i
`o o
`
`OXFORD
`PO BOX
`29135
`HOT
`SPRINGS
`
`AR 71903-
`
`GROUP
`CHANPVA
`FECA
`BLKLUNG
`HEALTHPLAN
`(Member3DS)
`ffD9)
`{|DS)
`R PATJENTSBlRTHDATE
`MM I DD I
`
`SEX
`
`la. )NSUREDES1.D.NUMBER
`
`OTHEli
`{&}
`
`PICA
`(ForFrogramb hem1)
`
`4. INSURED'SNAME(LastÑame.FirstName,MiddleInlilal)
`
`8. • · I T' MiiPithTIME
`
`s-
`
`6. PAT1ENTRELATIONSHIPTO INSURED
`
`7. JNSURFO'sADDRESS(No.,Street)
`
`CITY
`
`ZIPCODE
`
`9.
`
`STATE 8. RESERVEDFORNUCCUSE
`
`TELEPiTONE-(íñclWeAreaCode)
`
`CITY
`
`ZIPCODE
`
`STATE
`
`TELEPHONE(IncloiseAreaCode)
`
`ME(LastName.FirstName,Middisrghla|)
`
`10. 18PATIENT'SCONDATIONRELATEDTO:
`
`11. INSURED'SPOljCYGROUPOR FECANUMBER
`
`a. MHER INSURED'BPOLICYORGROUPNUMBER
`
`b. RE8ERVEDFORNUCCUSE
`
`c. RESERVEDPORNUCCUSE
`
`TTNBUI ANCEPl.ANNAMEORPROGRAMNAME
`
`YEB
`c. OTHERACClDENT?
`NO
`YES
`10d.CLAIMCODES(Dee1gnatedby NUCC)
`
`a EMPLOYMENT?(currentor Previous)
`X NO
`YES
`tL AUTOACCIDENT?
`PLACE(State) b.O
`X NO
`
`e. INSUREtysDATEOFBilUN
`
`SEX
`
`''
`
`c. INSURANCEPLANNAMEORPROGRAMNAME
`
`d. 18THEREANOTHERHEALTHBENEF1TPLAN?
`YES
`NO
`# yes,completeItems9, 98 arid9tl
`13.INSUREDSORAUTHOR1ZEDPERSON'SGlGNATURE1authoilet
`paymentof medcillbenefitsto theuridersignedphyalcianor auppliertor
`aervicesdescreedbelow,
`
`SIGNATURE
`ON
`FILE
`3,3
`14itDATESPATIENTUNABLETOWORKIN 00 RENTOCCUPATION
`YY
`MM i DD r
`g DD ,
`yy
`FROM
`TO
`I
`I
`18. HOSPIT
`TlONDATES liiLATEDTOCU E T 8 R ES
`1
`1
`FROM
`TO
`20.00TalDE I B?
`$ CHARGES
`YES
`NO
`22. RESUBM1SSION
`CODE
`
`ORlalNALREF.NO.
`
`........ . .
`
`READBACKDFPORMBRPÒREC6MPLETINf& slGNINthTFltsFORM.
`12. PATIENTaSORAUTHOR12EDPERSON'SSIGNAT.UREI authortzemeteleaseof anymedicalor otherinformallorinecessary
`to facesslhiselaim,I alsorequestpaymeritof govemrrientbenetilseitherto myselforto mepartywhoacceptsassigriment
`beaw,
`
`on
`File
`Signature
`3 14, DATE0F CURRENTILLNESS,INJURY,or PREGNANCY(LMP)
`MM
`YY
`DD g
`QUAL.1
`17. NAMEOFREFERRINGPROVIDEROROTHERSOQRCE
`I
`9 A D17101¾LCLA1M1NFORMATION(Deelgnatedby NUCC)
`
`œTe
`(5, OTHERDATE
`QUAL.
`
`08/12/2021
`
`MM 1 DD i
`
`YY
`
`17b. NPI
`
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`
`......
`
`..
`
`21. 0 AGHOSlSOR NA%lREOF ILLNESSOn INJURY.RelateA L to serviceInebelow(24E)
`
`A.
`E.L__
`L 1
`24. A.
`
`B.
`F.
`J.
`DATE(s)QFSERVICE
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`YY
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`C.
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`_...
`0. PROCEDUftES,8ERVICES,ORSUPPLIES
`(ExplainUnusualCircurnsteces)
`tFlER
`
`.
`20. PRIORAL/THORIZATIONNUMBER
`A105057304
`F.
`
`H.
`G.
`S EP
`
`$ CHARGES
`
`u
`
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`ID.
`QUAL
`
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`DIAGNOSIS
`POINTER
`
`.
`
`NPI
`
`NPI
`
`26. FEDERALTAXLD.NUMBER
`
`SSH EtN
`
`31.SIGNATUREOF PHYSIOlANORSUPPLIER
`INCLUD1NGDEGREESORCREnENTIALB
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`- • . c .• •
`: -
`apply • 4 . •
`
`£6. PATIENT'SACCOUNTNO.
`
`on/17/7071
`•·1710
`SIGNED
`DATE
`NUCC !nstn.dion Manual available at www.nucc.Org
`WCMS-150008-12
`
`53
`
`PLEASE PRINT OR TYPE
`
`14 of 17
`
`29. AM( UNTP..lD
`27.ACCEPTASSIGNMENT? 28. TOTALCHARGE
`
`Torg09t,C1811i11.$40bindQ
`150000:
`s
`Yus FjNO_
`*
`5922
`|41
`00
`PR VIDERINF) & H.
`82. SER E FAC1LITYLOCATIONINFORMATION
`33. 81
`MAURICE
`RO E,
`REGIONAL
`HUDSON
`HOSPITAL
`NORMAN
`EAST
`77TH
`STREE T
`71
`55 MEADOWLANDS
`PARKWAY
`NY
`100750000
`NEW YORK,
`SECAUCUS,NL
`EM.¤Q
`r70
`1215)H|t
`APP lOVED OMB 0938-1
`
`J.
`RENDERING
`FñGViOERID.#
`
`80. evdforNUCCuse
`
`D,
`
`MHA,
`
`LLC
`
`7 FOR d
`
`550 (02-12)
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`E
`E
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 16 of 18 PageID #: 24
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`.
`.
`
`FORM
`INSURANCE
`HEALTH
`CLAIM
`APPROVEDBYNATIONALUNIFORMCLAIMCOMMITTEE(NUCC)02f12
`P(CA
`t. MEDICARE
`
`MEDICA10
`
`TRICARE
`
`CHAMPVA
`
`OXFORD
`29135
`PO BOX
`HOT
`SPRINGS,
`
`AR
`
`71903-
`
`GROUP
`
`FECA
`
`0THER 1a. INSURED'81.DNUMBER
`
`PICA
`(F r Paogramla itan
`
`2. PATIENTSNAME(LastName FirstName,Mkidle011a1)
`
`3. PATIENT'SBIRTHDATE
`
`SEX
`
`ame, rstName,Midds n a)
`
`CITY
`
`ZI
`
`9,
`
`8. RE ERVEDFORNUCCUSE
`
`de)
`
`CITY
`
`21PCODE
`
`8TATE
`
`TELEPHONE(includeAreeCode)
`
`ME(LastName.FirstName,Middleinitial)
`
`10. ISPAT)ENT'SCONDITIONRELATEDTO:
`
`11.
`
`ICYGROUPORFECANUMBER
`
`a, MHER INSURED'SPOL1CYORGROUPNUMBER
`
`a. EMPLOYMENT?(Currentor Previous)
`
`a. ENSURED6 DATEOFBIRTH
`
`b. RESERVEDFORNUCCUSE
`
`o, RESERVEDFORN000 USE
`
`d. INSURANCEPLANNAMEOR PROGRAMNAME
`
`0. AUTOACC1DENT
`YE8
`c. UrHERACCIDENT?
`X NO
`YES
`1M CLAlMCODES(Designatedby NUCC)
`
`X NO
`
`READBACKOFPORMBl!FORECOMPLETIN0& SIGN114GTHISFOR51.
`12. PATIENT'SORAUTHORIZEDPERSON'sSIGNATUREI author|ze1hefelaeseof an medicalor otherInforroellonnecessary
`10 acessthisclairn.1alsorequestpaymentol govemmentbenefitseitherto myoslf
`tothe partywhoacceptsassignment
`beow.
`
`File
`on
`Signature
`DATE
`Sl0NED
`) 14. DATEOFCURRENTILLNESB,INJURY,or PREGNANCY(LMP) 15.OTHERDATE
`YY
`MM g 00 g
`QUALi
`QUAL.e
`17. NAMECFREFEFIRINGPROVIDEROROTHERSOURCE
`
`--
`
`08/02/2021
`
`MM
`
`g
`
`DD g
`g
`
`YY
`
`1m -
`
`-
`17t NPl
`
`I
`19. ADD1nONALCLAIMINFORMATION(Deelgriatedby NUCC)
`. .
`.
`21. DIAGNOSISORNATUREOF ILLNE da INJURY.RetateA-Lto servicelinebeow(24E)
`
`A
`E.L
`
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`F. |
`
`C.
`0. L
`
`'
`|
`100Ind.|O g
`D.|
`H 1
`
`c. INSURANCEPLANNAMEORPROGRAMNAME
`
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`F yes,cornpeteitems9,Gaanded.
`13.LNSURED'SORA0nl0R
`paymeritof medicalbenefitsto the unders|gnedphysicianor supplierfor
`servicesdescribedbelow.
`
`ON
`SIGNATURE
`FILE
`SIGNED
`18. DATESPATIENTUNABLETOWORK1NCURRENTOCCUPATION
`YY
`MM g DD
`MM DD i
`YY
`FROM
`TO
`18. HOSPITALIZATIONDATESREl.ATEDTOCURRENTSERVICES
`MM g DD i
`YY
`YY
`MM g DD i
`a
`1
`i
`FROM
`TO
`I
`f
`r
`I
`20. OUTSIDELAS?
`6 OHARGES
`ES
`22. RESUBMISSION
`CODE
`
`ORIGINALREF.No.
`
`24. A,
`
`DAlt(8) OFSERVICE
`From
`To
`YY MM DD
`M OD
`
`B.
`C.
`PLACE0F
`YY SERVICEEMG
`
`D. PROCEDURES.SERVICES,ORSUPPLIES
`(ExplttlnUriueualCircumstances)
`CPTMCPCS I
`MODIEEER.___
`
`E.
`DIAGNOSIS
`POINTER
`
`$ CHARGES
`
`G.
`H.
`1.
`oAwr EPam ID.
`QUAL
`u
`
`J,
`RENDERING
`PROVIDERID.#
`
`23. PRIORAUTHORIZATIONNUMBER
`A105057304
`F.
`
`18 10
`
`22
`
`19318
`
`50
`
`0
`
`ABC
`
`50ÒÓó
`
`00
`
`1
`
`..
`
`NPI
`
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`
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`
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`
`G M
`NO
`
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`28. TOTALCHARGE
`29. AW UNTP.JD
`* Q ª{°|
`1500001
`s
`00
`33. DILLINGPROVIDERINFO& PH.
`S
`COAST
`PLASTI
`EAST
`STREET
`STE
`333
`BROAD
`NJ
`RED
`077010000
`BANK,
`
`80. Re9dfor NUCCuse
`
`ERY,
`
`PC
`
`1A
`
`a
`25. FEDERALTAX1.D.NUMBER
`
`SSN ElN
`
`28. PATIElfFSACCOUNTH0.
`
`27.A
`
`31. 8IGNATUREOF PHYSICIANOR SUPPlJER
`INCLUDINGDEGREESOR CHEDENTIALS
`geariny1hattheelatememnonthereverse
`applya>misbwenderemadesportthereor.)
`
`SIGNED
`NUCCImtrúchManualredla
`
`.
`
`08/02/2021
`DATE
`atwww.nuoc.org
`WCMS-1500CS-12
`
`YES
`32. SERVICEFAClUTYLOCATEONINFORMATION
`REGIONAL
`HUDSON
`HOSPITAL
`55 MEADOWLANDS
`PARKWAY
`SECAUCUS,NJ
`
`0
`
`7
`
`.
`PLEASE PR1NT OR TYPE
`
`½
`RPPROVED OMB0938-1
`
`97 OhM1500(02-12
`
`15 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 17 of 18 PageID #: 25
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`OF NEW YORK
`SUPREME
`COURT
`OF THE
`STATE
`COUNTY
`OF QUEENS
`
`NORMAN
`MAURICE
`COAST
`EAST
`PLASTIC
`
`-Against-
`
`M.H.A.,L.L.C.
`
`ROWE,
`M.D.,
`SURGERY,
`Plaintiffs,
`
`PC,
`
`Index
`
`No.
`
`&
`
`AFFIRMATION
`
`OXFORD
`HEALTH
`PLANS
`
`LLC,
`
`HEALTH
`PLANS
`
`(NY),
`
`INC.,
`
`OXFORD
`INSURANCE,
`INC.;
`HEALTH
`OXFORD
`INC.;
`(NJ),
`HEALTH
`and OXFORD
`PLANS
`
`Defendants.
`
`STATE
`COUNTY
`
`OF NEW YORK)
`OF NASSAU)
`
`ss.
`
`ATTORNEYS
`
`VERIFICATION
`
`AND CERTIFICATION
`
`PURSUANT
`
`TO § 130-1:
`
`I, Michael
`Baglio,
`in
`the
`Courts
`& BAGLIO,
`penalties
`
`practice
`LEWIN
`under
`true
`
`Esq.,
`the
`
`of
`
`an
`
`State
`
`attorneys
`LLP,
`of perjury:
`
`and
`attorney
`of New York
`for
`plaintiff
`
`counselor
`
`and
`
`herein,
`
`at
`law,
`a mamher
`affirms
`
`duly
`with
`
`admitted
`
`to
`
`the
`
`law
`
`firm
`
`the
`
`following
`
`to
`
`be
`
`I have
`information
`
`upon
`
`read
`
`the
`
`and
`
`the
`therein
`
`contents
`
`to
`
`be
`
`and
`
`foregoing
`belief,
`
`COMPLAINT
`I believe
`the
`matters
`
`and
`
`know
`alleged
`
`thereof,
`true.
`
`The
`
`reason
`
`plaintiff
`
`resides
`
`maintained.
`
`verification
`this
`a county
`
`in
`
`other
`
`is made
`than
`the
`
`by
`
`deponent
`in
`
`one
`
`which
`
`and
`
`not
`your
`
`plaintiff
`
`by
`deponent's
`
`is
`
`that
`
`office
`
`is
`
`The
`
`source
`
`of
`
`your
`
`deponent's
`
`information
`
`communications,
`
`papers,
`
`reports
`
`and
`
`investigations
`
`and
`
`the
`
`contained
`
`of my
`grounds
`in my file.
`
`belief
`
`are
`
`Dated:
`
`September
`13,
`New York
`
`2021
`
`Westbury,
`
`DocuSignedby:
`
`-G,
`
`1D4ûG1473
`
`...
`
`Michael
`
`Baglio,
`
`Esq.
`
`L&B File No.:
`
`2125.COM.55
`
`16 of 17
`
`

`

`INDEX NO. 721010/2021
`FILED: QUEENS COUNTY CLERK 09/21/2021 02:57 PM
`DocuSign Envelope ID: 1B78A3C3-42E6-46C2-BF59-ED844DB27318
`Case 1:21-cv-06290 Document 1-1 Filed 11/11/21 Page 18 of 18 PageID #: 26
`NYSCEF DOC. NO. 1
`RECEIVED NYSCEF: 09/21/2021
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF QUEENS
`NORMAN MAURICE ROWE, M.D., M.H.A.,L.L.C. &
`EAST COAST PLASTIC SURGERY, PC
`
`
`
`
`
`
`Plaintiffs,
`
`
` - Against -
`
`
`OXFORD HEALTH INSURANCE, INC.; OXFORD
`HEALTH PLANS (NJ), INC.; OXFORD HEALTH
`PLANS (NY), INC., and OXFORD HEALTH PLANS
`LLC,
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Defendants.
`
`
`
`
`
`
`Index No.
`
`
`
`
`
`Pursuant to Section 130-1 of the rules of the chief administrator (22 NYCRR) I certify that to the
`best of my knowledge, information and belief, Formed after an inquiry reasonable under the
`circumstances, the within Summons and Verified Complaint are not frivolous
`
`
`
`___________________________________________
`By: Michael Baglio, Esq.
`
`
`
`Notice Pursuant to CPLR 2103(5) declining service by electronic transmittal
`
`
`SUMMONS AND COMPLAINT
`
`
`
`LEWIN & BAGLIO, LLP
`
`Attorneys for the Plaintiff
`1100 Shames Drive
`Suite 100
`Westbury, New York 11590
`Tel: (516) 307- 1777
`Fax: (516) 307- 1770
`L&B File No.: 2125.COM.55
`
`To:
`
`Attorney for defendant
`Service of a copy of the within SUMMONS AND COMPLAINT is hereby admitted.
`
`Dated:
`
`
`
`
`
`______________________
`Attorney for Defendant
`
`L&B File No.: 2125.COM.55
`
`17 of 17
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`